In this episode of IM Basics, Dr. Eric Acker is joined by Dr. Harmandip Parmar for a deep dive into atrial fibrillation (AFib)—the most common sustained arrhythmia worldwide. They explore AFib’s definitions, staging, risk factors, clinical presentation, diagnostic strategies, and evidence-based management, with a focus on the latest 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial FibrillationAfib【ACC/AHA 2023 Guidelines†DOI:10.1161/CIR.0000000000001193】.

Key Topics Covered

• AFib staging and progression: The episode reviews the updated classification from the ACC/AHA guidelines, beginning with “at risk” and “pre-AFib” states (associated with modifiable risk factors such as obesity, hypertension, diabetes, and sleep apnea) through paroxysmal, persistent, longstanding, and permanent AFib.
• Clinical presentation & workup: While many patients present with palpitations, dyspnea, or fatigue, others are asymptomatic and diagnosed incidentally. Recommended evaluation includes ECG confirmation, transthoracic echocardiography, thyroid and metabolic panels, and exclusion of reversible causes (e.g., hyperthyroidism, acute illness). Not all patients require ischemic evaluation, aligning with Class III recommendations.
• Stroke prevention & anticoagulation: The team emphasizes CHA₂DS₂-VASc scoring as central to risk stratification. Direct oral anticoagulants (DOACs) are first-line for most, with apixaban favored over rivaroxaban due to lower GI bleeding risk (supported by observational data and network meta-analyses). Warfarin remains the standard for patients with mechanical prosthetic valves or moderate-to-severe mitral stenosis.
• Risk factor modification: Lifestyle interventions—weight loss ≥10%, regular exercise (≥210 min/week), alcohol reduction, smoking cessation, and blood pressure optimization—are strongly recommended to reduce AFib burden【Pathak 2014 JACC†DOI:10.1016/j.jacc.2014.03.058】. While caffeine restriction is not recommended (Class III), screening and managing sleep apnea may prevent AFib progression.
• Lifestyle vs. ablation: The PRAGUE-25 trial showed catheter ablation to be superior, but notably ~35% of patients in the lifestyle modification arm achieved sinus rhythm without invasive intervention.
• Rate vs. rhythm control: The discussion contrasts findings from AFFIRM (rate and rhythm strategies equivalent in older populations with EAST-AFNET 4 (early rhythm control associated with lower cardiovascular outcomes, particularly in younger patients or those with HF).
• Procedural & pharmacologic strategies: Management options include synchronized cardioversion (with anticoagulation protocols), catheter ablation (radiofrequency, cryoballoon, or emerging pulse-field technologies), and antiarrhythmic drugs such as amiodarone, flecainide, dofetilide, or propafenone. The CAST trial warns against Class IC agents in structural heart disease, though nuances remain in non-ischemic cardiomyopathy.

Takeaway: AFib is a progressive disease requiring early identification, aggressive risk factor management, stroke prevention, and individualized rhythm or rate control strategies. As new therapies (e.g., Factor XI inhibitors, pulse-field ablation) emerge, ongoing research continues to refine optimal care.

• Episode reviewed by Dr. Mathhar Aldaoud - Interventional Cardiologist