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