Atrial Fibrillation (AF) — Treatment, Medications, and Management (2026)
- AF affects 1.4 million people in the UK and is the most common cardiac arrhythmia
- Stroke risk is 5× higher in AF — anticoagulation is the most important treatment decision
- Direct oral anticoagulants (DOACs) are safer than warfarin for most AF patients
- Catheter ablation achieves rhythm control in 60–80% of paroxysmal AF patients
- SGLT2 inhibitors and GLP-1 drugs both reduce AF recurrence in clinical trials
What Is Atrial Fibrillation?
Atrial fibrillation (AF) is a rapid, chaotic electrical rhythm in the atria (upper chambers of the heart) causing irregular, often fast heartbeats. The atria quiver rather than contract effectively — reducing cardiac output and, critically, allowing blood to pool and form clots in the left atrial appendage. These clots can travel to the brain, causing stroke.
The Three Pillars of AF Management
1. Anticoagulation — Stroke Prevention (Most Important)
Anticoagulation is typically the most important treatment decision in AF. The CHA₂DS₂-VASc score calculates stroke risk — most AF patients score ≥2 and should be on anticoagulation indefinitely.
| Drug | Type | Monitoring | Preferred For |
|---|---|---|---|
| Apixaban (Eliquis) | DOAC — twice daily | None required | Most AF patients — best safety profile |
| Rivaroxaban (Xarelto) | DOAC — once daily | None required | AF + VTE; once-daily convenience |
| Edoxaban (Lixiana) | DOAC — once daily | None required | AF anticoagulation |
| Warfarin | VKA — variable dosing | Regular INR tests | Mechanical heart valves, CKD eGFR <15 |
2. Rate Control
Slow the ventricular rate to improve cardiac function and symptoms. Target: heart rate below 110 bpm at rest (lenient) or below 80 bpm (strict — for symptomatic patients). Drugs used: beta-blockers (bisoprolol, metoprolol — first-line), calcium channel blockers (diltiazem, verapamil — if beta-blockers contraindicated), or digoxin (when exercise rate control not needed).
3. Rhythm Control
Restore and maintain sinus rhythm. Options: cardioversion (electrical shock), antiarrhythmic drugs (flecainide, amiodarone), or catheter ablation. The EAST-AFNET 4 trial showed early rhythm control reduces cardiovascular events — rhythm control is now pursued more aggressively early in AF diagnosis.
Catheter Ablation — The Growing Role
Radiofrequency or cryoablation of pulmonary vein triggers. Success rates: 60–80% for paroxysmal AF (single procedure); 50–60% for persistent AF. CABANA trial showed ablation superior to drug therapy for quality of life and some outcomes. Now recommended earlier in guidelines for symptomatic AF.