RECOGNITION AND ASSESSMENT

Symptoms (in order of increasing severity/urgency)

  • Palpitation
  • Dyspnoea
  • Chest pain
  • Dizziness
  • Syncope
  • Cardiac arrest

Signs

  • Heart rate <60 or >100 beats/min
  • Hypotension (systolic BP<100 mmHg)
  • Hypoperfusion
  • Jugular venous pressure (JVP) elevated
  • Cannon waves or flutter waves in internal jugular vein
  • Variable intensity of first heart sound
  • Signs of heart failure

Investigations

  • 12-lead ECG. A single-lead rhythm strip is an inferior alternative, but better than no ECG at all
  • Urgent U&E

Important differential diagnosis

  • Wolff-Parkinson-White (WPW) syndrome can present as AF. QRS complexes will be pre-excited (i.e. wide and bizarre), and ventricular response very fast with a tendency to degenerate to ventricular flutter and fibrillation (VF).
    • Never give digoxin or verapamil but seek urgent cardiology advice from on-call SpR with a view to restoring sinus rhythm with flecainide or sotalol, or with DC cardioversion

IMMEDIATE TREATMENT

  • If patient in peri-arrest situation, follow advanced life support – see Cardiopulmonary resuscitation – life support procedure guideline

Rhythm control

  • If AF present for <24 hr, seek urgent cardiology advice
    • aim is to restore sinus rhythm immediately using DC cardioversion or anti-arrhythmic drugs (amiodarone, flecainide or propafenone), unless there is a persistent underlying cause (e.g. thyrotoxicosis, mitral valve disease, pneumonia). Drugs other than amiodarone carry a risk of pro-arrhythmia and must be used with caution
    • if unable to cardiovert immediately, give unfractionated heparin IV – see IV unfractionated heparin guideline, and cardiovert as soon as practicable

Rate control

  • Once confident not WPW syndrome and if ventricular response to AF rapid during high sympathetic stress (e.g. pneumonia, myocardial infarction or postoperatively) and systolic BP >100 mmHg, options include:
    • either a beta-blocker (atenolol 2.5 mg IV at 1 mg/min, which can be repeated at intervals of 5 min to a maximum of 10 mg, or 50–100 mg oral) or a rate-limiting calcium channel blocker (verapamil 2.5 mg IV over 3 min, which can be repeated at intervals of 5 min to a maximum of 10 mg). Do not give both: check if patient already prescribed either drug
    • if rate does not fall sufficiently, add digoxin (for chronic use) – see Digoxin guideline
  • Where heart failure is a clinical issue, consider digoxin (see Digoxin guideline) but amiodarone for acute (not chronic) management conveys greater efficacy (contact on-call cardiology re use of amiodarone)

ANTICOAGULATION

  • Consider thromboprophylaxis with DOAC or warfarin (maintenance INR 2.5) for all patients with sustained or paroxysmal AF or flutter.

Choosing for the individual patient

  • Weigh the risk of thromboembolic stroke against the adverse risk of bleeding
    • Assess the risk of stroke, using the CHA2DS2VASc score
    • Assess the risk of major bleeding from anticoagulation (a bleed requiring hospital admission, a blood transfusion or causing stroke) by the HAS-BLED score
  • In considering whether to start DOAC or warfarin, discuss with patient and carers the risks and benefits and the need for regular therapy and, in the case of warfarin, INR checks
  • If a decision is made not to anticoagulate the patient, document the reason in the notes
  • If patient receiving clopidogrel for coronary stent, do NOT discontinue, contact cardiology SpR

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SUBSEQUENT MANAGEMENT

Chronic AF

  • For rate control, prefer bisoprolol 2.5–10 mg/atenolol 50–100 mg oral daily or (if no LV systolic dysfunction/heart failure)
    • consider calcium antagonist (verapamil 40–80 mg 8-hrly or diltiazem SR up to 300 mg/day)
    • digoxin will control resting rate but not exercise rate
  • For thromboembolic risk reduction, see ANTICOAGULATION

Back in sinus rhythm

  • If sinus rhythm restored after recurrent episode of AF with no obvious precipitant (e.g. pneumonia), consider long-term prophylactic therapy
    • patients with evidence of ischaemic heart disease/LV systolic dysfunction/LV hypertrophy, or hypertensive disease, use a beta-blocker (e.g. bisoprolol/atenolol). If contraindicated, seek advice from on-call cardiologist SpR
    • patients with no evidence of ischaemic heart disease/LV systolic dysfunction/LV hypertrophy, consider Class Ic agent (e.g. propafenone, flecainide) after seeking advice from on-call cardiology SpR

Unsuccessful cardioversion

  • If DC or chemical cardioversion unsuccessful, consider long-term control of the ventricular response
    • if heart failure present, use digoxin +/- beta-blocker or, if beta-blocker contraindicated, seek cardiology advice from on-call SpR on use of amiodarone
    • if no heart failure present, use beta-blocker or, if beta-blocker contraindicated, diltiazem or verapamil

Bradycardia/tachycardia form of sino-atrial disease

  • For prevention of AF in the bradycardia/tachycardia form of sino-atrial disease, consider pacing

Ablation therapy

  • Consider ablation therapy. Refer patients to Electro-physiology consultant with:
    • Wolff-Parkinson-White syndrome
    • persistent AF in whom ventricular response cannot be satisfactorily controlled with drug therapy
    • recurrent AF
    • taking an anti-arrhythmic agent
    • paroxysmal AF with symptoms

Alerts on drug combinations

  • Avoid combinations of anti-arrhythmic drugs (including beta-blockers, diltiazem and verapamil) except after specific cardiological advice
  • Avoid combinations of anti-arrhythmic drugs and diuretics if possible as hypokalaemia worsens pro-arrhythmic potential

DISCHARGE AND FOLLOW-UP

  • Do NOT discharge patient from hospital taking rhythm-controlling agents (unless advised to by a cardiologist) as these are unlikely to restore sinus rhythm and expose patient unnecessarily to risk of drug-induced arrhythmia

Follow-up

  • If new onset AF, consider cardiology referral for DC cardioversion
  • For any patient requiring on-going management of rate/rhythm not under current cardiology follow-up, refer to AF/arrhythmia nurse team
  • Otherwise ask for GP review
  • Request outpatient echocardiogram
    • request follow-up clinician to refer to cardiologist if echocardiogram abnormal

Anticoagulation

  • If taking DOAC, ask for GP review in 6 months for renal function/adherence
  • If taking warfarin, follow guidance in yellow anticoagulation book

© 2022 The Bedside Clinical Guidelines Partnership.

Created by University Hospital North Midlands and Keele University School of Computing and Mathematics.

Research and development team: James Mitchell, Ed de Quincey, Charles Pantin, Naveed Mustfa