Afib Management Is Irregularly Irregular

Spoon Feed Atrial fibrillation (afib) is associated with significant morbidity and mortality and is best treated through longitudinal management of rate control, stroke prevention, risk factor modification, and cardioversion.

Why does this matter?
Treatment of afib varies across the globe.  We have covered that delayed vs. early cardioversion is non-inferior, rhythm control in the first year may be superior to rate control, and there is no difference in acute rate control success with metoprolol vs. diltiazem (here as well). We know that the management is irregularly irregular but seems to encompass some form of rate control, stroke prevention, risk factor modification, and occasionally cardioversion.

The Beat Goes on and… on, on, on… on, and on
This is a concise article from the New England Journal reviewing the management of afib.  Afib increases the incidence of stroke, heart failure, dementia, and overall mortality.  It stems from electrophysiological abnormalities in the pulmonary vein sleeves, progressing from paroxysmal to persistent to long standing.  It is diagnosed with ECG.  This article spares the management of afib in the ED.  Most of the outpatient management involves identification and reduction of risk factors (HTN, alcohol use, diabetes), echocardiogram to look for structural issues, stroke risk prediction with CHA2DS2-VASc score to determine anticoagulation, and shared decision making for long-term rate vs. rhythm control. Overall, my take away for the Emergency Department is that we will see a wide variation of management strategies, and we should be aware of several complications discussed in this paper:

  1. Anticoagulation decreases stroke risk but does not eliminate it.

  2. Many rhythm control agents (flecainide, sotalol, and propafenone) dramatically increase the QT interval.

  3. Some patients with heart failure and afib are treated with digoxin – beware of toxicity.

  4. Many patients with ablations will return in afib (15–50%).

  5. Ablation-associated complications include left atrial-esophageal fistula, pulmonary vein stenosis, and cardiac tamponade.

Source
Atrial Fibrillation. N Engl J Med. 2021 Jan 28;384(4):353-361. doi: 10.1056/NEJMcp2023658.

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