Rate or rhythm, plus stroke prevention, considered separately
Expansion
Three separate decisions, and confusing them is the commonest error:
- Rate or rhythm control
- Anticoagulation, decided independently by stroke risk
- Treat the cause
Rate control is first line for most patients: beta blocker or rate limiting calcium channel blocker, with digoxin reserved for the sedentary or those in heart failure.
Rhythm control is preferred if the AF is new (under 48 hours), if there is a reversible cause, if there is heart failure caused by the AF, or if the patient remains symptomatic despite rate control.
Immediate cardioversion is required if there are adverse features: shock, syncope, myocardial ischaemia or heart failure.
The 48 hour rule: beyond 48 hours from onset, cardioversion requires either 3 weeks of anticoagulation beforehand or a transoesophageal echo to exclude atrial thrombus, and anticoagulation continues for at least 4 weeks afterwards regardless.
Causes, using PIRATES: Pulmonary (embolism, pneumonia), Ischaemia, Rheumatic valve disease, Alcohol and Atrial enlargement, Thyrotoxicosis, Electrolytes, Sepsis and Sleep apnoea.