CME credit available from Harvard Medical School through November 2022.
Atrial fibrillation (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.4 The primary goal of this educational program is to update primary care providers on the latest evidence for selecting an anticoagulant, review the role of rate control, and provide an overview of interventions used for managing rhythm.
Anticoagulation reduces the risk of stroke, especially in older adults5
Despite the reduction in risk of stroke, anticoagulation is often underutilized, with nearly 2 in 5 patients with atrial fibrillation not receiving it.6
Decrease the risk of stroke
Estimate the need for anticoagulation in patients with AF using the CHA2DS2-VASc score7
Use the CHA2DS2-VASc score to recommend an anticoagulation plan 2,8
Reduce the risk of bleeding
- Address modifiable risk factors (e.g., blood pressure, alcohol use).
- Monitor renal and liver function.
- Use an anticoagulant with the lowest risk of bleeding, especially for patients with a prior major bleed.
Direct oral anticoagulants (DOACs) reduce the risk of stroke in patients with AF. However, the risk of bleeding varies between the DOACs when compared to warfarin.
Relative risk of bleeding compared to warfarin9
DOACs preferred over warfarin, unless contraindicated or unaffordable.
Left atrial appendage devices (e.g., Watchman) are no less effective than warfarin after two years.10 It is an option for patients with significant stroke risk who are unable to tolerate long-term anticoagulation.
Rate vs. rhythm control
Rate control focuses on maintaining heart rate in a lenient (<110 beats per minute) or strict (<80 beats per minute) range. Decision regarding which strategy to engage is based on patient symptoms and ventricular function. Rhythm control strategies will often involve conversations with a cardiologist. Rhythm control strategies in general are determined by patient symptoms. Most have high rates of AF recurrence and will require continuous anticoagulation.
Information current at time of publication, November 2019.
The content of this website is educational in nature and includes general recommendations only; specific clinical decisions should only be made by a treating clinician based on the individual patient’s clinical condition.
Additional Resources for Patients
American Heart Association
Heart Rhythm Society
American College of Cardiology
- 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, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 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 Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019;140(2):e125-e151.
- Saffitz JE. Connexins, conduction, and atrial fibrillation. N Engl J Med. 2006;354(25):2712-2714.
- 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.
- Singer DE, Chang Y, Fang MC, et al. The net clinical benefit of warfarin anticoagulation in atrial fibrillation. Ann Intern Med. 2009;151(5):297-305.
- Ashburner JM, Atlas SJ, Khurshid S, et al. Electronic physician notifications to improve guideline-based anticoagulation in atrial fibrillation: a randomized controlled trial. J Gen Intern Med. 2018;33(12):2070-2077.
- Lip GY, Tse HF, Lane DA. Atrial fibrillation. Lancet. 2012;379(9816):648-661.
- Olesen JB, Lip GY, Hansen ML, et al. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. Bmj. 2011;342:d124.
- Graham DJ, Baro E, Zhang R, et al. Comparative Stroke, Bleeding, and Mortality Risks in Older Medicare Patients Treated with Oral Anticoagulants for Nonvalvular Atrial Fibrillation. Am J Med. 2019;132(5):596-604.e511.
- Reddy VY, Doshi SK, Sievert H, et al. Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3-Year Follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) Trial. Circulation. 2013;127(6):720-729.