The American College of Cardiology and the American Heart Association, the two largest organizations dedicated to the prevention and treatment of heart disease, have jointly published guidelines for just that: the prevention and treatment of Atrial Fibrillation. Atrial Fibrillation, a “chaotic, irregular atrial (upper heart chambers) rhythm” caused by multiple overexcitable veins in the pulmonary arteries of the left atrium. It is the most frequent arrhythmia Americans experience. Most patients are unaware they have it until they are examined by a doctor or have an EKG. Others are very aware of it and are significantly symptomatic with fatigue, weakness, palpitations, or chest pain.
The published guidelines are shared below:
EVALUATION: Electrocardiogram (EKG/ECG) captures the arrhythmia for confirmation of
diagnosis.
Echocardiogram (heart ultrasound through the chest wall) evaluates heart chamber size and
activity, heart valve functional status, presence of blood clots adherent to the
chamber walls, and pumping function of the heart.
Physical Examination—A good, old-fashioned exam of the heart and lungs by the doctor
with his stethoscope. A novel idea!
RISK REDUCTION: Significant risks for atrial fibrillation are:
Obesity
Sedentary lifestyle, ie. Lack of exercise
Smoking
Alcohol consumption
Caffeine
Hypertension (High Blood Pressure)—the most important risk factor for AF
Sleep disordered breathing, ie. Sleep Apnea
These risk factors demand attention and major effort to correct.
STROKE AND ATRIAL FIBRILLATION: A Fib patients are highly susceptible to stroke. At
least 25% of strokes occurring in atrial fibrillation happen before A Fib is diagnosed and are
called “cryptogenic,” of unknown origin. A Fib is found later.
Drug Therapy for Stroke Prevention: Anticoagulation (blood thinning) prevents stroke. In A
Fib, blood pools in a pocket in the left atrium (the left atrial appendage) and coagulates.
Clots then break loose and flow to the brain causing a stroke.
Warfarin (Coumadin): For A Fib patients with mitral valve problems or mechanical heart
valves, or who don’t tolerate DOAC’s, warfarin is recommended
Direct-Acting Oral Anticoagulants (DOAC’s): Eliquis, Pradaxa, Xarelto have the same
indications and have lower bleeding risk—not in my experience.
Miscellaneous Information:
Atrial Flutter increases stroke risk. Anticoagulation is recommended
After catheter ablation for Atrial Flutter, Anticoagulation is recommended
Atrial high-rate episodes increase stroke risk. Anticoagulation is recommended.
4% of patients taking oral anticoagulants have bleeding episodes.
Surgical Stroke Prevention: Clots form in the left atrial appendage, a pocket in the tip of
the left atrium.
The Watchman Procedure: A small umbrella-like filter is placed in the appendage to prevent
blood from collecting and clotting in the pocket. Successful placement eliminates the
need for oral anticoagulants.
Excision of left atrial appendage at the time of open-heart surgery
RHYTHM CONTROL: Atrial Fibrillation can be very symptomatic for some patients. Converting
the heart back to a normal sinus rhythm alleviates these symptoms. Normalization of rhythm
is accomplished by:
Cardioversion: Electrical stimulation of the heart under sedation synchronized with the
rhythm shocking the heart back into normal rhythm. A Transesophageal Echocardiogram
is done first to rule out clots in the left atrial appendage.
Drug Therapy: Multiple drugs are used, each with a special niche. Each is hoped to convert
Atrial Fib back to a normal rhythm.
Amiodarone
Flecainide
Propafenone
Dofetilide
Sotalol
Ablation: A complex procedure involving mapping of the electrical pathways of the inner
surface of the atria and radiofrequency burning of sites identified as initiating A Fib or A
Flutter. Effective 60% of the time. Repeat procedure often needed.
HEART RATE CONTROL: Slowing heart rate lessens bothersome symptoms, and occasionally
restores normal rhythm. Drugs prescribed are:
Beta Blockers: Metoprolol, carvedilol, atenolol, propranolol, sotalol
Calcium Channel Blockers: Diltiazem, Verapamil
Digitalis: Digoxin, Crystodigin—prescribed rarely today
Dr. G’s Opinion: There you have it! Everything you need to know about Atrial Fibrillation. I first experienced AF over 20 years ago. It decreased in frequency and severity soon after I retired at the end of 2013. I still have brief (1-10 hours) episodes every 3-4 months, but they are tolerable. Playing golf in atrial fibrillation is not a wise decision. I know when I’m in A Fib because my chest feels different. Drugs I was prescribed caused very bothersome thyroiditis (Amiodarone), and later, ventricular tachycardia (Flecainide). That was a very bad day.
For years, the treatment of AFib was pharmacologic with emphasis on rate and rhythm control. Unfortunately, drug therapy was largely ineffective. Anticoagulation was not used until a lot of patients suffered a devastating stroke. Then, a San Francisco electrophysiologist invented the complex procedure called radiofrequency ablation, which has become the standard of care for atrial fibrillation. Ablations are done often now and successful cessation of atrial flutter and fibrillation have been improving steadily. Today, ablations are safe and done with impunity. They aren’t 100% effective, yet, but technology is advancing rapidly. Ablation has improved the quality of life of millions of patients who had a bothersome arrhythmia. It can only get better.
Reference: Arnold MJ. Management of Atrial Fibrillation: Guidelines From the American College of Cardiology and the American Heart Association Am Fam Phys 2025 August;111(2):183-185.
