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HWN Suggests

More Atrial Fibrillation Management Pearls in the ED

Whether or not patients are acutely managed with rate or rhythm control, thromboembolic risk should always be considered. It should also be noted that patients with valvular atrial fibrillation are deemed high risk for stroke and should always be treated with warfarin. This is because none of the novel oral anticoagulants (NOACs) have been studied in patients with valvular atrial fibrillation.

All three societies [American Heart Association/American College of Cardiology (AHA/ACC), the Canadian Cardiovascular Society (CCS) and the European Society of Cardiology (ESC)} recommend using the same risk scores of CHADS2 (Congestive Heart Failure, Hypertension, Age > 75 years, Diabetes…

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Articles of Interest

CHADS₂ Score for Atrial Fibrillation Stroke Risk

Estimates stroke risk in patients with atrial fibrillation.

HAS-BLED Score for Major Bleeding Risk

Antithrombotic management is not about a single, simple decision to initiate antithrombotic drugs or not. Antithrombotic management is all about the continuous balancing of risk (assessment) and communication. HAS-BLED is an easy-to-use tool capable of both when it comes to the risk of major bleeding of your AF patients.

Managing Atrial Fibrillation

Anticoagulation for cardioversion (electrical or pharmacologic) is controversial. Some guidelines advise that no oral anticoagulation is required if the onset was within 48 hours and the patient is discharged from the ED in sinus rhythm. Others contend that oral anticoagulation should be offered according to usual anticoagulation guidelines (eg, CHA2DS2-VASc score), regardless of whether the patient is in sinus rhythm. We take the latter approach, and a recent study on ED cardioversion without oral anticoagulation supports this choice.

Outcomes After Aggressive Management of Recent-Onset Atrial Fibrillation in the ED

The rate control group argues that cardioversion runs the risk of causing a thromboembolic event (i.e. CVA, peripheral arterial occlusion). Thus, it should not be performed until the absence of clot in the left atrium is confirmed (by TEE) or appropriate anticoagulation has occurred. It has long been taught that if the patient has been in AF/AFl for < 48 hours, the risk of developing a clot in the left atrium is negligible and cardioversion may be pursued. However, some recent literature has called this classic teaching into question (Nuotio 2014). Prospective studies looking at outcomes of recent-onset AF/AFl patients after aggressive treatment in the ED are needed to further evaluate the risks of aggressive treatment.

Recent-Onset Atrial Fibrillation

Determine whether the AF is in response to another underlying process (see causes above) or is simply lone atrial fibrillation. In patients where AF is a response to another underlying process, management should be directed at treating the underlying process NOT at the dysrhythmia.