Last updated December 15, 2022

Management of Patients With Atrial Fibrillation

Diagnosis

Table 2. Clinical Evaluation

ECG documentation is recommended to establish the diagnosis of AF. ( C , I )
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Treatment

Table 4. Risk-Based Antithrombotic Therapy

NEW: NOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) are recommended over warfarin in NOAC-eligible patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve). ( A , I )
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MODIFIED: In patients with AF, anticoagulant therapy should be individualized on the basis of shared decision-making after discussion of the absolute risks and relative risks of stroke and bleeding, as well as the patient’s values and preferences. ( C , I )
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MODIFIED: Selection of anticoagulant therapy should be based on the risk of thromboembolism, irrespective of whether the AF pattern is paroxysmal, persistent, or permanent. ( B , I )
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MODIFIED: In patients with AF2 (except with moderate-to-severe mitral stenosis or a mechanical heart valve), the CHADS2-VASc score is recommended for assessment of stroke risk. ( B , I )
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MODIFIED: For patients with AF who have mechanical heart valves, warfarin is recommended. ( B , I )
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Warfarin (INR 2.0-3.0) ( A , I )
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Dabigatran, rivaroxaban or apixaban ( B , I )
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Edoxaban ( B-R , I )
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MODIFIED: Among patients treated with warfarin, the international normalized ratio (INR) should be determined at least weekly during initiation of anticoagulant therapy and at least monthly when anticoagulation (INR in range) is stable. ( A , I )
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MODIFIED: For patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve) who are unable to maintain a therapeutic INR level with warfarin, use of a NOAC is recommended. ( C-EO , I )
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MODIFIED: Reevaluation of the need for and choice of anticoagulant therapy at periodic intervals is recommended to reassess stroke and bleeding risks. ( C , I )
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MODIFIED: Renal function and hepatic function should be evaluated before initiation of a NOAC and should be reevaluated at least annually. ( B-NR , I )
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MODIFIED: For patients with atrial flutter, anticoagulant therapy is recommended according to the same risk profile used for AF. ( C , I )
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MODIFIED: For patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve) and a CHADS-VASc score of 0 in men or 1 in women, it is reasonable to omit anticoagulant therapy. ( B , IIa )
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MODIFIED: For patients with AF2 who have a CHADS-VASc score of ≥2 in men or ≥3 in women and who have end-stage chronic kidney disease (2CKD; creatinine clearance [CrCl] <15 mL/min) or are on dialysis, it might be reasonable to prescribe warfarin (INR 2.0 to 3.0) or apixaban for oral anticoagulation. ( B-NR , IIb )
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MODIFIED: For patients with AF2 (except with moderate-to-severe mitral stenosis or a mechanical heart valve) and a CHADS2-VASc score of 1 in men and 2 in women, prescribing an oral anticoagulant to reduce thromboembolic stroke risk may be considered. ( C-LD , IIb )
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MODIFIED: For patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve) and moderate-to-severe CKD (serum creatinine ≥1.5 mg/dL [apixaban], CrCl 15 to 30 mL/min [dabigatran], CrCl <50 mL/min [rivaroxaban], or CrCl2 15 to 50 mL/min [edoxaban]) with an elevated CHADS2-VASc score, treatment with reduced doses of direct thrombin or factor Xa inhibitors may be considered (e.g., dabigatran, rivaroxaban, apixaban, or edoxaban). ( B-R , IIb )
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In patients with AF undergoing percutaneous coronary intervention, bare-metal stents may be considered to minimize the required duration of dual antiplatelet therapy. Anticoagulation may be interrupted at the time of the procedure to reduce the risk of bleeding at the site of peripheral arterial puncture. ( C , IIb )
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Following coronary revascularization (percutaneous or surgical) in patients with AF2 and a CHADS-VASc score ≥2, it may be reasonable to use clopidogrel (75 mg 2QD) concurrently with oral anticoagulants but without aspirin. ( B , IIb )
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MODIFIED: In patients with AF and end-stage CKD or on dialysis, the direct thrombin inhibitor dabigatran or the factor Xa inhibitors rivaroxaban or edoxaban are NOT recommended because of the lack of evidence from clinical trials that benefit exceeds risk. ( C-EO , III (no benefit) )
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MODIFIED: The direct thrombin inhibitor dabigatran should NOT be used in patients with AF and a mechanical heart valve. ( B-R , III (harm) )
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Table 5. Recommendations for Interruption and Bridging Anticoagulation

