Atrial fibrillation is the most common sustained cardiac arrhythmia globally, characterized by disorganized, rapid atrial electrical activation, resulting in loss of atrial contraction, irregular ventricular response, and elevated risk of thromboembolism, heart failure, and stroke. It is classified by duration: paroxysmal AF (terminates spontaneously within 7 days), persistent AF (lasts >7 days), long-standing persistent AF (>12 months), and permanent AF (no further rhythm control attempts).

• Etiology: Common risk factors include advanced age, hypertension, coronary artery disease, heart failure, valvular heart disease, diabetes mellitus, obesity, obstructive sleep apnea (OSA), hyperthyroidism, excessive alcohol intake, and genetic predisposition.
• Clinical Manifestations: Common symptoms include palpitations, exertional dyspnea, fatigue, dizziness, and chest discomfort. Up to 30% of patients are asymptomatic (silent AF), with the first presentation being stroke or heart failure. AF is associated with a 5-fold increased stroke risk, 3-fold higher heart failure risk, and 2-fold higher all-cause mortality.
• Diagnosis: The gold standard is a 12-lead ECG showing absent consistent P waves, irregularly irregular RR intervals, and chaotic atrial activity. For paroxysmal AF, ambulatory monitoring (Holter, implantable loop recorder) is used for detection. TTE assesses structural heart disease, left atrial size, and left ventricular function, with additional testing including thyroid function and OSA screening.

• Stroke Prevention: The cornerstone of AF care, with risk stratification via the CHA₂DS₂-VASc score. Oral anticoagulation (OAC) is recommended for men with a score ≥2 and women ≥3. First-line options for non-valvular AF are non-vitamin K antagonist oral anticoagulants (NOACs), with warfarin used for valvular AF or NOAC contraindications. Left atrial appendage closure (LAAC) is a recommended alternative for patients with long-term OAC contraindications.
• Rate Control: For all AF patients, targeting a resting heart rate <80 bpm for symptomatic patients and <110 bpm for asymptomatic patients with preserved left ventricular function. First-line medications include beta-blockers, non-dihydropyridine calcium channel blockers, and digoxin for heart failure or hypotension. Atrioventricular node ablation with pacing is reserved for refractory cases.
• Rhythm Control: For patients with persistent symptoms despite optimal rate control, to restore and maintain sinus rhythm. Options include electrical cardioversion, antiarrhythmic drugs (AADs), and catheter ablation (first-line guideline-recommended therapy for symptomatic paroxysmal and persistent AF, with superior efficacy to AADs). The gold standard ablation procedure is pulmonary vein isolation (PVI) via radiofrequency or cryoballoon ablation.
• Risk Factor Modification: Critical for long-term management, including strict blood pressure control, diabetes management, weight loss, OSA treatment, alcohol cessation, and regular exercise.