Atrial Fibrillation

Categorization

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)

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

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

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)

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

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

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