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Clinical Review

Management of atrial fibrillation

BMJ 2009; 339 doi: (Published 23 December 2009) Cite this as: BMJ 2009;339:b5216
  1. Carmelo Lafuente-Lafuente, consultant, internal medicine1,
  2. Isabelle Mahé, professor of therapeutics2,
  3. Fabrice Extramiana, associate professor of cardiology3
  1. 1Service de Médecine A, Hôpital Lariboisière, Université Paris 7, Paris
  2. 2Service de Médecine Interne 5, Hôpital Louis Mourier, Université Paris 7, Paris
  3. 3Service de Cardiologie, Hôpital Lariboisière, Université Paris 7, Paris
  1. Correspondence to: Dr C Lafuente-Lafuente, Service de Médecine A, Clinique Thérapeutique, Hôpital Lariboisière, Assistance Publique—Hôpitaux de Paris, Université Paris 7 Diderot, 2, rue Ambroise Paré, 75010 Paris, France c.lafuente{at}

    Summary points

    • Atrial fibrillation is common and highly variable in its clinical presentation and evolution; it causes substantial morbidity and mortality, including impaired quality of life, heart failure, systemic emboli, and stroke

    • The first priority is to control heart rate (if tachycardia is present) and provide adequate antithrombotic treatment for preventing complications of embolism

    • Patients with moderate to high risk of stroke require warfarin long term for preventing emboli; aspirin is adequate in patients with low risk of stroke

    • When a patient should but cannot take warfarin, aspirin plus clopidogrel can be an intermediate option

    • For long term treatment of atrial fibrillation, rate control matches rhythm control in terms of mortality and major cardiovascular events but has fewer adverse events related to the treatment and fewer hospital admissions

    • Consider referring for rhythm control younger patients with lone atrial fibrillation, patients with symptomatic atrial fibrillation, and patients with atrial fibrillation secondary to a corrected precipitant

    • If antiarrhythmic drugs fail to maintain sinus rhythm, percutaneous catheter ablation is an alternative for rhythm control

    Atrial fibrillation is the commonest sustained arrhythmia encountered in clinical practice. Its prevalence increases with age, rising from 0.7% in people aged 55-59 years to 18% in those older than 85 years.1 Consequently, the public health burden associated with atrial fibrillation is increasing.w1 The therapeutics of atrial fibrillation is evolving. In recent years, publication of several randomised controlled trials and meta-analyses have improved our understanding of the advantages and inconveniences of rate and rhythm control strategies, and effective, new non-pharmacological treatments have been introduced. New antiarrhythmic and anticoagulant drugs are expected in the near future.

    Clinical manifestations of atrial fibrillation: what is important to know?

    Atrial fibrillation is characterised by a chaotic electrical activity in the atria that induces an irregular and usually rapid contraction of the ventricles (figure 1). Patients may be asymptomatic; may have mild symptoms, …

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