From the Guidelines
A comprehensive atrial fibrillation (AFib) workup should include a 12-lead ECG to confirm the diagnosis, followed by a complete blood count, comprehensive metabolic panel, thyroid function tests, and cardiac biomarkers to identify underlying causes, as recommended by the 2024 ESC guidelines 1.
Initial Evaluation
The initial evaluation of a patient with suspected or proven AF involves characterizing the pattern of the arrhythmia as paroxysmal or persistent, determining its cause, and defining associated cardiac and extracardiac factors pertinent to the etiology, tolerability, and management 2.
- A careful history will result in a well-planned, focused workup that serves as an effective guide to therapy.
- Physical examination may suggest AF on the basis of irregular pulse, irregular jugular venous pulsations, variation in the intensity of the first heart sound, or absence of a fourth sound heard previously during sinus rhythm.
Diagnostic Testing
- Echocardiography is essential to assess cardiac structure and function, particularly left atrial size and ventricular function.
- A 24-hour Holter monitor or longer-term event recorder helps determine AFib burden and pattern (paroxysmal, persistent, or permanent).
- Risk stratification using the CHA₂DS₂-VASc score guides anticoagulation decisions, with direct oral anticoagulants (DOACs) like apixaban 5mg twice daily or rivaroxaban 20mg daily preferred for most patients with scores ≥2, as recommended by the 2016 ESC guidelines 3.
Management
- Rate control is typically achieved with beta-blockers (metoprolol 25-100mg twice daily) or calcium channel blockers (diltiazem 120-360mg daily).
- For rhythm control, antiarrhythmic medications like flecainide 50-150mg twice daily or amiodarone 200mg daily may be considered after cardioversion.
- Additional testing may include sleep studies to rule out sleep apnea, stress tests to evaluate for coronary artery disease, and electrophysiology studies for patients considering ablation therapy.
Patient-Centered Approach
- Patient empowerment is critical in any long-term medical problem to achieve better outcomes, encourage adherence, and to seek timely guidance on changes in clinical status, as emphasized in the 2024 ESC guidelines 1.
- A patient-centred, shared decision-making approach will facilitate the choice of management that suits each individual patient, particularly in AF where some therapies and interventions improve clinical outcomes, and others are focused on addressing symptoms and quality of life.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Diagnosis of Atrial Fibrillation
- Atrial fibrillation is diagnosed based on history and physical examination findings, and should be confirmed with 12-lead electrocardiography or other recording device 4, 5, 6
- Pulse palpation and heart auscultation may also detect atrial fibrillation 6
- Screening with ECG can identify new cases of atrial fibrillation, especially in asymptomatic patients 6
Initial Evaluation
- The initial evaluation should include transthoracic echocardiography; serum electrolyte levels; complete blood count; and thyroid, kidney, and liver function tests 4
- Stroke risk should be assessed in patients with atrial fibrillation using the CHA2DS2-VASc score 4, 5
- The HAS-BLED score can estimate the risk of bleeding 5
Treatment
- Treatment is based on decisions made regarding when to convert to normal sinus rhythm vs. when to treat with rate control, and, in either case, how to best reduce the risk of stroke 5
- Rate control is preferred to rhythm control for most patients 5
- Anticoagulation reduces the risk of stroke while increasing the risk of bleeding 4, 5
- Warfarin, dabigatran, factor Xa inhibitors, and aspirin are options for stroke prevention 5
- Ablation therapy can be used to destroy abnormal foci responsible for atrial fibrillation 5
- Left atrial appendage obliteration is an option for reducing stroke risk 5
Management in the Emergency Department
- Atrial fibrillation is responsible for 600,000 emergency department visits each year in the USA 7
- Treatment protocols have been developed to address challenges associated with atrial fibrillation management in the emergency department, including initiation of oral anticoagulant therapy, cardioversion, and arranging for outpatient follow-up 7
- Published treatment protocols for atrial fibrillation in the emergency department have been shown to reduce unnecessary hospital admissions and improve adherence to guideline-directed oral anticoagulant therapy 7
Comprehensive Care
- Building a comprehensive center of excellence for atrial fibrillation care can provide high-quality, individualized care 8
- Standardized protocols can promote best practices, and data collection can improve quality of care 8
- A dedicated atrial fibrillation clinic can demonstrate an improvement in the rate of anticoagulation usage and a reduction in hospitalizations among patients included in the program 8