Atrial fibrillation is an irregular heart rate during which the atria of the heart beat irregularly — completely out of sync with the ventricles of the heart. A patient may present with palpitations and shortness of breath.



AF be classified into 3 classes

 One episode of Atrial Fibrillation , irrespective of whether it was asymptomatic / self resolving or symptomatic.

. Recurrent A FIB

  • Patient with 2 or more episodes
  • Paroxysmal (Episodes of AFIB resolve spontaneously within 7 days )
  • Persistent AFIB (Episodes of AFIB persists beyond 7 days)
  • Permanent AFIB (continuous AFIB, cant be cardioverted )

In permanent AFIB rate control and anticoagulation are resorted to if appropriate.                        

AFIB Guidelines

    • In AFIB patients warfarin is the drug of choice following stroke or TIA.
    • Before initiating warfarin a 2 week gap should be given post stroke or TIA
    • A large infarct should prompt a further delay of initiating warfarin
    • Aspirin can be added or continued with this regimen to address comorbidities
    • For rate control, beta blockers, CCBs or digoxin is used
    • Digoxin isn’t first line as it has poor rate control in exercise
    • Digoxin is the drug of choice if there is coexisting heart failure with AFIB
    • Amiodarone (if structural heart disease is present) and flecainide (if structural heart disease is not present) are employed for rhythm control
    • Rate control is preferred to rhythm control especially if patient is greater than 65 years of age with a history of IHD
    • If AF onset  is less than 48 hours then patient is heparainized, TTE is done to exclude thrombus and cardioversion is done (DC or Chemical). Following cardioversion if AF is confirmed to be less than 48 hours duration then no further anticoagulation is necessary.
    • If AF onset is greater than 48 hours then heparinize for at least 3 weeks prior to cardioversion. If an immediate TOE is done to exclude a thrombus in the left atrium then cardioversion can be done immediately in this case too.

  • in high risk cases prone to recurrence and failure , a 4 week gap with sotalol or amiodarone cover is preferred before cardioversion
  • After cardioversion at least 4 weeks anticoagulation should be done. Longer duration depends on the physicians choice wrt individual scenarios.