Should you use an antiarrhythmic agent plus coumadin/NOAC for atrial fibrillation?

In short, if the patient has symptoms and finds atrial fibrillation intolerable, yes. But as this good article of clinical pearls states, “the treatment should not be worse than the disease.” If a patient is elderly, has a lot of co-morbidities, or other cardiac issues, it may be okay to focus on rate control and anticoagulation.

People who have no structural heart disease or reduced EF may not have to be anticoagulated. However, this is a discussion that needs to take into account the patient’s lifestyle, goals, and attitude towards treatment.

The first-line antiarrhythmic for patients with afib without structural heart disease is often flecainide or procainamide.

The first-line antiarrhythmic for patients with afib with structural heart disease is often amiodarone, but there are other options depending on the situation. One cards fellow told me, “Amiodarone is often a drug of last resort.” Although, really, the drug of last resort is digoxin. See Figure 4 of this review.

ARISTOTLE recently showed that amiodarone in particular was associated with more adverse bleeding events when used in combination with coumadin compared to other antiarrhythmics. This study also provided support for the use of apixiban specifically because of lessened major bleeding risk (Eliquis).

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