From the Guidelines
The management of a 75-year-old male presenting to the ED with palpitations and newly diagnosed rapid atrial fibrillation (AF) with normal blood pressure and no history of atrial fibrillation or ischemic heart disease should prioritize rate control as the initial step, using beta-blockers such as metoprolol or digoxin, according to the 2024 ESC guidelines for the management of atrial fibrillation 1. The initial evaluation should include a thorough medical history, assessment of symptoms and their impact, blood tests, echocardiography, and patient-reported outcome measures to identify potential triggers and comorbidities, as recommended in the guidelines 1. Key considerations in the management of this patient include:
- Rate control therapy: using beta-blockers (any ejection fraction), digoxin (any ejection fraction), or diltiazem/verapamil (LVEF >40%) as initial therapy in the acute setting, as outlined in the guidelines 1
- Anticoagulation: calculating the CHA₂DS₂-VASc score to determine stroke risk, with anticoagulation likely indicated given the patient's age, and using DOACs (apixaban, dabigatran, edoxaban, and rivaroxaban) as preferred over VKAs (warfarin and others) 1
- Rhythm control: considering cardioversion or antiarrhythmic drugs, but prioritizing safety and anticoagulation, and delaying cardioversion for at least 3 weeks if AF duration is >24 hours 1 The patient should be admitted for observation and further management, including initiation of oral rate control medications and anticoagulation, as needed, to balance immediate symptom control with assessment of underlying causes and prevention of thromboembolic complications, in line with the guidelines 1.
From the Research
Management of Atrial Fibrillation
The management of a 75-year-old male presenting to the Emergency Department (ED) with palpitations and newly diagnosed rapid atrial fibrillation (AF) with normal blood pressure and no history of atrial fibrillation or ischemic heart disease involves several key considerations:
- Immediate direct-current (DC) cardioversion should not be performed in this case, as the patient has normal blood pressure and no signs of acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope 2, 3.
- Intravenous beta blockers, diltiazem, or verapamil may be administered to slow immediately a very rapid ventricular rate in AF 2, 3.
- An oral beta blocker, verapamil, or diltiazem should be used in persons with AF if a fast ventricular rate occurs at rest or during exercise despite digoxin 2, 3.
- Amiodarone may be used in selected patients with symptomatic life-threatening AF refractory to other drugs 2, 3.
Rate and Rhythm Control Strategies
The treatment of AF involves two main strategies: prevention of stroke and systemic embolism and symptom control with either a rate or a rhythm control strategy 4.
- Rate control is often the initial strategy used for symptom control in AF, using medications like beta-blockers and non-dihydropyridine calcium channel blockers 4.
- Rhythm control with antiarrhythmic medications with or without catheter ablation may lead to a reduction in major adverse cardiovascular events, particularly in patients newly diagnosed with AF 4.
Anticoagulation Therapy
Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0 2, 3.