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Atrial fibrillation

Definition
AF is a cardiac arrhythmia characterized by a diffuse and abnormal pattern of electrical activity in the atria of the heart.
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Pathophysiology
The development of AF is related to structural and electrophysiological abnormalities resulting from comorbid conditions (including hypertension, diabetes mellitus, obesity, obstructive sleep apnea, myocardial infarction, HF), genetics, sex, and other factors.
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Epidemiology
The prevalence of AF in the US ranges is estimated at 700-775 cases per 100,000 persons.
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Disease course
In patients with AF, rapid and irregular atrial contractions lead to tachyarrhythmias, which lead to symptoms of palpitations, dyspnea, and an increased risk of HF; as well as stasis of blood in the LAA, which increases the risk of stroke and systemic embolism.
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Prognosis and risk of recurrence
AF is estimated to cause 15% of all strokes and is associated with a 5-fold increased risk of stroke and a 2-fold risk for all-cause mortality, respectively.
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Key sources
The following summarized guidelines for the evaluation and management of atrial fibrillation are prepared by our editorial team based on guidelines from the American Heart Association (AHA/HRS/ACC/ACCP 2024), the Society of Thoracic Surgeons (STS 2024), the European Society of Hypertension (ESH 2023), the Canadian Cardiovascular Society (CCS/CAIC 2023), the Society for Cardiovascular Angiography and Interventions (SCAI/HRS 2023), the U.S. Preventive Services Task Force (USPSTF 2022), the European Society of Cardiology (ESC/EACTS 2021), the Canadian Cardiovascular Society (CCS/CHRS 2020), the Cardiac Society of Australia and New Zealand (CSANZ/NHFA 2018), the American Academy of Family Physicians (AAFP 2017), and the American Academy of Neurology (AAN 2014).
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Guidelines

1.Screening and diagnosis

Indications for screening, general population, USPSTF: insufficient evidence to assess the balance of benefits and harms of screening for AF in individuals aged ≥ 50 years without a diagnosis or symptoms of AF and without a history of TIA or stroke.
I
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  • Indications for screening (stroke)

  • Indications for screening (hypertension)

  • Indications for screening (obstructive sleep apnea)

  • Indications for screening (previous atrial arrhythmias)

  • Indications for screening (cardiac implantable electronic devices)

  • Confirmatory testing

2.Classification and risk stratification

Stroke risk assessment
As per ACC 2024 guidelines:
Assess the annual risk of thromboembolic events using a validated clinical risk score, such as the CHA2DS2-VASc score, in patients with AF.
B
Take into consideration factors that might modify the risk of stroke to help inform the decision in patients with AF at intermediate annual risk of thromboembolic events (based on risk scores, such as equivalent to CHA2DS2-VASc score of 1 in males or 2 in females) remaining uncertain about the benefit of anticoagulation.
B

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  • Bleeding risk assessment

3.Diagnostic investigations

Initial evaluation: as per ACC 2024 guidelines, obtain a TTE to assess cardiac structure, laboratory testing including a CBC, metabolic panel, and thyroid function, and when clinical suspicion exists, targeted testing to assess for other medical conditions associated with AF to determine stroke and bleeding risk factors, as well as underlying conditions that will guide further management in patients with newly diagnosed AF.
B

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  • Evaluation for hypertension

  • Evaluation for ischemia

  • Evaluation for sleep apnea

4.Medical management

General principles: as per ACC 2024 guidelines, provide comprehensive care addressing guideline-directed lifestyle risk factor modification, AF symptoms, risk of stroke, and other associated medical conditions to reduce AF burden, progression, or consequences.
A
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  • Management of intercurrent conditions

  • Management of secondary causes

  • Rate control (acute control, targets)

  • Rate control (acute control, choice of agents)

  • Rate control (long-term control, beta-blockers and CCBs)

  • Rate control (long-term control, digoxin)

  • Rate control (long-term control, amiodarone and dronedarone)

  • Rate control (long-term control, targets)

  • Rhythm control (general indications)

  • Rhythm control (pharmacological cardioversion, indications)

  • Rhythm control (pharmacological cardioversion, choice of agent)

  • Rhythm control (pharmacological cardioversion, pill-in-the-pocket)

  • Rhythm control (electrical cardioversion)

  • Rhythm control (maintenance therapy)

  • Anticoagulant therapy (general indications)

  • Anticoagulant therapy (DOACs)

  • Anticoagulant therapy (VKAs)

  • Anticoagulant therapy (peri-cardioversion)

  • Anticoagulant therapy (peri-catheter ablation)

  • Antiplatelet therapy

  • Management of bleeding (general principles)

  • Management of bleeding (direct thrombin inhibitors)

  • Management of bleeding (direct factor Xa inhibitors)

  • Management of bleeding (VKAs)

  • Management of bleeding (resumption of anticoagulation)