Bridging therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is recommended for patients with AF and a mechanical heart valve undergoing procedures that require interruption of warfarin. Decisions regarding bridging therapy should balance the risks of stroke and bleeding. ( C , I )
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MODIFIED: For patients with AF without mechanical heart valves who require interruption of warfarin for procedures, decisions about bridging therapy (UFH or LMWH) should balance the risks of stroke and bleeding and the duration of time a patient will not be anticoagulated. ( B-R , I )
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NEW: Idarucizumab is recommended for the reversal of dabigatran in the event of life-threatening bleeding or an urgent procedure. ( B-NR , I )
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NEW: Andexanet alfa can be useful for the reversal of rivaroxaban and apixaban in the event of life-threatening or uncontrolled bleeding. ( B-NR , IIa )
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Table 6. Cardiac Surgery/Percutaneous Approaches— LAA Occlusion/Excision

NEW: Percutaneous LAA occlusion may be considered in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation. ( B-NR , IIb )
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MODIFIED: Surgical occlusion of the LAA may be considered in patients with AF undergoing cardiac surgery, as a component of an overall heart team approach to the management of AF. ( B-NR , IIb )
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Table 9. Rate Control

Control of the ventricular rate using a beta blocker or nondihydropyridine calcium channel antagonist is recommended for patients with paroxysmal, persistent, or permanent AF. ( B , I )
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IV administration of a beta blocker or nondihydropyridine calcium channel blocker is recommended to slow ventricular heart rate in the acute setting in patients without pre-excitation. In hemodynamically unstable patients, electrical cardioversion is indicated. ( B , I )
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In patients who experience AF-related symptoms during activity, the adequacy of heart rate control should be assessed during exertion, adjusting pharmacological treatment as necessary to keep the ventricular rate within the physiological range. ( C , I )
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A heart rate control (resting heart rate <80 bpm) strategy is reasonable for symptomatic management of AF. ( B , IIa )
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IV amiodarone can be useful for rate control in critically ill patients without pre-excitation. ( B , IIa )
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AV nodal ablation with permanent ventricular pacing is reasonable to control heart rate when pharmacological therapy is inadequate and rhythm control is not achievable. ( B , IIa )
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Lenient rate control strategy (resting heart rate <110 bpm) may be reasonable as long as patients remain asymptomatic and LV systolic function is preserved. ( B , IIb )
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Oral amiodarone may be useful for ventricular rate control when other measures are unsuccessful or contraindicated. ( C , IIb )
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AV nodal ablation with permanent ventricular pacing should NOT be performed to improve rate control without prior attempts to achieve rate control with medications. ( C , III (harm) )
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Nondihydropyridine calcium channel antagonists should NOT be used in patients with decompensated HF as these may lead to further hemodynamic compromise. ( C , III (harm) )
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In patients with pre-excitation and AF, digoxin, nondihydropyridine calcium channel antagonists, or intravenous amiodarone should NOT be administered as they may increase the ventricular response and may result in ventricular fibrillation. ( B , III (harm) )
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Dronedarone should NOT be used to control the ventricular rate in patients with permanent AF as it increases the risk of the combined endpoint of stroke, MI, systemic embolism, or cardiovascular death. ( B , III (harm) )
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Table 11. Electrical and Pharmacological Cardioversion of AF and Atrial Flutter

