The main goals of treatment are to prevent circulatory instability and stroke. Rate or rhythm control is used to achieve the former, whereas anticoagulation is used to decrease the risk of the latter. If cardiovascularly unstable due to uncontrolled tachycardia, immediate cardioversion is indicated. Many antiarrhythmics, when used long term, increase the risk of death without any meaningful benefit. An integrated management approach, which includes stroke prevention, symptoms control and management of associated comorbidities was associated with better outcomes in patients with<unk> . Lifestyle modification Regular aerobic exercise improves<unk>  symptoms and<unk> -related quality of life. The effect of high-intensity interval training on reducing<unk>  burden is unclear. Weight loss of at least 10% is associated with reduced<unk>  burden in people who are overweight or obese. Comorbidity treatment For people who have both<unk>  and obstructive sleep apnea, observational studies suggest that continuous positive airway pressure (CPAP) treatment appears to lower the risk of<unk>  recurrence<unk> ter undergoing ablation. Randomized controlled trials examining the role of obstructive sleep apnea treatment on<unk>  incidence and burden are lacking. Guideline-recommended lifestyle and medical interventions are recommended for people with<unk>  and coexisting conditions such as hyperlipidemia, diabetes mellitus, or hypertension without specific blood sugar or blood pressure targets for people with<unk> . Bariatric surgery may reduce the risk of new-onset<unk>  in people with obesity without<unk>  and may reduce the risk of a recurrence of<unk> <unk> ter an ablation procedure in people with coexisting obesity and<unk> . It is important for all people with<unk>  to optimize the control of all coexisting medical conditions that can worsen their<unk> , such as hyperthyroidism, diabetes, congestive heart<unk> ilure, high blood pressure, chronic obstructive pulmonary disease, stimulant use (e.g., methamphetamine dependence), and excessive alcohol consumption. Anticoagulants Anticoagulation can be used to reduce the risk of stroke from<unk> . Anticoagulation is recommended in most people other than those at low risk of stroke or those at high risk of bleeding. The risk of<unk> lls and consequent bleeding in frail elderly people should not be considered a barrier to initiating or continuing anticoagulation since the risk of<unk> ll-related brain bleeding is low and the benefit of stroke prevention often outweighs the risk of bleeding. Similarly, the presence or absence of<unk>  symptoms does not determine whether a person warrants anticoagulation and is not an indicator of stroke risk. Oral anticoagulation is underused in<unk> , while aspirin is overused in many who should be treated with a direct oral anticoagulant (DOAC) or warfarin. In 2019, DOACs were often recommended over warfarin by the American Heart Association. The risk of stroke from non-valvular<unk>  can be estimated using the CHA2DS2-VASc score. In the 2019 AHA/ACC/HRS guidelines anticoagulation is recommended in non-valvular<unk>  if there is a score of two or more in men and three or more in women and may be considered if there is a score of one in men or two in women; not using anticoagulation is reasonable if there is a score of zero in men or one in women. Guidelines from the American College of Chest Physicians, Asia-Pacific Heart Rhythm Society, Canadian Cardiovascular Society, European Society of Cardiology, Japanese Circulation Society, Korean Heart Rhythm Society, and the National Institute for Health and Care Excellence recommend the use of novel oral anticoagulants or warfarin with a CHA2DS2-VASc score of one over aspirin and some directly recommend against aspirin. Experts generally advocate for most people with<unk>  with CHA2DS2-VASc scores of one or more receiving anticoagulation though aspirin is sometimes used for people with a score of one (moderate risk for stroke). There is little evidence to support the idea that the use of aspirin significantly reduces the risk of stroke in people with<unk> . Furthermore, aspirin's major bleeding risk (including bleeding in the brain) is similar to that of warfarin and DOACs despite its inferior efficacy. Anticoagulation can be achieved through several means including warfarin, heparin, dabigatran, rivaroxaban, edoxaban, and apixaban. Many issues should be considered related to their comparative effectiveness, including the cost of DOACs, risk of stroke, risk of<unk> lls, comorbidities (such as chronic liver or kidney disease), the presence of significant mitral stenosis or mechanical heart valves, compliance, and speed of the desired onset of anticoagulation. The optimal approach to anticoagulation in people with<unk>  and who simultaneously have other diseases (e.g., cirrhosis and end-stage kidney disease on dialysis) that predispose a person to both bleeding and clotting complications is unclear. For