Decision support only — not a substitute for the ESC 2024 / CSANZ guidelines, eTG, or your cardiology team. Always look for a reversible trigger (sepsis, thyrotoxicosis, alcohol, PE, electrolytes). Anticoagulation is decided by stroke risk, not by whether AF is paroxysmal or persistent. Verify all doses.
1 AF-CARE — the framework for everything ongoing
CComorbiditynow listed first
Hypertension, HF, obesity, OSA, diabetes, alcohol.
Treat the substrate. Weight loss LEGACY · CARDIO-FIT, BP control, OSA, alcohol reduction — reduces AF recurrence and progression.
AAvoid strokeanticoagulation
CHA₂DS₂-VA drives the decision.
DOAC by stroke risk (see §3). Not by AF pattern. No aspirin for stroke prevention.
RReduce symptomsrate & rhythm
Most patients need a combination, re-evaluated over time.
Rate control + early rhythm control where appropriate EAST-AFNET 4. Ablation for suitable patients (see §4).
EEvaluationdynamic reassessment
AF and its risks change over time.
Re-score stroke risk periodically; reassess rate/rhythm strategy, symptoms, and comorbidities at every review.
ESC 2024 replaced the ABC pathway with AF-CARE and deliberately moved Comorbidity management to the front — the substrate, not the rhythm, increasingly drives outcomes. Applying AF-CARE is itself a Class I recommendation.
2 Acute first contact — the time-critical fork
When you meet the patient in AF, two questions come before everything else: are they stable, and can you cardiovert safely without an embolic risk?
Haemodynamically unstablethe only true emergency
Hypotension, ischaemia, pulmonary oedema, shock attributable to AF.
Emergency synchronised DCCV — don't wait for anticoagulation. Then anticoagulate.
Stable, onset <24hlow embolic risk window
Clear onset under 24h.
Rate control + wait-and-see for spontaneous conversion, or cardiovert. Anticoagulate around it.
Stable, ≥24h / uncertaincardiovert only if covered
Onset ≥24h or unknown.
Anticoagulate ≥3 weeks before cardioversion, or do a TOE to exclude atrial thrombus first.
Always after cardioversionregardless of score
Any cardioversion, electrical or chemical.
Anticoagulate ≥4 weeks afterwards — even if CHA₂DS₂-VA is 0 — then continue long-term by score.
ESC 2024 cut the early-cardioversion window from 48h to 24h and now advises a wait-and-see approach for spontaneous conversion. And always hunt the precipitant — treating sepsis, thyrotoxicosis or alcohol may resolve the AF without any rhythm intervention.
3 Avoid stroke — anticoagulation
Who, and with what
- ScoreCHA₂DS₂-VA (ESC 2024 dropped female sex): 0 → none; 1 → consider (IIa); ≥2 → anticoagulate (I).
- AgentDOAC over warfarin RE-LY · ROCKET-AF · ARISTOTLE · ENGAGE-AF.
- WarfarinOnly for mechanical valve or moderate–severe mitral stenosis.
- Always OACHCM or cardiac amyloidosis — anticoagulate irrespective of score.
The common errors
- AspirinNo role in AF stroke prevention — don't use it as a "safer" substitute.
- HAS-BLEDUse it to identify and modify reversible bleeding risk, not to withhold anticoagulation.
- AF patternDon't use paroxysmal-vs-persistent to decide on OAC — risk is by score.
- ReversalMajor bleed: idarucizumab (dabigatran), andexanet/PCC (factor Xa), PCC + vit K (warfarin).
DOAC dosing & reduction criteria
- Apixaban5 mg bd → 2.5 mg bd if ≥2 of: age ≥80, weight ≤60 kg, creatinine ≥133 µmol/L.
- Rivaroxaban20 mg od with food → 15 mg od if CrCl 15–49 mL/min.
- Dabigatran150 mg bd → 110 mg bd if age ≥80, higher bleeding risk, or verapamil co-therapy.
- Edoxaban60 mg od → 30 mg od if CrCl 15–50 mL/min, weight ≤60 kg, or a potent P-gp inhibitor.
- WarfarinTarget INR 2.0–3.0 — only for a mechanical valve or moderate–severe mitral stenosis.
4 Reduce symptoms — rate & rhythm
Rate control — doses
- Acute IVMetoprolol 2.5–5 mg IV over 2 min, repeat to ~15 mg; or verapamil 2.5–5 mg IV (EF >40% only).
- OralMetoprolol 25–100 mg bd, bisoprolol 2.5–10 mg od, or diltiazem/verapamil SR 180–360 mg/day.
- DigoxinLoad 250–500 mcg IV/PO (max ~1.5 mg/24h), maintenance 62.5–250 mcg/day — EF <40%, sedentary, or add-on.
- Amiodarone300 mg IV over 20–60 min then 900 mg/24h — critically ill / severe LV dysfunction only.
- TargetLenient <110 bpm resting if asymptomatic RACE II. Avoid non-DHP CCB in HFrEF.
Rhythm control — doses
- Chemical CVFlecainide 2 mg/kg IV over 10 min (max 150 mg) — no structural/IHD; or amiodarone 300 mg IV over 20–60 min then 900 mg/24h.
- Pill-in-pocketFlecainide 200–300 mg PO single dose — selected patients, with an AV-nodal blocker, first dose supervised.
- ElectricalSynchronised DCCV (~150–200 J biphasic).
- MaintainFlecainide/sotalol (structurally normal heart) or amiodarone; early rhythm control improves prognosis EAST-AFNET 4.
- AblationFirst-line for suitable paroxysmal AF CABANA; prognostic benefit in AF + HFrEF CASTLE-AF.
5 Comorbidity, triggers & the whole patient
Modify the substrate (the C-first shift)
- WeightStructured weight loss reduces AF burden & recurrence LEGACY · CARDIO-FIT.
- OSAScreen and treat — untreated OSA undermines rhythm control.
- BP / alcoholTreat hypertension; reduce alcohol (a dose-dependent trigger).
- ActivityModerate exercise; manage diabetes and other cardiometabolic risk.
Don't forget
- TriggersSepsis, thyrotoxicosis, PE, electrolytes, alcohol — treat the cause; the AF may settle without rhythm intervention.
- CHA₂DS₂-VANote the score changed from VASc (sex removed, 2024) — some Australian local tools still use VASc; check which you're applying.
- ReassessRe-score stroke risk and review strategy over time — risk is dynamic.
- LAALeft atrial appendage occlusion for those with a genuine long-term OAC contraindication.
Sources.
ESC/EACTS 2024 Guidelines for the management of atrial fibrillation (Eur Heart J 2024 — AF-CARE framework, CHA₂DS₂-VA, 24h cardioversion window, rhythm-control upgrade). CSANZ/NHFA Australian clinical guidelines for AF (+ 2022 catheter-ablation update). eTG for Australian anticoagulant/antiarrhythmic selection.
Key trials: RE-LY, ROCKET-AF, ARISTOTLE, ENGAGE-AF (DOACs vs warfarin); EAST-AFNET 4 (early rhythm control); CABANA & CASTLE-AF (catheter ablation; HFrEF); RACE II (lenient rate control); AFFIRM (rate vs rhythm); LEGACY & CARDIO-FIT (weight loss).
Caveats: CHA₂DS₂-VA (ESC 2024) differs from the CHA₂DS₂-VASc still embedded in some Australian tools — confirm which you're using. Cardioversion anticoagulation rules assume no atrial thrombus; TOE if uncertain. Antiarrhythmic and anticoagulant choice is patient- and renal-specific — verify against eTG/product information. Companion to the cardiac set (ACS, HFrEF).