Prevention of Thromboembolism

MODIFIED: For patients with AF or atrial flutter of ≥48 hours’ duration, or when the duration of AF is unknown, anticoagulation with warfarin (INR2 2.0 to 3.0), a factor Xa inhibitor, or direct thrombin inhibitor is recommended for ≥3 weeks before and ≥4 weeks after cardioversion, regardless of the CHADS2-VASc score or the method (electrical or pharmacological) used to restore sinus rhythm. ( B-R , I )
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For patients with AF or atrial flutter of >48 hours duration or unknown duration that requires immediate cardioversion for hemodynamic instability, anticoagulation should be initiated as soon as possible and cont'd for ≥4 weeks after cardioversion unless contraindicated. ( C , I )
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MODIFIED: After cardioversion for AF of any duration, the decision about long-term anticoagulation therapy should be based on the thromboembolic risk profile and bleeding risk profile. ( C-EO , I )
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MODIFIED: For patients with AF2 or atrial flutter of <48 hours’ duration with a CHADS2-VASc score of ≥2 in men and ≥3 in women, administration of heparin, a factor Xa inhibitor, or a direct thrombin inhibitor is reasonable as soon as possible before cardioversion, followed by long-term anticoagulation therapy. ( B-NR , IIa )
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For patients with AF or atrial flutter of ≥48 hours duration or of unknown duration who have not been anticoagulated for the preceding 3 weeks, it is reasonable to perform TEE before cardioversion and proceed with cardioversion if no LA thrombus is identified, including in the LAA, provided that anticoagulation is achieved before TEE and maintained after cardioversion for ≥4 weeks. ( B , IIa )
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For patients with AF or atrial flutter of ≥48 hour duration or when duration of AF is unknown, anticoagulation with dabigatran, rivaroxaban, or apixaban is reasonable for ≥3 weeks before and 4 weeks after cardioversion. ( C , IIa )
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MODIFIED: For patients with AF2 or atrial flutter of less than 48 hours’ duration with a CHADS2-VASc score of 0 in men or 1 in women, administration of heparin, a factor Xa inhibitor, or a direct thrombin inhibitor, versus no anticoagulant therapy, may be considered before cardioversion, without the need for postcardioversion oral anticoagulation. ( B-NR , IIb )
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Direct-Current Cardioversion

In pursuing a rhythm-control strategy, cardioversion is recommended for patients with AF or atrial flutter as a method to restore sinus rhythm. If cardioversion is unsuccessful, repeated attempts at direct-current cardioversion may be made after adjusting the location of the electrodes, applying pressure over the electrodes or following administration of an antiarrhythmic medication. ( B , I )
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Cardioversion is recommended when a RVR to AF or atrial flutter does not respond promptly to pharmacological therapies and contributes to ongoing myocardial ischemia, hypotension, or HF. ( C , I )
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Cardioversion is recommended for patients with AF or atrial flutter and pre-excitation when tachycardia is associated with hemodynamic instability. ( C , I )
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It is reasonable to perform repeated cardioversions in patients with persistent AF, provided that sinus rhythm can be maintained for a clinically meaningful period between cardioversion procedures. Severity of AF symptoms and patient preference should be considered when embarking on a strategy requiring serial cardioversion procedures. ( C , IIa )
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Pharmacological Cardioversion

Flecainide, dofetilide, propafenone, and intravenous ibutilide are useful for pharmacological cardioversion of AF or atrial flutter, provided contraindications to the selected drug are absent. ( A , I )
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Administration of oral amiodarone is a reasonable option for pharmacological cardioversion of AF. ( A , IIa )
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Propafenone or flecainide (“pill-in-the-pocket”) in addition to a beta blocker or nondihydropyridine calcium channel antagonist is reasonable to terminate AF outside the hospital once this treatment has been observed to be safe in a monitored setting for selected patients. ( B , IIa )
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Dofetilide therapy should NOT be initiated out of hospital because of the risk of excessive QT prolongation that can cause torsades de pointes. ( B , III (harm) )
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Table 13. Antiarrhythmic Drugs to Maintain Sinus Rhythm

Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended. ( C , I )
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The following antiarrhythmic drugs are recommended in patients with AF to maintain sinus rhythm, depending on underlying heart disease and comorbidities:
  1. Amiodarone
  2. Dofetilide
  3. Dronedarone
  4. Flecainide
  5. Propafenone
  6. Sotalol
( A , I )
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The risks of the antiarrhythmic drug, including proarrhythmia, should be considered before initiating therapy with each drug. ( C , I )
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Because of its potential toxicities, amiodarone should only be used after consideration of risks and when other agents have failed or are contraindicated. ( C , I )
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A rhythm-control strategy with pharmacological therapy can be useful in patients with AF for the treatment of tachycardia-induced cardiomyopathy. ( C , IIa )
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It may be reasonable to continue current antiarrhythmic drug therapy in the setting of infrequent, well-tolerated recurrences of AF when the drug has reduced the frequency or symptoms of AF. ( C , IIb )
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including dronedarone. ( B , III (harm) )
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Dronedarone should NOT be used for treatment of AF in patients with NYHA class III and IV HF or patients who have had an episode of decompensated HF in the past 4 weeks. ( B , III (harm) )
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Table 14. Upstream Therapy

