My 3-Stage approach to treating AF
The principles of AF management focus on the key factors for the patient - preventing complications and long-term problems, and treating important symptoms.
1. Prevent Strokes
Our first priority is to prevent strokes that may arise if the individual is at higher risk, and this is done by anticoagulation either by warfarin or by one of the newer NOAC anticoagulants. Nowadays almost all my patients prefer being on a NOAC, and I recommend changing from Warfarin to NOAC unless there is a specific reason not to. Aspirin does not in fact have benefits above the side-effect risks in preventing strokes in AF and can be avoided.
2. Control the heart rate when AF is ongoing
Our second priority is controlling the rate that the heart is in during AF. This is often best done with a betablocker or calcium channel blocker. Digoxin can also be useful, particularly in combination with either one of the other medications.
3. Establish normal heart rhythm
In many patients, just controlling the heart rate and preventing strokes is enough for long-term management of patients. However, in many patients establishing normal heart rhythm early does prevent long-term problems arising from AF, and with the safety of ablation this tends to be my go-to choice for "rhythm control".
But control of the heart rhythm to prevent AF from happening can be provided either by drugs or by catheter ablation. There is increasing evidence that maintenance of sinus rhythm, which is best done by ablation, has benefits for both quality of life and in reducing heart failure. In my own practice, I have been definitely moving ablation up the list and am keen to ablate early if possible (i.e. offer definitive treatment quickly).