Atrial Fibrillation: Is Rhythm Control Required, and If So, How, and What Is the Internist's Role?

  • James A. Reiffel
    Requests for reprints should be addressed to James A. Reiffel, MD, Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians & Surgeons, c/o 202 Birkdale Lane, Jupiter, FL 33458.
    Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
    Search for articles by this author


      Atrial fibrillation—no primary care physician can escape it! Atrial fibrillation is the most common tachyarrhythmia encountered in clinical practice—whether family practice, internal medicine, cardiology, pulmonology medicine, etc. Moreover, with growth of the older segment of our population and better survival of patients with cardiovascular disorders, the incidence and prevalence of atrial fibrillation are both increasing progressively. Currently, a review of major guidelines shows that the treatment approach to atrial fibrillation involves 4 “pillars”—treatment of contributory comorbidities (“upstream therapy”), control of the ventricular response to the rapid atrial rates during atrial fibrillation, prevention of thromboembolism with oral anticoagulation or left atrial appendage occlusion (except in the minority of patients at too low a thromboembolic risk), and rhythm control in those patients who require it. The latter is the most complex of the 4, and many, if not most, primary care physicians currently prefer to leave this “pillar” to the care of a cardiologist or electrophysiologist. Nonetheless, it is important for the primary care physician to be familiar with the rhythm treatment components and choices (both overall and, specifically, the ones in which they must participate) as they will impact many interactions with their patients in multiple ways. This review details for the primary care physician the components of care regarding rhythm control of atrial fibrillation and the areas in which the primary care physician/internist must be knowledgeable and proactively involved.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hindricks G
        • Potpara T
        • Dagres N
        • et al.
        2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS): the Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC); Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC.
        Eur Heart J. 2021; 42: 373-498
        • January CT
        • Wann S
        • Alpert JS
        • et al.
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        Circulation. 2014; 130: e199-e267
        • Staerk L
        • Sherer JA
        • Ko D
        • Benjamin EJ
        • Helm RH
        Atrial fibrillation: epidemiology, pathophysiology, and clinical outcomes.
        Circ Res. 2017; 120: 1501-1517
        • Stock JP
        New frontiers in arrhythmias.
        Br Heart J. 1971; 33: 809-816
        • Middeldorp ME
        • Ariyaratnam J
        • Lau D
        • Sanders P
        Lifestyle modifications for treatment of atrial fibrillation.
        Heart. 2020; 106: 325-332
      1. Boyle TA, Blumenthal RS, Calkins H, Chrispin J, Spragg D. Risk factor modification is an integral part of atrial fibrillation management. American College of Cardiology. Available at: Accessed March 22, 2021.

