Show Notes: A.Fib**Caveat: Dr. Bhan recommends that 24h be the cutoff timeframe for symptom onset

and due credence and respect is given to this informed opinion. Current AHA guidelines and multiple studies confirm that 48h is an appropriate cutoff.**

1) Troponins and Other Testing Currently recommended that all patients have serial troponins despite the fact

that ACS rarely is the cause of AF (EHRA et al. Guidelines for the management of atrial fibrillation. Eur Heart J, 2010) AF before or after incident MI was associated with increased risk for

mortality (ACP Journal Club, 2011) For new-onset AF pts (first time presentation, no known hx) it is recommended

that the following lab tests be ordered… Accucheck CBC (Anemia? Leukocytosis pointing to underlying infection? Coagulopathy?) BMP (Electrolyte deficiency? Renal failure?) Troponin (AMI?) Thyroid studies U-hcg (women) D-dimer (Dr. Avula’s recommendation for screening for PE as cause of onset)

Little evidence exists necessitating BNP or LFT panels in new-onset patients For chronic AF pts (known hx, +/- current anticoagulation, stable disease) it is

important to elicit history and order testing appropriately All these patients DO NOT require troponins, BNP simply on the basis of

having AF and should only be considered as adjuncts to the clinical context (chest pain, concern for CHF exacerbation/ACS/AMI, etc)

Imaging studies should include… CXR (PNA? PTX? PCE?) Bedside echo (Effusion? Wall motion abns? Dilated CM?) +/- formal Echo

(might save the pt an o/p Echo their future cardiologist will surely order) EKG (obviously)

2) Defining Onset Most AF is insidious and goes unnoticed, so it is difficult to accurately define

onset of AF with any degree of certainty Current studies use patient-reported symptoms as time=0 for defining

“symptom onset.” If the pt has waxing and waning “symptoms”, the clock starts at the time of onset

of their first symptoms (weakness, fatigue, palpitations, chest pain, etc), whatever their current condition is a continuation of.

The clock does not “reset” with cessation of symptoms as it is impossible to tell if the pt is truly pathology-free or just symptom-free in the face of ongoing pathology.

3) Rate Control vs Rhythm Control EPs should consider rhythm control for all patients with self-reported symptom

onset of <24h duration For patients with a prior h/o AFib, you should consider their recurrence rate

when deciding on rhythm control… If they have been having waxing and waning symptoms for the last month

and have not sought medical attention, they are no longer classic candidates for ED conversion.

If this is their twice-a-year ED visit for cardioversion, they are good candidates.

Rhythm control confers a greater morbidity benefit than rate control New-onset AF was associated with increased risk for mortality in initially

healthy, middle-aged women (JAMA, 2011) Pts who are simply rate controlled do not require hospitalization and can be sent

home if asymptomatic and rate controlled under 110bpm EPs should be familiar and consider chemical cardioversion with ibutalide (with

Mag in combination) as a first line agent, or flecainide (with a beta-blocker in combination) in younger patients.

Digoxin should only be considered for patients in AF with a known h/o CHF who are hypotensive

4) Anticoagulation Patients who spontaneously convert uder 24h duration can be sent home

without anticoagulation beyond daily aspirin… Patients presenting with <24h sxs who are cardioverted in the ED (either

chemically or electrically) require 4wks of anticoagulation and Dr. Bhan recommends Pradaxa as a first-line medication.

Patients presenting with sxs of >24h onset who spontaneously convert need to be assessed using the CHADS2 score: ≤1 home on ASA ≥2 4wks anticoagulation

Patients who do not spontaneously convert should be heparinized for o/p (or inpatient) TEE and CV

5) Atrial Flutter Atrial flutter is an organized, circuitous rhythm that is able to be easily ablated in

the EP lab Successful ablation does not require pts to have active atrial flutter These patients should be managed according to the same guidelines as AF pts

but referred to an EP physician for future ablation

6) CHADS 2 and CHADS 2 -VASc Scores See provided information on Anticoagulation Controversies