QuickDoc.

Diagnosis

• Palpate carotid for more reliable measure of pulse.
• Suspect paroxysmal AF if symptoms are episodic and last less than 48 hours
• Absence of irregular pulse makes AF unlikely. Its presence does not reliably indicate AF.
• ECG in AF has – no P-wave, a chaotic baseline and an irregular ventricular rate
• Rate is usually 160-180 BPM, but can be lower in typically in asymptomatic patients
• If paroxysmal AF suspected and not found on ECG
  • Arrange ambulatory ECG
  • 24 hour ECG if symptoms < 24h apart, or event recorder ECG/7 Day Holter if > 24h apart

Management

• Onset in last 48h
  • If haemodynamic instability (Pulse > 150BPM) and/or Low BP (systolic < 90) or LOC, severe dizziness, chest pains or SOB -> A&E for electrical cardioversion
  • Else – consider management in primary care if appropriate or refer to acute medical unit for immediate cardioversion
    • if has suspected decompensated HF, seek specialist advice on use of BB and avoid CCB.
    • Most people with symptomatic acute onset AF are initially managed in secondary care.
• For others (including paroxysmal AF)
  • Admit if – haemodynamic instability, or other serious associated condition, e.g. CVA, PE, pneumonia, thyrotoxicosis, severe HF
  • Else – Screen for causes of AF and manage or refer as appropriate
    • Cardiac – HTN, Valve disease, HF, IHD
    • Respiratory – LRTI, Lung cancer
    • Systemic causes – Alcohol, hyperthyroidism, Electrolyte imbalance (U&E, calcium and magnesium), infection, DM
  • Cardiology referral needed if
    • A pre-excitation syndrome e.g. WPW syndrome
    • Valve disease associated with AF
    • HF suspected
    • For consideration of pharmacological or electrical rhythm control (Cardioversion)
      • AF has reversible cause – e.g. LRTI
      • HF caused or worsened by AF
  • Primary care management
    • Assess stroke risk using CHA2DS2VASc assessment tool
    • Assess bleeding risk using ORBIT bleeding risk tool 
    • If anticoagulation necessary
      • Offer DOAC
        • Apixaban, Rivaroxaban, Dabigatran and Edoxaban are all suitable
          • Apixaban and Rivaroxaban are reversed by Andexanet alfa and Dabigatran is reversed by Idarucizumab. Edoxaban has no reversing agent.
          • Do not withhold solely because of age or falls risk
      • Warfarin if DOAC not suitable
      • If anticoagulation is contraindicated – consider combination Aspirin and Clopidogrel
    • Rate control
      • 1st line – BB (other than sotalol) or CCB (Diltiazem or verapamil note avoid in HF with reduced EF)
      • 2nd line – Digoxin (for non-paroxysmal AF if they do little/no exercise or others rate limiting drugs ruled out)
      • Arrange follow up in 1 week
        • Aim 60-80 BMP at rest, and 90-115 at moderate exercise
          • Titrate up to maximum dosage if needed to control HR and/or BP
          • If still poorly controlled – consider combination with any two of BB, digoxin or Diltazem*
            • * Specialist advice needed for BB and Diltazem combination (risk bradycardia, AV block, asystole or sudden death)
        • Consider referral for cardioversion if symptoms continue or rate control fails – to see specialist within 4 weeks