An ACE inhibitor or ARB is reasonable for primary prevention of new-onset AF in patients with HF with reduced LVEF. ( B , IIa )
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Therapy with an ACE inhibitor or ARB may be considered for primary prevention of new-onset AF in the setting of hypertension. ( B , IIb )
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Statin therapy may be reasonable for primary prevention of new-onset AF after coronary artery surgery. ( A , IIb )
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Therapy with an ACE inhibitor, ARB, or statin is NOT beneficial for primary prevention of AF in patients without cardiovascular disease. ( B , III (no benefit) )
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Table 16. AF Catheter Ablation to Maintain Sinus Rhythm

AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm-control strategy is desired. ( A , I )
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Before consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual patient is recommended. ( C , I )
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AF catheter ablation is reasonable for some patients with symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication. ( A , IIa )
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In patients with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm-control strategy before therapeutic trials of antiarrhythmic drug therapy, after weighing the risks and outcomes of drug and ablation therapy. ( B , IIa )
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AF catheter ablation may be considered for symptomatic long-standing (>12 months) persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm-control strategy is desired. ( B , IIb )
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NEW: AF catheter ablation may be reasonable in selected patients with symptomatic AF and HF with reduced left ventricular (LV) ejection fraction (HFrEF) to potentially lower mortality rate and reduce hospitalization for HF. ( B-R , IIb )
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AF catheter ablation may be considered before initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication for symptomatic persistent AF when a rhythm-control strategy is desired. ( C , IIb )
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AF catheter ablation should NOT be performed in patients who cannot be treated with anticoagulant therapy during and following the procedure. ( C , III (harm) )
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AF catheter ablation to restore sinus rhythm should NOT be performed with the sole intent of obviating the need for anticoagulation. ( C , III (harm) )
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Pacemakers and Implantable Cardioverter-Defibrillators in the Management of AF

  • The primary role of pacemakers in the treatment of patients with AF is to treat of symptomatic bradycardia. Permanent pacing is not indicated for the prevention of AF in patients without other indications for pacemaker implantation.

Athletes

  • Paroxysmal or persistent AF is common in athletes and may be autonomically mediated or triggered by other supraventricular tachycardias. Contributing conditions such as hypertension and CAD should be considered, particularly for older athletes, and a transthoracic echocardiogram is helpful to evaluate for structural heart disease. Evaluation of the rate of ventricular response during an episode of AF is warranted and may require ambulatory ECG monitoring and/or exercise testing to a level of exertion similar to that of the intended sport. Other therapies such as radiofrequency catheter ablation or a “pill-in-the-pocket” approach can be considered in athletes.

Elderly

  • It is critical to consider the implications of comorbidities to ensure that the patient’s overall goals of care are factored into management decisions.

Table 18. Surgical Maze Procedures

An AF surgical ablation procedure is reasonable for selected patients with AF undergoing cardiac surgery for other indications. ( C , IIa )
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A standalone AF surgical ablation procedure may be reasonable for selected patients with highly symptomatic AF not well managed with other approaches. ( B , IIb )
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Table 19. Hypertrophic Cardiomyopathy

Anticoagulation is indicated in patients with HCM with AF2 independent of the CHADS2-VASc score. ( B , I )
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Antiarrhythmic medications can be useful to prevent recurrent AF in patients with HCM. Amiodarone or disopyramide combined with a beta blocker or nondihydropyridine calcium channel antagonists are reasonable therapies. ( C , IIa )
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AF catheter ablation can be beneficial in patients with HCM in whom a rhythm-control strategy is desired when antiarrhythmic drugs fail or are not tolerated. ( B , IIa )
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Sotalol, dofetilide, and dronedarone may be considered for a rhythm-control strategy in patients with HCM. ( C , IIb )
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Table 20. AF Complicating ACS

