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 underlying 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? ? Is the AF causing an immediate problem? When to consider rhythm control first: Emergent AF with severe decompensation: hypotension (SBP<100 or <110 for patients 65 and older), acute heart failure, altered mental status, cardiac ischemia if yes --> 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. Why is AF happening now? Fix electrolytes (magnesium is an effective rhythm control treatment). Fix volume status. Look for untreated infection. Remove beta-agonists. Should I worry about long-term problems from the AF? 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 2019 AHA/ACC/HRS Update 2014 AHA/ACC/HRS Guideline 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. 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. 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. 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. 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. 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. Bosch NA et al. Atrial fibrillation in the ICU. Chest. 2018;154:1424-1434. Supplemental Materials “Etiology of Atrial Fibrillation” schematic.