The prevalence and incidence of atrial fibrillation increase with age. Atrial 
fibrillation is associated with a higher incidence of coronary events, stroke, 
and mortality than sinus rhythm. A fast ventricular rate associated with atrial 
fibrillation may cause tachycardia-related cardiomyopathy. Management of atrial 
fibrillation includes treatment of underlying causes and precipitating factors. 
Immediate direct-current cardioversion should be performed in persons with 
atrial fibrillation associated with acute myocardial infarction, chest pain due 
to myocardial ischemia, hypotension, severe heart failure, or syncope. 
Intravenous beta-blockers, verapamil, or diltiazem may be used to immediately 
slow a fast ventricular rate associated with atrial fibrillation. An oral 
beta-blocker, verapamil, or diltiazem should be given to persons with atrial 
fibrillation if a rapid ventricular rate occurs a rest or during exercise 
despite digoxin. Amiodarone may be used in selected persons with symptomatic 
life-threatening atrial fibrillation refractory to other drug therapy. Nondrug 
therapies should be performed in persons with symptomatic atrial fibrillation in 
whom a rapid ventricular rate cannot be slowed by drug therapy. Paroxysmal 
atrial fibrillation associated with the tachycardia-bradycardia syndrome should 
be managed with a permanent pacemaker in combination with drugs. A permanent 
pacemaker should be implanted in persons with atrial fibrillation in whom 
symptoms such as dizziness or syncope associated with non-drug-induced 
ventricular pauses longer than 3 seconds develop. Elective direct-current 
cardioversion has a higher success rate and a lower incidence of cardiac adverse 
effects than medical cardioversion in converting atrial fibrillation to sinus 
rhythm. Unless transesophageal echocardiography shows no thrombus in the left 
atrial appendage before cardioversion, oral warfarin should be given for 3 weeks 
before elective direct-current or drug cardioversion of atrial fibrillation and 
continued for at least 4 weeks after maintenance of sinus rhythm. Many 
cardiologists prefer the treatment strategy of ventricular rate control plus 
warfarin rather than to maintain sinus rhythm with antiarrhythmic drugs, 
especially in older patients. Digoxin should not be used in persons with 
paroxysmal atrial fibrillation. Patients with chronic or paroxysmal atrial 
fibrillation who are at high risk for stroke should be treated with long-term 
warfarin to achieve an International Normalized Ratio (INR) of 2.0 to 3.0. 
Persons with atrial fibrillation who are at low risk for stroke or who have 
contraindications to warfarin should receive 325 mg aspirin daily.