MODIFIED: For patients with ACS and AF2 at increased risk of systemic thromboembolism (based on CHADS2-VASc risk score of ≥2), anticoagulation is recommended unless the bleeding risk exceeds the expected benefit. ( B-R , I )
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Urgent direct-current cardioversion of new-onset AF in the setting of ACS is recommended for patients with hemodynamic compromise, ongoing ischemia, or inadequate rate control. ( C , I )
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Intravenous beta blockers are recommended to slow a RVR to AF in patients with ACS who do not display HF, hemodynamic instability, or bronchospasm. ( C , I )
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NEW: If triple therapy (oral anticoagulant, aspirin, and P2Y12 inhibitor) is prescribed for patients with AF2 at increased risk of stroke (based on CHADS-VASc risk score of ≥2) who have undergone percutaneous coronary intervention (PCI) with stenting for 2ACS, it is reasonable to choose clopidogrel in preference to prasugrel. ( B-NR , IIa )
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NEW: In patients with AF2 at increased risk of stroke (based on CHADS-VASc risk score of ≥2) who have undergone PCI with stenting for 2ACS, double therapy with a P2Y12 inhibitor (clopidogrel or ticagrelor) and dose-adjusted vitamin K antagonist is reasonable to reduce the risk of bleeding as compared with triple therapy. ( B-NR , IIa )
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NEW: In patients with AF2 at increased risk of stroke (based on CHADS-VASc risk score of ≥2) who have undergone PCI with stenting for 2ACS, double therapy with P2Y12 inhibitors (clopidogrel) and low-dose rivaroxaban 15 mg daily is reasonable to reduce the risk of bleeding as compared with triple therapy. ( B-NR , IIa )
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NEW: In patients with AF2 at increased risk of stroke (based on CHADS-VASc risk score of ≥2) who have undergone PCI with stenting for 2ACS, double therapy with a P2Y12 inhibitor (clopidogrel) and dabigatran 150 mg twice daily is reasonable to reduce the risk of bleeding as compared with triple therapy. ( B-NR , IIa )
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NEW: If triple therapy (oral anticoagulant, aspirin, and P2Y12 inhibitor) is prescribed for patients with AF2 who are at increased risk of stroke (based on CHADS-VASc risk score of ≥2) and who have undergone PCI with stenting (drug eluting or bare metal) for 2ACS, a transition to double therapy (oral anticoagulant and P2Y12 inhibitor) at 4 to 6 weeks may be considered. ( B-NR , IIa )
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Administration of amiodarone or digoxin may be considered to slow a RVR in patients with ACS and AF associated with severe LV dysfunction and HF or hemodynamic instability. ( C , IIb )
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Administration of nondihydropyridine calcium antagonists might be considered to slow a RVR in patients with ACS and AF only in the absence of significant HF or hemodynamic instability. ( C , IIb )
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Table 21. Device Detection of AF and Atrial Flutter

In patients with cardiac implantable electronic devices (pacemakers or implanted cardioverter-defibrillators), the presence of recorded atrial high-rate episodes (AHREs) should prompt further evaluation to document clinically relevant AF to guide treatment decisions. ( B-NR , I )
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In patients with cryptogenic stroke (i.e., stroke of unknown cause) in whom external ambulatory monitoring is inconclusive, implantation of a cardiac monitor (loop recorder) is reasonable to optimize detection of silent AF. ( B-R , IIa )
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Table 22. Weight Loss in Patients with AF

NEW: For overweight and obese patients with AF, weight loss, combined with risk factor modification, is recommended. ( B-R , I )
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Table 23. Hyperthyroidism

Beta blockers are recommended to control ventricular rate in patients with AF complicating thyrotoxicosis unless contraindicated. ( C , I )
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In circumstances in which a beta blocker cannot be used, a nondihydropyridine calcium channel antagonist is recommended to control the ventricular rate. ( C , I )
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Table 24. Pulmonary Disease

A nondihydropyridine calcium channel antagonist is recommended to control the ventricular rate in patients with AF and chronic obstructive pulmonary disease. ( C , I )
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Direct-current cardioversion should be attempted in patients with pulmonary disease who become hemodynamically unstable as a consequence of new onset AF. ( C , I )
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Table 25. WPW and Pre-Excitation Syndromes

Prompt direct-current cardioversion is recommended for patients with AF, WPW, and RVR who are hemodynamically compromised. ( C , I )
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Intravenous procainamide or ibutilide to restore sinus rhythm or slow the ventricular rate is recommended for patients with pre-excited AF and RVR who are not hemodynamically compromised. ( C , I )
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Catheter ablation of the accessory pathway is recommended in symptomatic patients with pre-excited AF, especially if the accessory pathway has a short refractory period that allows rapid antegrade conduction. ( C , I )
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Administration of intravenous amiodarone, adenosine, digoxin (oral or intravenous), or nondihydropyridine calcium channel antagonists (oral or intravenous) in patients with WPW syndrome who have pre-excited AF is potentially harmful because these drugs accelerate the ventricular rate. ( B , III (harm) )
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Table 26. Heart Failure

