Atrial Fibrillation Rate/Rhythm Control Strategy — free guideline decision tool

This tool gives rate-control targets/drugs, rhythm-control direction, and cardioversion anticoagulation for atrial fibrillation, branching first on hemodynamic stability.

Unstable → emergency synchronized cardioversion. Stable → rate control (resting < 110, drug by LVEF) ± early rhythm control if symptomatic/HF/new; cardioversion anticoagulation by AF duration (3 weeks pre + 4 weeks post if ≥ 48 h, or TEE-guided).

Use to manage AF: unstable patients get emergency cardioversion, while stable patients are guided to rate or rhythm control by LVEF, symptoms, and AF duration.

In pre-excitation with rapid AF, digitalis, non-dihydropyridine CCB, and amiodarone are avoided and the patient is cardioverted directly. (original synthesis · not guideline verbatim) Symptomatic, comorbid-HF, or newly diagnosed patients benefit from early rhythm control (EAST-AFNET 4). At LVEF ≤ 40%, non-dihydropyridine CCBs are contraindicated; rate control uses β-blocker ± digitalis.

For licensed clinicians and clinical researchers. Interpret results with history, investigations and local protocols; not a diagnosis or prescription, and not a substitute for multidisciplinary decision-making or local guidelines.

Inputs: Hemodynamics Unstable (hypotension/shock/acute HF/ongoing ischemia), Left ventricular ejection fraction LVEF > 40%, Symptomatic / comorbid HF / newly diagnosed early Yes, Pre-excitation syndrome Yes, AF duration (when planning cardioversion) New-onset / < 48 h / no thrombus on TEE → Result: Disposition Emergency synchronized cardioversion（Emergency cardioversion: Hemodynamically unstable AF → emergency synchronized cardioversion (Class I); pre-excitation with rapid AF → direct cardioversion, avoid digitalis/non-dihydropyridine CCB/amiodarone, Anticoagulation & precipitants: Fully assess thromboembolic risk before/after cardioversion and decide anticoagulation; correct reversible precipitants (infection, ischemia, electrolytes, etc.), Basis: Chinese Emergency Management Guideline for Acute Atrial Fibrillation 2024 / Chinese AF management guideline） Inputs: Hemodynamics Stable, Left ventricular ejection fraction LVEF ≤ 40%, Symptomatic / comorbid HF / newly diagnosed early No, Pre-excitation syndrome No, AF duration (when planning cardioversion) ≥ 48 h or unknown duration → Result: Strategy Hemodynamically stable: rate/rhythm control（Rate target: Long-term without HF: lenient target resting < 110 bpm; if still symptomatic or tachycardia-induced cardiomyopathy suspected → stricter, Rate drugs: LVEF ≤ 40%: β-blocker and/or digitalis (non-dihydropyridine CCB contraindicated), Rhythm control: If minimally symptomatic, rate control first; when it is unclear whether symptoms relate to AF, attempting to restore sinus rhythm first is reasonable）