Atrial fibrillation: rhythm control

Restoration and maintenance of sinus rhythm in paroxysmal and persistent atrial fibrillation. Per ESC AF 2024, early rhythm control (within one year of diagnosis) in symptomatic patients or HFrEF improves prognosis (EAST-AFNET 4). Antiarrhythmic choice depends on structural heart disease: with preserved structure – propafenone/flecainide; with HFrEF or CAD – amiodarone. Catheter ablation is a first-line alternative for paroxysmal AF in young patients.

ICD-10 I48.91 drug

Also known as: AF rhythm control

Drugs used for this condition

AAmiodaroneFirst line · Class III antiarrhythmics (Vaughan Williams)Per ESC AF 2024, amiodarone is first-line antiarrhythmic for sinus rhythm maintenance in patients with structural heart disease (HFrEF, CAD, hypertrophy). With preserved cardiac structure, propafenone and flecainide are preferred – they have less extracardiac toxicity. Oral loading 600–800 mg/day for 1–4 weeks, maintenance 100–200 mg/day. IV loading for emergency cardioversion: 5–7 mg/kg over 1–2 hours. Long-term use requires scheduled monitoring of thyroid function (TSH), lungs, and liver enzymes. Amiodarone potentiates warfarin (higher INR, bleeding risk, reduce the warfarin dose) and raises digoxin levels (risk of glycoside toxicity).

How to read tiers A–F

Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.

AStrong evidence – first or second line in international guidelines
BRecommended in selected cases
CStudy data contradict each other
DBenefit not proven, no documented harm
FDocumented harm, or risk without benefit