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

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

• “Etiology of Atrial Fibrillation” schematic.