Control of resting heart rate using either a beta blocker or a nondihydropyridine calcium channel antagonist is recommended for patients with persistent or permanent AF and compensated HFpEF. ( B , I )
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In the absence of pre-excitation, intravenous beta-blocker administration (or a nondihydropyridine calcium channel antagonist in patients with HFpEF) is recommended to slow the ventricular response to AF in the acute setting, with caution needed in patients with overt congestion, hypotension, or HF with reduced LVEF. ( B , I )
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In the absence of pre-excitation, intravenous digoxin or amiodarone is recommended to control heart rate acutely in patients with HF. ( B , I )
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Assessment of heart rate control during exercise and adjustment of pharmacological treatment to keep the rate in the physiological range is useful in symptomatic patients during activity. ( C , I )
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Digoxin is effective to control resting heart rate in patients with HF with reduced EF. ( C , I )
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A combination of digoxin and a beta blocker (or a nondihydropyridine calcium channel antagonist for patients with HFpEF) is reasonable to control resting and exercise heart rate in patients with AF. ( B , IIa )
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It is reasonable to perform AV node ablation with ventricular pacing to control heart rate when pharmacological therapy is insufficient or not tolerated. ( B , IIa )
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Intravenous amiodarone can be useful to control the heart rate in patients with AF when other measures are unsuccessful or contraindicated. ( C , IIa )
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For patients with AF and RVR causing or suspected of causing tachycardia-induced cardiomyopathy, it is reasonable to achieve rate control by either AV nodal blockade or a rhythm-control strategy. ( B , IIa )
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For patients with chronic HF who remain symptomatic from AF despite a rate-control strategy, it is reasonable to use a rhythm-control strategy. ( C , IIa )
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Oral amiodarone may be considered when resting and exercise heart rate cannot be adequately controlled using a beta blocker (or a nondihydropyridine calcium channel antagonist in patients with HFpEF) or digoxin, alone or in combination. ( C , IIb )
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AV node ablation may be considered when the rate cannot be controlled and tachycardia-mediated cardiomyopathy is suspected. ( C , IIb )
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AV node ablation should NOT be performed without a pharmacological trial to achieve ventricular rate control. ( C , III (harm) )
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For rate control, intravenous nondihydropyridine calcium channel antagonists, intravenous beta blockers, and dronedarone should NOT be administered to patients with decompensated HF. ( C , III (harm) )
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Table 27. Familial (Genetic) AF

For patients with AF and multigenerational family members with AF, referral to a tertiary care center for genetic counseling and testing may be considered. (C, IIb)
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Table 28. Postoperative Cardiac and Thoracic Surgery

Treating patients who develop AF after cardiac surgery with a beta blocker is recommended unless contraindicated. ( A , I )
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A nondihydropyridine calcium channel blocker is recommended when a beta blocker is inadequate to achieve rate control in patients with postoperative AF. ( B , I )
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Preoperative administration of amiodarone reduces the incidence of AF in patients undergoing cardiac surgery and is reasonable as prophylactic therapy for patients at high risk for postoperative AF. ( A , IIa )
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It is reasonable to restore sinus rhythm pharmacologically with ibutilide or direct-current cardioversion in patients who develop postoperative AF, as advised for nonsurgical patients. ( B , IIa )
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It is reasonable to administer antiarrhythmic medications in an attempt to maintain sinus rhythm in patients with recurrent or refractory postoperative AF, as advised for other patients who develop AF. ( B , IIa )
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It is reasonable to administer antithrombotic medication in patients who develop postoperative AF, as advised for nonsurgical patients. ( B , IIa )
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It is reasonable to manage well-tolerated, new-onset postoperative AF with rate control and anticoagulation with cardioversion if AF does not revert spontaneously to sinus rhythm during follow-up. ( C , IIa )
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Prophylactic administration of sotalol may be considered for patients at risk of developing AF following cardiac surgery. ( B , IIb )
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Administration of colchicine may be considered for patients postoperatively to reduce AF after cardiac surgery. ( B , IIb )
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Recommendation Grading

Overview

Title

Management of Patients With Atrial Fibrillation

Authoring Organizations

Endorsing Organization

Publication Month/Year

January 28, 2019

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Long term care

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D001281 - Atrial Fibrillation

Keywords

atrial fibrillation, anticoagulation, afib, Anticoagulation

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
70
Literature Search Start Date
August 1, 2016
Literature Search End Date
December 31, 2017
Specialties Involved
Cardiology, Emergency Medicine, Family Medicine, Geriatric Medicine, Internal Medicine General, Thoracic Surgery, Electrophysiology, Cardiology
Percentage of Authors Reporting COI
100