EVIDENCE BASED MANAGEMENT OF (stable) AFIB

New Diagnosis of Afib

Step #1: Is this Primary vs Secondary Afib?

Primary AFib vs Seconary Afib
Look for Secondary Causes
-Surgery
-Thyroid
-EToH, Drugs etc
-Valvular Disease
-Pulmonary Embolism (PE)
-Acute MI

Class I: Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is
recommended (ACC/ AHA Guidelines on AFib: Circulation 2014; 130: e229)


Step #2: Are they Symptomatic? (Including if they have low LVEF)?



          Step 3: Determining Anticoagulation
          -In patients with non-valvular AF with a CHADS2VASc Score > 2 anticoagulate
          (ACC/ AHA Guidelines on AFib Circulation 2014; 130: e212)
          -If inpatient and wanting to DCCV start anticoagulation (ie heparin gtt, LMWH etc)
          “For patients with AF or atrial flutter of more than 48 hours’ duration or unknown duration that requires immediate cardioversion for hemodynamic instability, anticoagulation should be initiated as soon as possible and continued for at least 4 weeks after cardioversion unless contraindicated.”
          “For patients with AF or atrial flutter of less than 48 hours’ duration and high risk of stroke, intravenous heparin or LMWH, or administration of a factor Xa or direct thrombin inhibitor is recommended as soon as possible before or immediately after cardioversion, followed by long term anticoagulation therapy”
          (ACC/ AHA Guidelines on AFib Circulation 2014; 130: e226)



          Step 4: Working up new onset Afib
          -Determine potential causes of Secondary afib and obtain labs as appropriate (ie TSH
          etc)
          -Obtain TTE



          Step 5: Initial Trial of Rhythm Control (DCCV +/- AAD)
          It is a Reasonable Approach that for every New Diagnosis / New Onset Afib they get at least 1 chance at sinus rhythm (DCCV +/- AAD)
          “For patients with new-onset atrial fibrillation in particular, at least 1 attempt at restoration of normal sinus rhythm by either electrical or chemical cardioversion may be reasonable.”
          -Ryan Aleong and Paul Varosy. “Evaluation and Management of New-Onset Atrial Fibrillation” Journal of Clinical Outcomes Management
          We believe that most patients with symptomatic new onset AF and most patients with apparently asymptomatic AF should have at least one attempt at cardioversion (either electrical or chemical) to sinus rhythm.”
          -Uptodate: Phange, Robert and Brian Olshansky, MD. “Management of new onset atrial fibrillation.”  


          (Please note that the Affirm Trial studied recurrent Afib, **
          NOT** new onset afib)