From the Guidelines
Atrial fibrillation (A fib) that developed after a dental procedure in a previously normotensive patient with resolved bradycardia should be managed according to the AF-CARE pathway, which includes comorbidity and risk factor management, avoidance of stroke and thromboembolism, reduction of symptoms by rate and rhythm control, and evaluation and dynamic reassessment. The management strategy should prioritize the patient's individual risk of thromboembolism, symptoms, and quality of life 1.
Initial Evaluation and Management
The initial evaluation should include a thorough medical history, assessment of symptoms and their impact, blood tests, echocardiography or other imaging, patient-reported outcome measures, and risk factors for thromboembolism and bleeding 1. The patient's CHA₂DS₂-VASc score should be assessed to determine the risk of stroke and thromboembolism, and anticoagulation should be initiated accordingly.
Rate Control and Rhythm Control
For rate control, beta-blockers such as metoprolol or calcium channel blockers like diltiazem can be used to control heart rate to less than 110 beats per minute 1. Rhythm control can be considered in all suitable AF patients, and the decision to use cardioversion, antiarrhythmic drugs, or catheter or surgical ablation should be made based on the patient's individual characteristics and preferences.
Anticoagulation
Direct oral anticoagulants (DOACs) such as apixaban are preferred over vitamin K antagonists (VKAs) for anticoagulation, unless the patient has a mechanical heart valve or mitral stenosis 1. The dose of the anticoagulant should be adjusted based on the patient's individual risk factors and renal function.
Follow-up and Reassessment
Close follow-up within 1-2 weeks is essential to reassess the patient's rhythm status, medication effectiveness, and adjust the management strategy as needed. The patient should be educated on the importance of adherence to the treatment plan, recognition of symptoms, and follow-up appointments to ensure optimal management of their AF.
Key considerations in the management of this patient include:
- Assessment of the patient's individual risk of thromboembolism and bleeding
- Initiation of anticoagulation based on the CHA₂DS₂-VASc score
- Use of beta-blockers or calcium channel blockers for rate control
- Consideration of rhythm control strategies such as cardioversion or antiarrhythmic drugs
- Education and follow-up to ensure optimal management and adherence to the treatment plan 1.
From the Research
Management of Atrial Fibrillation after Dental Procedure
- The management of atrial fibrillation (A fib) in a previously normotensive patient with resolved bradycardia that developed after a dental procedure involves rate control using medications such as diltiazem, metoprolol, or verapamil 2, 3, 4.
- Studies have shown that there is no significant difference in the effectiveness of these medications for rate control in A fib patients 2, 3.
- However, one study found that diltiazem was more effective in achieving rate control in patients with atrial fibrillation or flutter with rapid ventricular rate in the emergency department 4.
- Another study found that metoprolol was associated with a lower risk of adverse events, including hypotension and bradycardia, compared to diltiazem 5.
- It is also important to consider the potential triggers of A fib, such as anxiety and stress, which can be exacerbated by dental procedures 6.
Medication Options
- Diltiazem: a calcium channel blocker that can be used for rate control in A fib patients 2, 3, 4.
- Metoprolol: a beta-blocker that can be used for rate control in A fib patients 2, 3, 5.
- Verapamil: a calcium channel blocker that can be used for rate control in A fib patients 2.