For people with potentially reversible or new-onset AF, those with heart failure due to AF, or for certain forms of atrial flutter, NICE says a standard beta-blocker (but not sotalol) or a rate€‘limiting calcium€‘channel blocker such as diltiazem (off label) or verapamil, can be offered to control the heart rate.19

Digoxin can be considered for people with non-paroxysmal AF who do no or very little physical exercise if comorbidities/preferences do not permit another rate-limiting drug.

If monotherapy is insufficient, then combination therapy using any two of a beta-blocker, diltiazem or digoxin may be considered.

Amiodarone should not be used for long-term rate control. However it may be suitable for AF patients with left ventricular impairment or heart failure. People with paroxysmal AF may not need daily medication but could have a ‘pill in the pocket’ strategy to take medication only when an episode of AF starts.

Antiarrhythmic drugs can be considered, but class 1c antiarrhythmic drugs such as flecainide or propafenone should not be offered to people with known ischaemic or structural heart disease. Long-term rhythm control can also respond to standard beta-blockers.

Cardioversion, a process to try and restore normal heart rhythm, can be done with electric stimuli and/or medication. Electronic cardioversion is preferred for AF persisting more than 48 hours. Dronedarone may be suitable as a second€‘line treatment option for long€‘term rhythm control after successful cardioversion.

While anticoagulants are used in managing atrial flutter, catheter ablation can be the best treatment. Usually performed under local anaesthetic, this uses radiofrequency energy to destroy the cardiac cells causing the increased atrial contraction rate.21

For AF, left ventricle ablation options include radio-frequency point-to-point ablation, cryoballoon (freezing the affected tissue) or laser balloon ablation.19