Is atrial fibrillation (AFib) an emergency?

From the Guidelines

Atrial fibrillation (AFib) is not always an emergency, but it can be in certain situations, such as when accompanied by severe symptoms, and the most recent guidelines from 2024 emphasize the importance of managing comorbidities and risk factors to improve patient outcomes 1. When considering the management of AFib, it's crucial to prioritize the patient's overall health and well-being, taking into account their individual risk factors, symptoms, and medical history. The 2024 ESC guidelines for the management of atrial fibrillation highlight the need for a comprehensive approach, including comorbidity and risk factor management, stroke prevention, symptom reduction, and regular evaluation and reassessment 1.

Some key points to consider in the management of AFib include:

• The importance of early detection and treatment of underlying conditions that may be contributing to the development of AFib, such as hypertension, heart failure, or thyroid disease 1.
• The use of medications such as beta-blockers, calcium channel blockers, and antiarrhythmics to control heart rate and rhythm, as well as blood thinners to prevent stroke and other thromboembolic events 1.
• The potential benefits and risks of procedures such as cardioversion and ablation, and the need for individualized decision-making based on the patient's specific circumstances 1.
• The importance of patient education and empowerment, as well as a collaborative approach to care that involves the patient, their family, and their healthcare team 1.

In terms of when to seek emergency medical attention, the following situations are considered emergencies:

• First-time onset of AFib, especially if accompanied by severe symptoms such as chest pain, severe shortness of breath, or fainting 1.
• Significant change in symptoms or worsening of existing symptoms in patients with known AFib 1.
• Failure of usual management plan to resolve symptoms or improve patient outcomes 1.

Overall, the management of AFib requires a comprehensive and individualized approach that takes into account the patient's unique needs and circumstances, and prioritizes their overall health and well-being. By following the most recent guidelines and recommendations, healthcare providers can help improve patient outcomes and reduce the risk of complications associated with AFib 1.

From the Research

Definition and Prevalence of Atrial Fibrillation

• Atrial fibrillation is a supraventricular arrhythmia that increases the risk of stroke and all-cause mortality 2.
• It is the most common cardiac dysrhythmia in adults in the primary care setting, and its prevalence increases with age 2.
• Approximately 10.55 million adults in the US have atrial fibrillation, which is associated with significantly increased risk of stroke, heart failure, myocardial infarction, dementia, chronic kidney disease, and mortality 3.

Symptoms and Diagnosis

• Symptoms of atrial fibrillation include palpitations, dyspnea, chest pain, presyncope, exertional intolerance, and fatigue, although approximately 10% to 40% of people with atrial fibrillation are asymptomatic 3.
• Diagnosis is based on history and physical examination findings and should be confirmed with 12-lead electrocardiography or other recording device 2.
• The initial evaluation should include transthoracic echocardiography; serum electrolyte levels; complete blood count; and thyroid, kidney, and liver function tests 2.

Emergency Management

• Hemodynamically unstable patients, including those with decompensated heart failure, should be evaluated and treated emergently 2.
• Most hemodynamically stable patients should be treated initially with rate control and anticoagulation 2.
• There is increasing evidence that selected patients with acute atrial fibrillation can be safely managed in the emergency department without the need for hospital admission 4.
• Atrial fibrillation and heart failure with reduced ejection fraction are associated with worse outcomes, and catheter ablation for atrial fibrillation in patients with heart failure and reduced ejection fraction has shown superiority in improving survival, quality of life, and ventricular function 5.

Treatment and Management

• Warfarin and direct oral anticoagulants reduce the risk of stroke by preventing atrial thrombus formation and subsequent cerebral or systemic emboli 2.
• Anticoagulation with a vitamin K antagonist or direct oral anticoagulant reduces stroke risk by 60% to 80% compared with placebo in patients with estimated risk of stroke and thromboembolic events of 2% or greater per year 3.
• Early rhythm control with antiarrhythmic drugs or catheter ablation to restore and maintain sinus rhythm is recommended for some patients with atrial fibrillation 3.
• Lifestyle and risk factor modification, including weight loss and exercise, are recommended to prevent atrial fibrillation onset, recurrence, and complications 3.