        • Chung MK
        • Refaat M
        • Shen WK
        • et al.
        Atrial fibrillation: JACC council perspectives.
        J Am Coll Cardiol. 2020; 75: 1689-1713
        • Gorenek B
        • Pelliccia A
        • Benjamin EJ
        • et al.
        European Heart Rhythm Association (EHRA)/European Association of Cardiovascular Prevention and Rehabilitation (EACPR) position paper on how to prevent atrial fibrillation endorsed by the Heart Rhythm Society IHRS) and Asia Pacific Heart Rhythm Society (APHRS).
        Europace. 2017; 19: 190-225
        • Lau DH
        • Nattel S
        • Kalman JM
        • Sanders S
        Modifiable risk factors and atrial fibrillation.
        Circulation. 2017; 136: 583-596
        • Gallagher C
        • Hendriks JML
        • Mahajan R
        • et al.
        Lifestyle management to prevent and treat atrial fibrillation.
        Expert Rev Cardiovasc Ther. 2016; 14: 799-809
        • Sardana M
        • Doshi RN
        Atrial fibrillation: the year of 2021 in review.
        J Innov Cardiac Rhythm Manage. 2022; 13: 4847-4851
        • Nguyen BO
        • Rienstra M
        • Hobbelt AH
        • et al.
        Optimal treatment of underlying conditions improves rhythm control outcome in atrial fibrillation – data from RACE 3.
        Am Heart J. 2020; 226: 235-239
        • Choi A
        • Steinberg JS
        • Mittal S.
        Upstream treatments for atrial fibrillation.
        US Cardiol. 2007; 4: 20-22
        • Gumprecht J
        • Domek M
        • Lip GYH
        • Shantsila A
        Invited review: hypertension and atrial fibrillatin: epidemiology, pathophysiology, and implications for management.
        J Hum Hypertens. 2019; 33: 824-836
        • Madrid AH
        • Bueno MG
        • Rebollo JGM
        • et al.
        Use of irbesartan to maintain sinus rhythm in patients with long-lasting persistent atrial fibrillation: a prospective and randomized study.
        Circulation. 2002; 106: 331-336
        • Singh BN
        Beta-adrenergic blockers as antiarrhythmic and antifibrillatory compounds: an overview.
        J Cardiovasc Pharmacol Ther. 2005; 10: S3-S14
        • Kowey PR
        A review of carvedilol arrhythmia data in clinical trials.
        J Cardiovasc Pharmacol Ther. 2005; 10: S59-S68
        • Patoulias D
        • Toumpourleka M
        • Papadopoulos C
        • Doumas M
        Meta-analysis evaluating the risk of atrial fibrillation with newer antidiabetics across the cardiovascular and renal outcomes trials.
        Am J Cardiol. 2021; 139: 139-141
        • Granger CB
        • Mahaffey KW
        Preventing atrial fibrillation with treatments for diabetes mellitus.
        Circulation. 2020; 141: 1235-1237
        • Li WJ
        • Chen XQ
        • Xu LL
        • Li YQ
        • Luo BH
        SGLT2 inhibitors and atrial fibrillation in type 2 diabetes: a systematic review with a meta-analysis of 16 randomized controlled trials.
        Cardiovasc Diabetol. 2020; 19: 130
        • Bell DSH
        • Goncalves E
        Atrial fibrillation and type 2 diabetes: prevalence, etiology, pathophysiology, and effect of anti-diabetic therapies.
        Diabetes Obes Metab. 2019; 21: 210-217
        • Fauchier L
        • Fauchier G
        • Bisson A
        • et al.
        Antidiabetic drugs use and new-onset atrial fibrillation in patients with diabetes mellitus.
        Eur Heart J. 2021; 42 (ehab 724.0457)
        • Kirchhof P
        • Camm AJ
        • Goette A
        • et al.
        Early rhythm-control therapy in patients with atrial fibrillation.
        N Engl J Med. 2020; 383: 1305-1316
        • Camm AJ
        • Blomstrom-Lundqvist C
        • Boriani G
        • et al.
        AIM-AF: a physician survey in the United States and Europe.
        J Am Heart Assoc. 2022; 11e023838
        • January CT
        • Wann LS
        • Calkins H
        • et al.
        2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice guidelines and the Heart Rhythm Society in collaboration with the Society of Thoracic Surgeons.
        Circulation. 2019; 140: e125-e151
        • Wazni OM
        • Marrouche NF
        • Martin DO
        • et al.
        Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial.
        JAMA. 2005; 293: 2634-2640
        • Cosedis NJ
        • Johannessen A
        • Raatikainen P
        • et al.
        Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation.
        N Engl J Med. 2012; 367: 1587-1595
        • Morillo CA
        • Verma A
        • Connolly SJ
        • et al.
        Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial.
        JAMA. 2014; 311: 692-700
        • Andrade JG
        • Wells GA
        • Deyell MW
        • et al.
        Cryoablation or drug therapy for initial treatment of atrial fibrillation.
        N Engl J Med. 2021; 384: 305-315
        • Wazi OM
        • Dandamudi G
        • Sood N
        • et al.
        Cryoballoon ablation as initial therapy for atrial fibrillation.
        N Engl J Med. 2021; 384: 316-324
        • Kuniss M
        • Pavlovic N
        • Velagic V
        • et al.
        Cryoablation vs antiarrhythmic drugs: first-line therapy for patients with paroxysmal atrial fibrillation.
        Europace. 2021; 23: 1033-1041
        • Packer DL
        • Mark DB
        • Robb RA
        • et al.
        Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: the CABANA randomized clinical trial.
        JAMA. 2019; 321: 1261-1274
        • Marrouche NF
        • Brachmann J
        • Andresen D
        • et al.
        Catheter ablation for atrial fibrillation with heart failure.
        N Engl J Med. 2018; 378: 417-427