# Cardiovascular



# Evaluation and Management of Atrial Fibrillation

#### Purpose

- Establish a unified guideline for the diagnosis and treatment of atrial fibrillation (AF) in Acute Care Surgery patients.

#### Background/Definitions

- Primary AF: AF with no precipitating cause
- Secondary AF: AF precipitated by a secondary or reversible cause (e.g., volume overload, surgery, sepsis, etc. --most of your ICU patients)

#### Inclusion Criteria

- Patients with new onset atrial fibrillation.

#### Exclusion Criteria

- Patients with chronic atrial fibrillation.

#### Diagnostic Evaluation

- History: 
    - previous history of arrhythmia?
    - currently on anticoagulation?
- Physical: 
    - irregular heart rhythm
- Imaging/Labs/Tests: 
    - ECG
    - BMP+Mg+Phos
    - Other labs at discretion of provider (CBC, blood cultures/infectious work-up, cardiac enzymes, etc)

#### Practice Recommendations for Management 

- New-onset, secondary AF is an organ dysfunction that signals something is wrong--need to address <span style="text-decoration: underline;">*underlying*</span> *cause* while seeking to control rate/rhythm.
- Helpful questions to guide initial approach of patient with AF: 
    - 1) is the AF causing an immediate problem?
    - 2)why is AF happening now (is this primary or secondary AF)?
    - 3) should I worry about longer-term problems from the AF? ?

- <span style="text-decoration: underline;">Is the AF causing an immediate problem?</span>
    - When to consider rhythm control first: 
        - - Emergent AF with severe decompensation: 
                - - hypotension (SBP&lt;100 or &lt;110 for patients 65 and older), acute heart failure, altered mental status, cardiac ischemia
                    - if yes --&gt; DCCV (direct current cardioversion)
                    - consider pairing DCCV with anti-arrhythmic such as amiodarone to increase probability of longer-term success.
            - Non-emergent AF: 
                - - consider a rhythm control strategy first if you think the patient needs atrial kick (i.e. severe mitral stenosis, aortic stenosis) or cannot tolerate nodal blocker (Wolf Parkinson White Syndrome)
    - When to consider rate control first: 
        - - *Note: in most instances you can use rate control FIRST.*
            - Heart rate is higher than it would be with acute illness, but not immediately life threatening to require DCCV.
            - Patient has contraindications to anticoagulation.
            - Evidence to support a rate control strategy first during secondary AF: success of DCCV is low in secondary AF (as in ICU) --43% at 1 hr, 23% at 24 hrs remain in NSR.

- <span style="text-decoration: underline;">Why is AF happening now?</span>  
    
    - Fix electrolytes (magnesium is an effective rhythm control treatment).
    - Fix volume status.
    - Look for untreated infection.
    - Remove beta-agonists.

- <span style="text-decoration: underline;">Should I worry about long-term problems from the AF?</span>
    - Arterial thromboembolism and AF recurrence are long-term concerns after new-onset AF in critically ill patients 
        - - 44% af AF recurrence in 1 year after new-onset AF in sepsis.
    - Cardiology follow-up (either inpatient or outpatient) for long-term rhythm monitoring and treatment plan should be considered.

#### Outcome Measures and Guideline Adherence

- AF (arrhythmia) is a PI filters for Trauma and Critical Care Surgery that is actively tracked/monitored.

#### Related Policies

#### Key Contributors

- Keely Buesing ,MD, FACS, Acute Care Surgery Division

#### Last Updated

February, 2023

#### References

1. 2019 AHA/ACC/HRS Update
2. 2014 AHA/ACC/HRS Guideline
3. Um K et al. Pre- and post-treatment with amiodarone for elective electrical cardioversion of atrial fibrillation: a systematic review and meta-analysis. Europace. 2019;21(6):856-863.
4. Arrigo M et al. Disappointing success of electrical cardioversion for new-onset atrial fibrillation in cardiosurgical ICU patients. Crit Care Med. 2015;43(11):2354-2359.
5. Walkey AJ et al. Practice patterns and outcomes of treatments for atrial fibrillation during sepsis: a propensity-matched cohort study. Chest. 2016;149:74-83.
6. Bosch NA et al. Comparative effectiveness of heart rate control medications for the treatment of sepsis-associated atrial fibrillation. Chest. 2021;159(4):1452-1459.
7. Davey MJ et al. A randomized controlled trial of magnesium sulfate, in addition to usual care, for rate control in atrial fibrillation. Ann Emerg Med. 2005;45(4):347-353.
8. Onalan O et al. Meta-analysis of magnesium therapy for the acute management of rapid atrial fibrillation. Am J Cardiol. 2007;99(12):1726-1732.
9. Bosch NA et al. Atrial fibrillation in the ICU. Chest. 2018;154:1424-1434.

#### Supplemental Materials

- <span style="font-size: 11.0pt; line-height: 107%; font-family: 'Calibri',sans-serif; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin; mso-bidi-font-family: 'Times New Roman'; mso-bidi-theme-font: minor-bidi; mso-ansi-language: EN-US; mso-fareast-language: EN-US; mso-bidi-language: AR-SA;">“Etiology of Atrial Fibrillation” schematic.</span>