Management of Acute Atrial Fibrillation and Atrial Flutter in Non-Pregnant Hospitalized Adults [2014 new]
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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
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
The University of Michigan Medical School designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
This CME activity was prepared for release in April 2015 with credit available through March 2018. The activity was reviewed in April 2018 and availability of credit extended through May 2021. Continuation of credit from that date depends on a thorough review of the content currency and accuracy.
Release Date: April 2015
Termination Date: May 2021
Continued availability of CME credit for this activity depends on a thorough review of its content every three years. This activity was last reviewed for currency and accuracy in April 2018, and availability of CME credit continued.
Jeffrey M. Rohde, MD; Internal Medicine
Thomas C. Crawford, MD; Cardiology
Sarah E. Hartley, MD; Internal Medicine
Sarah Hanigan, PharmD; Pharmacy Services
Jules Lin, MD; Thoracic Surgery
Lewis B. Morgenstern, MD; Neurology (Stroke)
F. Jacob Seagull, PhD; Medical Education
David M. Somand, MD; Emergency Medicine
David H. Wesorick, MD; Internal Medicine
James B. Froehlich, MD; Cardiology
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