Atrial fibrillation: How best to use rate control, rhythm control, cardioversion, anticoagulation

Rate control is often the first priority in the treatment of atrial fibrillation. Calcium channel blockers and β-blockers are usually more effective than digoxin for achieving ventricular rate control but may have adverse effects, including decreased cardiac output and lowered blood pressure. Rhythm control is appropriate for many patients, particularly those who remain symptomatic or hemodynamically unstable despite adequate rate control. Radiofrequency ablation of the atrioventricular node requires a permanent pacemaker. Either pharmacologic or electrical cardioversion can restore sinus rhythm (SR); potential risks include embolization, proarrhythmia, and complications related to anesthesia. Antiarrhythmic drugs can help maintain SR after cardioversion but may cause proarrhythmia. New therapies to maintain SR include surgery, radiofrequency ablation, pacemakers, and implantable defibrillators. Warfarin helps reduce the danger of stroke. Stratify patients according to risk to determine the most effective and safest antithrombotic regimen.