Atrial fibrillation in South Africa: anti-arrhythmic and anticoagulation therapy – clinical considerations for pharmacists

Abstract

Background: Atrial fibrillation (AF) represents the most prevalent persistent cardiac rhythm disorder encountered in routine clinical care and is a leading contributor to stroke, systemic embolic events, and heart failure. In South Africa, the occurrence of AF is currently lower than anticipated, though it is showing an upward trend, driven in part by the substantial prevalence of hypertension, obesity, and valvular heart disease, frequently linked to rheumatic heart disease (RHD). Furthermore, the risk for arrhythmias is increased with structural heart disease due to fibrotic scar formation caused by myocardial infarction. Pharmacological and non-pharmacological treatments are used to limit the effect of arrhythmias on morbidity and potential mortality. The therapeutic approach to AF typically includes strategies for rhythm or rate regulation using anti-arrhythmic agents, in combination with anticoagulation agents to reduce the risk of thromboembolic events. In the public healthcare sector, warfarin continues to be the predominant anticoagulant, whereas direct oral anticoagulants (DOACs) are being adopted with increasing frequency in private healthcare settings.

Objectives: This review summarises current epidemiology of AF in South Africa, outlines anti-arrhythmic and anticoagulation strategies, and highlights key considerations for pharmacists, including drug interactions, adverse effects, and patient counselling.

Results: While beta-blockers, calcium channel blockers, amiodarone, and sotalol remain mainstays for rate/rhythm control, newer agents have improved tolerability profiles. Anticoagulation decisions should be guided by the CHA₂DS₂-VA and HAS-BLED scores, in line with the 2024 ESC guideline, balancing stroke prevention with bleeding risk. DOACs offer practical advantages but cost, accessibility, and reversal agent availability remain limiting factors in public healthcare.

Conclusion: Pharmacists play a critical role in AF management through patient education, adherence support, adverse effect monitoring, and optimisation of therapy in line with national and international guidelines.