Last Updated on August 19, 2026
Classification / Types
Haemodynamically stable AF
Haemodynamically unstable AF
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Fast AF
Rate controlled AF
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First detected AF
Paroxysmal AF
Persistent AF
Permanent AF
Causes
Cardiovascular causes | Non-cardiac causes |
• Hypertension | • Electrolyte imbalance: hypokalaemia, hypomagnesaemia Pulmonary embolism |
Presentation
Symptomatic
• Palpitations, SOB on exertion
Asymptomatic
• Identified from features in cardiac monitor / ECG
Investigations
ECG
• Rate: can be >150 bpm
• Rhythm: Irregularly irregular
• P wave: absent
• QRS complex: narrow
Echocardiogram
• TRO valvular heart disease
Management
Initial management
Haemodynamic unstable
Features of unstable atrial fibrillation Abbreviation: SBP • Systolic blood pressure • Spontaneous bacterial peritonitis
• Hypotension (
SBP
• Acutely altered mental status
• Cardiac ischaemia / Ischaemic chest discomfort
• Severely due to the irregularly irregular cardiac rhythm
Management
• Proceed with synchronised cardioversion
• If synchronised cardioversion is successful, provide PO amiodarone
• If synchronised cardioversion is unsuccessful, provide IV amiodarone
Haemodynamic stable
Normal left ventricular function (no underlying
CCF
Abbreviation: CCF Congestive cardiac failure • Start anticoagulation if atrial fibrillation is persistent for ≥48 hours or if cardioversion is contemplated Abbreviation: CCF Congestive cardiac failure
• Onset <48 hours: rate control / rhythm control
• Persistent ≥48 hours or uncertain: rate control +
anticoagulation
• Duration of therapeutic anticoagulation is minimum 3 weeks
Reduced left ventricular function (underlying
CCF
• Rhythm control
• Cardioversion
• Anticoagulation
Rate control
- First line treatment strategy
- Medications
- Beta-blockers
- Exception: Sotalol is a class III anti-arrhythmic drug; for rhythm control rather than rate control
- Beware of the contraindications
- Non-dihydropyridine calcium-channel blockers
- Avoid non-dihydropyridine CCB if patient has underlying heart failure, as it has negative inotropic effect
-
Digoxin
×
• Digoxin monotherapy is no longer considered first-line for rate control, as it is less effective during exercise
• May be preferred in patients with heart failure and a sedentary lifestyle
- Beta-blockers
Rhythm control
- Amiodarone
- Especially if patient has underlying heart failure
- Beta blocker e.g. sotalol
Anticoagulation
Indication Valvular heart disease + atrial fibrillation = absolute indication for anticoagulation • Abbreviation of Novel oral anticoagulants
• Presence of
valvular heart disease
• Based on CHA2DS2VASc score
Options
• Warfarin
•
NOAC
• Benefit: does not require regular INR monitoring
• 1st line of anticoagulation for atrial fibrillation, but limited due to quota/ cost
Medications for pharmacotherapy (rate / rhythm control) in emergency
- IV Digoxin 0.25 – 0.50 mg in 100 mL normal saline over 1 hour
- IV Verapamil 2.5 – 5 mg slow bolus
- IV Amiodarone 150 – 300 mg in 50 mL D5% over 30 minutes
- IV Esmolol 0.5 mg/kg
Related Scoring
- CHA2DS2-VASc score to assess the need for anticoagulation
- ORBIT score to assess bleeding risk
- Previously, HAS-BLED score to assess bleeding risk
Q&A
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Take Home Message
1. The first step in managing atrial fibrillation is to identify haemodynamic stability
2. Search and treat identifiable underlying causes