Last Reviewed 12/7/2012 12:00:00 AM

Atrial Fibrillation Guidelines

The American College of Cardiology and the American Heart Association have developed standards for treating patients with atrial fibrillation (AFib). They apply to most patients, but also give your doctor the flexibility to tailor treatment to your specific clinical needs. Below is a summary of key information and recommendations.

Print out this check list and bring it with you to your next doctor visit so that you can ask questions and have a record of your treatment. When you get home, visit the CardioSmart Atrial Fibrillation condition center to help remind you of what you talked about with your doctor and what you need to do to take care of yourself or your loved one.

The Initial Evaluation

To diagnose atrial fibrillation and determine the best treatment, your doctor may:

  • Ask you detailed questions about the types of symptoms you are experiencing, when you first noticed them, how often they occur, how long they last, and how much they interfere with your everyday activities.
  • Perform an electrocardiogram (ECG or EKG) to evaluate your heart rhythm. If your AFib comes and goes, your doctor may arrange for you to wear a Holter monitor, which records your heart’s electrical activity and rhythm for 24 to 48 hours.
  • Perform an echocardiogram (ultrasound for the heart), to check the size of your heart and how well it is functioning.
  • Run blood tests to check your thyroid gland, kidneys, and liver.
  • Calculate your risk of stroke.

In some cases, your doctor may also do the following tests:

  • Exercise stress test, or a six-minute-walk test, to see how your heart responds to exercise
  • Transesophageal echocardiography. This involves passing a small ultrasound probe into your mouth and down your throat while you are sedated. In this position, the transducer is very close to your heart, so that it can easily detect any blood clots that may have formed in your atrium.
  • Electrophysiology (EP) study. This involves passing into your heart a special tube, or catheter, that can sense electrical activity. It may be helpful in figuring out what is causing your AFib and in planning for a treatment known as catheter ablation.
  • Chest X-ray 

Your Treatment Plan

Before coming up with a specific treatment plan, your doctor will determine whether your AFib is paroxysmal (it comes and goes) or persistent. If you have persistent AFib, or if your paroxysmal AFib keeps coming back, your doctor will talk with you about the pros and cons of two treatment strategies: using medication to simply keep the heart rate from going too fast (rate control), or going a step further and trying to convert the AF back to a normal heart rhythm and keep it that way (rhythm control).

The choice between rhythm control and rate control depends on several things, including:

  • How long you’ve had AFib
  • How severe your symptoms are
  • Whether you have other types of heart disease
  • Your age

With rate control, your doctor may aim for a heart rate of less than 110 beats per minute at rest. This is called lenient rate control. Patients with poor heart function or intolerable symptoms may need a lower heart rate, or stricter rate control. Your doctor may use a variety of medications to achieve rate control, including:

As long as your heart stays in atrial fibrillation, you will need to take anti-clotting medication (also called anticoagulants) to prevent a stroke, even if your AF comes and goes and your heart rate is well controlled. That’s because the quivering atrium allows blood to pool, where it can form blood clots that can travel to your brain. Medications that reduce blood clotting include:

  • Aspirin, for patients with no more than one characteristic linked to a moderate risk of stroke
  • Warfarin (Coumadin), for patients at moderate to high risk for stroke
  • Dabigatran (Pradaxa), an alternative to warfarin for patients at moderate to high risk for stroke
  • Aspirin plus the anti-clotting medication clopidogrel (Plavix), for moderate- to high-risk patients who cannot take warfarin

If you and your doctor have decided it’s best to eliminate your atrial fibrillation (rhythm control), your doctor will attempt to convert your heart back to a normal rhythm. This process, called cardioversion, can be achieved through:

Once your heart is again beating with a normal rhythm, it may be necessary to take anti-arrhythmic medications to keep it that way. These may include:

  • Amiodarone
  • Dofetilide
  • Dronedarone
  • Flecainide
  • Propafenone
  • Sotalol

You will also need to take anti-clotting medications before cardioversion and for at least 4 weeks afterward to prevent a stroke. Since there is a chance that your atrial fibrillation could come back, your doctor may recommend that you continue to take anti-clotting medications over a long period of time.

Your doctor may recommend a procedure called catheter ablation if you are experiencing intolerable symptoms and:

  • Cardioversion is unsuccessful in getting your heart rhythm back to normal; or
  • Cardioversion is successful at first, but anti-arrhythmic medications aren’t able to keep your heart rhythm normal over the long run.

During catheter ablation, a slender tube (catheter) is threaded into your heart. It delivers bursts of radiofrequency energy that destroy the abnormal cells that are causing the atrial fibrillation.

Read the full guidelines in the Journal of the American College of Cardiology