  • Management of hypertension (antihypertensive therapy)

  • Management of hypertension (rate control)

  • Management of hypertension (anticoagulation)

5.Nonpharmacologic interventions

Lifestyle modifications
Advise strict control of risk factors and avoidance of triggers as part of the rhythm control strategy.
B
Advise modifying unhealthy lifestyles to reduce the burden and symptom severity of AF.
B

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  • Weight loss

  • Physical activity

  • Smoking cessation

  • Alcohol restriction

  • Caffeine restriction

6.Therapeutic procedures

Catheter ablation, indications, HRS/ACCP/AHA/ACC: consider performing catheter ablation to improve symptoms in patients with symptomatic AF if antiarrhythmic drugs have been ineffective, contraindicated, not tolerated, or not preferred, and continued rhythm control is desired.
B
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  • Catheter ablation (technical considerations)

  • Catheter ablation (post-ablation antiarrhythmics)

  • Catheter ablation (post-ablation anticoagulation)

  • Atrioventricular nodal ablation (indications)

  • Atrioventricular nodal ablation (pacemaker placement)

7.Perioperative care

Pre-procedural anticoagulation interruption: as per ACC 2024 guidelines, interrupt oral anticoagulation without bridging anticoagulation in patients with AF, excluding patients with recent stroke or TIA or a mechanical valve, receiving oral anticoagulation with either warfarin
B
or a DOAC scheduled to undergo an invasive procedure or surgery.
B
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  • Pre-procedural anticoagulation bridging

  • Post-procedural resumption of anticoagulation

8.Surgical interventions

Left atrial appendage closure, indications, HRS/ACCP/AHA/ACC: consider performing percutaneous LAA occlusion in patients with AF, a moderate-to-high risk of stroke (CHA2DS2-VASc score ≥ 2), and contraindications to long-term oral anticoagulation due to a nonreversible cause.
C
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  • LAA closure (perioperative imaging)

  • LAA closure (technical considerations)

  • LAA closure (management of complications)

  • LAA closure (postoperative anticoagulation)

  • Surgical ablation

9.Specific circumstances

Athletes, physical activity, EACTS/ESC: counsel professional athletes that long-lasting, intense sports participation may promote AF, while moderate physical activity prevents AF.
B

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  • Athletes (catheter ablation)

  • Young patients

  • Elderly patients

  • Pregnant patients (rate control)

  • Pregnant patients (cardioversion)

  • Pregnant patients (maintenance therapy)

  • Pregnant patients (anticoagulation)

  • Critically ill patients

  • Patients with subclinical AF (evaluation)

  • Patients with subclinical AF (anticoagulation)

  • Patients with postoperative AF (prevention)

  • Patients with postoperative AF (rate and rhythm control)

  • Patients with postoperative AF (anticoagulation)

  • Patients with postoperative AF (monitoring)

  • Patients with atrial flutter (catheter ablation)

  • Patients with atrial flutter (anticoagulation)

  • Patients with WPW and pre-excitation syndromes (rate control)

  • Patients with WPW and pre-excitation syndromes (cardioversion)

  • Patients with WPW and pre-excitation syndromes (catheter ablation)

  • Patients with obesity

  • Patients with chronic liver disease

  • Patients with CKD

  • Patients with AIS

  • Patients with ICH

  • Patients with CAD

  • Patients with ACS

  • Patients with PAD

  • Patients with VHD

  • Patients with CHD (general principles of management)

  • Patients with CHD (anticoagulation)

  • Patients with CHD (catheter ablation)

  • Patients with CHD (surgery)

  • Patients with HCM

  • Patients with HF (evaluation)

  • Patients with HF (rate control)

  • Patients with HF (catheter ablation)

  • Patients with HF (atrioventricular nodal ablation and pacing)

  • Patients with pulmonary disease

  • Patients with hyperthyroidism

  • Patients with cancer

10.Patient education

General counseling: as per ESC 2021 guidelines, inform patients about the advantages/limitations and benefits/risks associated with treatment options to optimize shared decision-making about specific treatment options. Discuss the potential burden of the treatment and include the patient's perception of the treatment burden in the treatment decision.
B

11.Preventative measures

Primary prevention: as per ACC 2024 guidelines, offer comprehensive guideline-directed lifestyle risk factor modification for AF, targeting obesity, physical inactivity, unhealthy alcohol consumption, smoking, diabetes, and hypertension in patients at increased risk of AF.
B

12.Follow-up and surveillance

Serial clinical assessment: as per CCS 2020 guidelines, assess patient-reported AF-related symptoms and QoL with validated instruments as part of the longitudinal management of patients with AF.
B
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  • Serial electrocardiographic assessment

  • Assessment of treatment response

13.Quality improvement

Quality of care: as per ESC 2021 guidelines, consider introducing tools to measure quality of care and identifying opportunities for improved treatment quality and patient outcome.
C
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