Approaching the Management of Atrial Fibrillation

Deepak L. Bhatt, MD, MPH, FACC, FAHA, FSCAI, FESC: There are a lot of considerations in managing patients with atrial fibrillation. We want to think about rate control vs rhythm control. A lot of randomized clinical trial data can help guide us. It’s interesting, the newer data are a bit stronger for rhythm control than older data that suggested rate control is as good as rhythm control. But now that we’re getting better with rhythm control, safer antiarrhythmics than some of the older ones, better knowledge of how to use them and what doses are better, that has enhanced the ability to deliver rhythm control. In particular, atrial fibrillation ablation—that is, procedural ablation—has gotten a lot better and safer. In carefully selected patients, there’s a role for everything. For some patients, it may be reasonable just to control their rate. If they’re asymptomatic and happy, leave them alone. For patients who continue to have symptoms despite rate control, or if their rate control at rest is sufficient but rate control with exercise isn’t, more rate control could help. Rhythm control might also be useful in that. Rhythm control might be antiarrhythmic medications, procedural care, procedural care if antiarrhythmic medications fail. There are a lot of options.

It’s important to know that with antiarrhythmic drugs, some are better in patients with heart failure, but some are much worse in patients with heart failure. For many drug interactions, you might want to consult a cardiac electrophysiologist or pharmacist if you’re getting into polypharmacy with a number of the atrial fibrillation drugs. Nonetheless, there are a lot of options these days in not only rate control but also potentially rhythm control.

The other important thing to consider beyond that aspect is anticoagulation, because the biggest risk from atrial fibrillation is stroke. It’s very important that the majority of these patients get anticoagulated. Look at things like the CHA2DS2-VASc score. You can use that. There are online calculators. Many electronic health records incorporate automatic calculation of the CHA2DS2-VASc. In patients with very low scores, perhaps anticoagulation can be avoided. But the vast majority of patients with atrial fibrillation should get anticoagulated. It’s not just if they have sustained atrial fibrillation. Even patients with intermittent or paroxysmal atrial fibrillation, barring contraindications, should be anticoagulated.

Contraindications get tricky. We used to say, “If the patient falls a lot, don’t anticoagulate them.” But studies have shown the patient needs to fall many times before the benefits of anticoagulation are outweighed by those risks. Other than the most frail patient, one who’s had previous head trauma with bleeds into their brain, the majority of patients—even older ones—should be anticoagulated. In fact, it’s that older patient who’s at risk for thromboembolic stroke that could be disabling or fatal. There is vast underutilization of anticoagulation. We want to be much more thorough in identifying patients who could benefit from anticoagulation if they got atrial fibrillation.

The agents of choice are clearly DOACs [direct oral anticoagulants] or NOACs [novel oral anticoagulants], the non–vitamin K oral anticoagulants. I guess they’re not novel anymore. In fact, the majority of prescriptions for new cases of atrial fibrillation worldwide, not just the United States, are NOACs. That’s because they reduce intracranial hemorrhage risk vs even good warfarin use. Even when the INR [international normalized ratio] is well controlled, the NOACs beat warfarin for intracranial hemorrhage and are at least as efficacious. They’re safer, at least as efficacious, and easier to use than warfarin, without any need for routine monitoring. That’s the standard of care worldwide. There are some exceptions. If patients have mechanical heart valves, we still would use warfarin. There’s some debate that if they’ve got antiphospholipid antibodies or are in hypercoagulable states, warfarin might be better. There are still subgroups where warfarin has a role if they also have atrial fibrillation. But most atrial fibrillation patients need to be anticoagulated. Most atrial fibrillation patients should be receiving a NOAC.

Make sure to check the label and dose appropriately. Don’t underdose. A number of NOACs have lower-dosing regimens. Don’t use them unless the label supports the lower dosing. Be cognizant of the kidney function, in particular, and in some cases the weight, depending on the NOAC. Kidney function can fluctuate, especially in older patients who might necessitate a change in the NOAC-dosing regimen depending on the NOAC. Check the label of whatever NOAC you’re using, dose appropriately, and depending on the particular NOAC, factor in kidney function for sure and in some cases age and weight. If there are any questions beyond the label, ask your pharmacist. This is a place where dosing error, underdosing and accidental overdosing, can occur. Be vigilant for those possibilities, and try to avoid them.

Transcript Edited for Clarity