Management of Acute Atrial Fibrillation and Atrial Flutter in Non-Pregnant Hospitalized Adults [2014 new]

Description: Atrial fibrillation (AF) and atrial flutter (AFL) are the most common sustained arrhythmias in the U.S., affecting 2.5 million adults with the majority of patients over the age of 65. AF/AFL is associated with numerous comorbidities including hypertension, coronary artery disease, heart failure, and valvular heart disease. The cost of direct care of patients with AF in the U.S. is an estimated $6.65 billion annually, the majority of which is attributed to hospitalizations due to rapid ventricular response, heart failure, and stroke. There are over 150 admissions to the UMHS annually with the principle diagnosis of new-onset AF, and there are many more than that for recurrent or chronic atrial fibrillation.

Diagnosis
Electrocardiogram (ECG) is essential in the diagnosis of AF/AFL. The initial evaluation is summarized in Table 1 and should include:

• Physical exam
• Laboratory evaluation: CBC, basic metabolic profile, magnesium, thyroid-stimulating hormone, and cardiac enzymes as indicated
• Imaging: Chest X-ray, echocardiogram
• Continuous telemetry monitoring in the hospital

Treatment
Initial treatment of AF/AFL depends on hemodynamic stability:

Unstable AF/AFL (Figure 1)

• Begin resuscitation and consider other conditions contributing to instability
• If instability due to AF/AFL - immediate direct current cardioversion

Stable AF/AFL (Figure 2):

• For ED patients: Screen for early cardioversion in the Emergency Department (Figure 4)
• Administer rate controlling agents as indicated (Table 4) – [I, B]
  • EP consult for uncontrolled rate despite adequate trial of rate controlling agents
• Consider the appropriateness of a rhythm control strategy (Table 3) – [I, B]
  • If rhythm control strategy is appropriate/desired, consult EP and start immediate anticoagulation (Figure 3)
• Consider anticoagulation based on CHA2DS2-VASc score (Table 2, Figure 3) – [I, A].
  • The choice of anticoagulant will depend on the patients clinical circumstances and renal function (Figure 3)
  • Obtain Neurology consult prior to initiation of anticoagulation for patients with recent ischemic stroke within the prior two weeks
  • Patients with valvular disease and those requiring concomitant treatment with dual antiplatelet therapy should be anticoagulated with warfarin
  • Target-specific oral anticoagulants are preferred over warfarin in many cases