those with non-valvular<unk> , DOACs are at least as effective as warfarin for preventing strokes and blood clots embolizing to the systemic circulation (if not more so) and are generally preferred over warfarin. DOACs carry a lower risk of bleeding in the brain compared to warfarin, although dabigatran is associated with a higher risk of intestinal bleeding. Dual antiplatelet therapy with aspirin and clopidogrel is inferior to warfarin for preventing strokes and has comparable bleeding risk in people with<unk> . In those who are also on aspirin, however, DOACs appear to be better than warfarin. Warfarin is the recommended anticoagulant choice for persons with valvular<unk> <unk>  in the presence of a mechanical heart valve and/or moderate-severe mitral valve stenosis). The exception to this recommendation is in people with valvular<unk>  who are unable to maintain a therapeutic INR on warfarin therapy; in such cases, treatment with a DOAC is then recommended. Rate versus rhythm control There are two ways to approach<unk>  using medications: rate control and rhythm control. Both methods have similar outcomes. Rate control lowers the heart rate closer to normal, usually 60 to 100 bpm, without trying to convert to a regular rhythm. Rhythm control tries to restore a normal heart rhythm in a process called cardioversion and maintains the normal rhythm with medications. Studies suggest that rhythm control is more important in the acute setting<unk> , whereas rate control is more important in the chronic phase. The risk of stroke appears to be lower with rate control versus attempted rhythm control, at least in those with heart<unk> ilure.<unk>  is associated with a reduced quality of life, and, while some studies indicate that rhythm control leads to a higher quality of life, some did not find a difference. Neither rate nor rhythm control is superior in people with heart<unk> ilure when they are compared in various clinical trials. However, rate control is recommended as the first-line treatment regimen for people with heart<unk> ilure. On the other hand, rhythm control is only recommended when people experience persistent symptoms despite adequate rate control therapy. In those with a<unk> st ventricular response, intravenous magnesium significantly increases the chances of achieving successful rate and rhythm control in the urgent setting without major side-effects. A person with poor vital signs, mental status changes, preexcitation, or chest pain often will go to immediate treatment with synchronized DC cardioversion. Otherwise, the decision of rate control versus rhythm control using medications is made. This is based on several criteria that include whether or not symptoms persist with rate control. Rate control Rate control to a target heart rate of fewer than 110 beats per minute is recommended in most people. Lower heart rates may be recommended in those with left ventricular hypertrophy or reduced left ventricular function. Rate control is achieved with medications that work by increasing the degree of the block at the level of the AV node, decreasing the number of impulses that conduct into the ventricles. This can be done with: * Beta blockers (preferably the "cardioselective" beta blockers such as metoprolol, bisoprolol, or nebivolol) * Non-dihydropyridine calcium channel blockers (e.g., diltiazem or verapamil) * Cardiac glycosides (e.g., digoxin) – have less use, apart from in older people who are sedentary. They are not as effective as either beta-blockers or calcium channel blockers. Patients with chronic<unk>  are recommended to take either beta blockers or calcium channel blockers. In addition to these agents, amiodarone has some AV node blocking effects (in particular when administered intravenously) and can be used in individuals when other agents are contraindicated or ineffective (particularly due to hypotension). Cardioversion Cardioversion is the attempt to switch an irregular heartbeat to a normal heartbeat using electrical or chemical means. * Electrical cardioversion involves the restoration of normal heart rhythm through the application of a DC electrical shock. The exact placement of the pads does not appear to be important. * Chemical cardioversion is performed with medications, such as amiodarone, dronedarone, procainamide (especially in pre-excited<unk> , dofetilide, ibutilide, propafenone, or flecainide.<unk> ter successful cardioversion, the heart may be stunned, which means that there is a normal rhythm, but the restoration of normal atrial contraction has not yet occurred. Surgery Ablation Catheter ablation (CA) is a procedure performed by an electrophysiologist, a cardiologist who specializes in heart rhythm problems, to restore the heart's normal rhythm by destroying, or electrically isolating, specific parts of the atria.
Atrial fibrillation
Arrhythmia
Atrial flutter
Sinus arrhythmia
Ventricular flutter
Supraventricular tachycardia
Torsades de pointes
Atrial tachycardia