From the Guidelines
A comprehensive atrial fibrillation (AFib) workup should prioritize the AF-CARE framework, focusing on comorbidity and risk factor management, avoiding stroke and thromboembolism, reducing symptoms through rate and rhythm control, and evaluation and dynamic reassessment, as outlined in the 2024 ESC guidelines 1. The workup should begin with 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.
- Echocardiography is essential to assess cardiac structure and function, particularly left atrial size and ventricular function.
- Additional testing may include ambulatory ECG monitoring (24-hour Holter or longer event monitors) to characterize the AFib pattern and frequency.
- Risk stratification using the CHA₂DS₂-VASc score guides anticoagulation decisions, with options including warfarin (target INR 2-3) or direct oral anticoagulants like apixaban (5mg twice daily), rivaroxaban (20mg daily), or dabigatran (150mg twice daily) 1.
- Rate control medications typically include beta-blockers (metoprolol 25-100mg twice daily), calcium channel blockers (diltiazem 120-360mg daily), or digoxin (0.125-0.25mg daily).
- For rhythm control, options include antiarrhythmic drugs like amiodarone, flecainide, or propafenone, with consideration for cardioversion or catheter ablation in appropriate candidates, as recommended in the 2016 ESC guidelines 1. This comprehensive approach is necessary because AFib increases stroke risk five-fold and can indicate underlying cardiac or systemic disease requiring specific management, emphasizing the importance of patient empowerment, education, and a patient-centered, shared decision-making approach 1.
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 2
- The initial evaluation should include transthoracic echocardiography; serum electrolyte levels; complete blood count; and thyroid, kidney, and liver function tests 2
- Pulse palpation and heart auscultation also may detect atrial fibrillation 3
Risk Assessment
- Stroke risk should be assessed in patients with atrial fibrillation using the CHA2DS2-VASc score 2
- The American Heart Association/American College of Cardiology, the European Society of Cardiology, and the Canadian Cardiovascular Society provide recommendations for management of atrial fibrillation 4
- Patients with atrial fibrillation are at increased risk of stroke and all-cause mortality, with a 5-fold increased risk for stroke without anticoagulant treatment 3
Management of Atrial Fibrillation
- Hemodynamically unstable patients, including those with decompensated heart failure, should be evaluated and treated emergently 2, 4
- Most hemodynamically stable patients should be treated initially with rate control and anticoagulation 2, 4
- Rhythm control, using medications or procedures, should be considered in patients with hemodynamic instability or in some patients based on risk factors and shared decision-making 2, 4
- Electrical cardioversion may be appropriate as first-line rhythm control 2, 4
- Direct oral anticoagulants are a safe and reliable option for anticoagulation 4, 5
- Warfarin and direct oral anticoagulants reduce the risk of stroke by preventing atrial thrombus formation and subsequent cerebral or systemic emboli 2, 5
Treatment Protocols
- Several 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 6
- 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 6