Management of Atrial Fibrillation
For Primary Care Physicians
CME credit available from Harvard Medical School through July 2018.
The primary goal of this educational program is to update primary care physicians on the management of atrial fibrillation (AF). We present the latest evidence on the use of antithrombotic therapy as well as selecting between rate and rhythm control strategies.
AF is the most common sustained cardiac arrhythmia, affecting about 5 million Americans.1 It substantially increases a patient’s risk for stroke, heart failure, hospitalization, and death.2 About 15% of strokes in the United States are caused by AF,3 and AF contributes to nearly 100,000 deaths in the U.S. every year.2
AF patients have increased morbidity and mortality compared to patients of the same age without AF. 2,4
Anticoagulation in atrial fibrillation
Anticoagulation reduces the risk of stroke by almost two-thirds,5 but carries an increased risk of bleeding. This benefit and risk must be balanced to select an anticoagulation plan. Two validated tools are available to assess a patient’s risk of stroke and bleeding, namely CHA2DS2-VASc and HAS-BLED.
CHA2DS2-VASc score estimates risk of stroke6
HAS-BLED score estimates risk of bleeding7
Using these two tools assists in the selection of a plan for anticoagulation that balances the risks and benefits of treatment.
Guidance for choosing the best anticoagulation plan8-10
Selecting anticoagulation in patients with a CHA2DS2-VASc score = 1
Rate vs. rhythm control
Independent of managing anticoagulation is the decision about managing the arrhythmia. Based on the results from AFFIRM, strict rate control (<80 beats per minute (bpm) at rest, <110 bpm while exercising) and rhythm control have no difference in mortality, though patients using rhythm control had more side effects and hospitalizations.11 RACE II found that strict rate control compared to lenient rate control (<110 bpm at rest) had similar outcomes, but lenient rate control required fewer office visits to achieve heart rate goals. Therefore lenient rate control will be the best approach for most patients, but there are some for whom a different approach may be necessary.
Patient characteristics drive the selection of rate or rhythm control
- American Heart Association
- Heart Rhythm Society
- American Stroke Association
- American College of Cardiology
- Stroke Prevention in Atrial Fibrillation Risk Tool (SPARC)
Information current at time of publication, July 2015.
The content of this website is educational in nature and includes general recommendations only; specific clinical decisions should only be made by a treating physician based on the individual patient’s clinical condition.
- Colilla S, Crow A, Petkun W, Singer DE, Simon T, Liu X. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol. 2013;112(8):1142-1147.
- January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):e1-76.
- Saffitz JE. Connexins, conduction, and atrial fibrillation. N Engl J Med. 2006;354(25):2712-2714.
- Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics–2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28-e292.
- Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146(12):857-867.
- Lip GY, Tse HF, Lane DA. Atrial fibrillation. Lancet. 2012;379(9816):648-661
- Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010;138(5):1093-1100.
- Friberg L, Rosenqvist M, Lip GY. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study. Eur Heart J. 2012;33(12):1500-1510.
- Olesen JB, Lip GY, Lindhardsen J, et al. Risks of thromboembolism and bleeding with thromboprophylaxis in patients with atrial fibrillation: A net clinical benefit analysis using a ‘real world’ nationwide cohort study. Thromb Haemost. 2011;106(4):739-749.
- Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962.
- Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347(23):1825-1833.