← Diagnosis and Management Guides
Atrial Fibrillation
Key considerations: Rapid AFib with hemodynamic instability, WPW with AFib, New AFib from PE, sepsis, or MI
Cannot miss
- Rapid AFib with hemodynamic instability
- WPW with AFib
- New AFib from PE, sepsis, or MI
Likely diagnoses
- Atrial fibrillation
- Atrial flutter
- Multifocal atrial tachycardia
- Frequent PACs
Red flags
- Hemodynamic instability
- Rate >150 with symptoms
- Chest pain
- Acute heart failure
Workup
- history: Palpitations, dyspnea, duration, prior episodes, anticoagulation; exam: Irregularly irregular pulse, signs of CHF; labs: TSH, BMP, CBC, magnesium, troponin if chest pain; BNP if CHF concern; imaging: CXR, echo (evaluate for structural heart disease, LA size); bedside: 12-lead ECG
Management
- immediate: Unstable: synchronized cardioversion 100-200J; Stable with RVR: IV diltiazem 0.25mg/kg bolus or metoprolol 5mg IV; general: Rate control target <110 bpm at rest; Anticoagulation: CHA2DS2-VASc score — DOAC preferred over warfarin; Rhythm control if symptomatic despite rate control
Disposition
- admit: New AFib with heart failure, unable to rate control, requiring cardioversion; discharge: Known AFib with controlled rate and on anticoagulation; consults: Cardiology for ablation consideration, new-onset with structural disease
Clinical pearls
- Unstable = cardiovert, regardless of anticoagulation status or duration
- New-onset AFib <48hr can be cardioverted without TEE; >48hr needs TEE or 3 weeks of anticoagulation first
Source and review
- AHA/ACC AFib Guidelines 2023. Last reviewed: 2024-11-01