Mount Carmel Health Partners Clinical Guidelines Atrial Fibrillation

Atrial Fibrillation Clinical Guideline Patient presents with signs and/or symptoms of possible a-fib or atrial flutter (See Table C) Evaluation Treatment Quick Guide • Atrial fibrillation (AF) is usually a symptom of another underlying cause. It is rarely a primary arrhythmia. • AF can be managed through rhythm control or rate control. • Most AF patients should have long-term anticoagulation, even if restored to sinus rhythm, depending on their stroke risk. • The best anticoagulation strategies are based on factors specific to each patient. • Consider early referral to a cardiologist: - for AF ablation which is critical for a successful outcome (normal sinus rhythm) - if the patient has failed medication or cannot tolerate an antiarrhythmic medication. Pursue pharmacologic rhythm control. Consider cardiology input. (see Table G) No Is the patient unstable? (See Table D) No Perform history, physical, and ECG Are there any reasons to not pursue rhythm control? (see Table B) No Is AF definitely known to be <48 hours and no history of mitral stenosis or prosthetic valves and no history of TIA, stroke, or thromboembolism? (see Table F) Is TEE available? Unsuccessful Consider starting antiarrhythmic if patient has structural heart disease Load with antiarrhythmic and achieve therapeutic anticoagulation, then reattempt DC cardioversion Ongoing follow-up: • Monitor INR If warfarin is prescribed • Evaluate and manage any side effects (see medication tables) • Reconsider rhythm control Was second attempt successful? No Yes One month anticoagulation post DC cardioversion (see Table F) No Therapeutic anticoagulation x 4 weeks pre- cardioversion; initiate rate control if symptomatic or heart rate is >100 Successful Chronic anticoagulation (see Table I) Yes TEE before cardioversion; includes DC cardioversion or pharmacologic Yes Pursue chronic rate control (see Table H) Yes Electrical (DC) cardioversion Is immediate DC cardioversion available? Yes No Send to ED with EMS transport if possible Yes Follow-up: re-evaluate in 1 month for ongoing treatment including chronic anticoagulation; determine ongoing follow-up schedule including INR and evaluate need for continued antiarrhythmia medication Yes Is a thrombus present? No Does AF reoccur or did cardioversion fail? Yes Follow up with cardiologist October 2017