======Atrial Fibrillation=====

=====Categorization=====

  * Paroxysmal
  * Persistent: greater than 7 days
  * Long-standing persistent: more than a year
  * Permanent: no longer trying to restor NSR
  * Valvular: moderate to severe` MS or mechanical valve

===== Evaluation =====
  * EKG: irregulary irregular without distinct p waves
  * TTE: chamber sizes, valve disease, LVH, pericardial disease
  * Labs: TFT, basic labs
  * Exercise stress testing if s/s of ischemic heart disease
  * Cardiac monitoring if suspicion for intermittent not captured on telemetry (e.g. cryptogenic stroke)
  
==== Cardioversion =====
  * Immediate synchronized cardioversion
    * Evidence of hypoperusion or shock
    * Active ischemia
    * Manifestations of severe HF
    * Hypotension (thought to be due to AF)
  * At least 4 weeks of anticoagulation ASAP s/p cardioversion

==== Anticoagulation =====
  * No cardioversion planned: based on CHA2DS2-Vasc
  * Cardioversion planned:
    * Less than 48 hours, ASAP
    * More than 48 hours or unknown, for 3 weeks prior to cardioversion
    * TTE cardioversion: evaluate for thrombus, if negative, can immediately cardiovert
    * Minimum of 4 weeks post cardioversion
  * Regardless of rate vs. rhythm control, classification of AF
  * DOACs > warfarin if eligible
  * Warfarin recommended in valvular AF regardless of CHA2DS2-Vasc
  * Renal adjustment:
    * CKD 5 or ESRD: warfarin or apixaban
    * Other NOACs can be adjusted based on CrCl
  
===== Rate Control =====
  * Usually before attempts to restore NSR
  * Usually BB (MTP, esmolol) and non-DHPR CCB (dilitiazem, verapamil)
    * CCB avoided in LV dysfunction
    * Both avoided if evidence of pre-excitation (procainamide)    
    * digoxin (not first line)
    * amiodarone (not first line)
    
===== Rhythm Control =====
  * Preferred when:
    * Failure of rate control
    * Heart failure
    * Younger patients
    * Early in natural history of AF (non-dilated LA, reversible cause, no HTN)
  * Pharmacologic:
    * Flecainde (without structural disease)
    * Propafenone (without structural disease)
    * Ibutilide (IV only, risk of QT prolongation)
    * Dofetilide (maintenance)
    * Amiodarone (structural heart disease, but numerous SEs)
    * Sotalolol
  * Non-pharmacologic
    * Catheter ablation: symptomatic despite other interventions
    * Surgical MAZE: usually when undergoing cardiac surgery for another reason
    
===== Stroke Prevention =====
  * Watchman device (percutaneous LA appendage occlusion)
  * SUrgical occlusion of LA appendage
  
===== AF and ACS =====
  * Stable ACAD: usually single agent anticoagulant
  * ACS with PCI:
    * consider double therapy (oral anticoagulant and P2Y12 inhibitor)
    * if triple therapy, consider transition to double therapy at 4-6 weeks

=====Medications======

^  Preferred antiarrhythmics in patients with AF  ^^
| No CAD or structural disease | Flecainide \\ Propafenone |
| LVH | Dronedarone \\ Amiodarone |
| CAD without heart failure | Sotalol \\ Dronedarone |
| Heart failure | Amiodarone \\ Dofetilide |
| Recurrent AF refractory to meds | Radiofrequency ablation |