Management of acute atrial fibrillation and atrial flutter in non-pregnant hospitalized adults.

Note from the University of Michigan Health System (UMHS) and the National Guideline Clearinghouse (NGC): The following guidance was current as of May 2014. Because UMHS occasionally releases minor revisions to its guidance based on new information, users may wish to consult the original guideline document 

Note from NGC: The following key points summarize the content of the guideline. Refer to the full text of the original guideline document for detailed information on each of the screening procedures.

The strength of recommendation (I-III) and levels of evidence (A-D) are defined at the end of the "Major Recommendations" field.

Key Points

Clinical Presentation

Patients presenting with palpitations, irregular pulse, chest pain, dyspnea, fatigue, lightheadedness, syncope, cardio-embolic disease and new or recurrent heart failure should be evaluated for atrial fibrillation/atrial flutter (AF/AFL). While AF may be asymptomatic and found incidentally, AFL is usually highly symptomatic.

Diagnosis

Electrocardiogram (ECG) is essential in the diagnosis of AF/AFL. The initial evaluation is summarized in Table 1 in the original guideline document and should include:

• Physical exam
• Laboratory evaluation: complete blood count (CBC), basic metabolic profile, magnesium, thyroid-stimulating hormone, and cardiac enzymes as indicated
• Imaging: chest X-ray, echocardiogram
• Continuous telemetry monitoring in the hospital

Treatment

Initial treatment of AF/AFL depends on hemodynamic stability.

Unstable AF/AFL (refer to Figure 1 in the original guideline document):

• Begin resuscitation and consider other conditions contributing to instability.
• If instability due to AF/AFL - immediate direct current cardioversion.

Stable AF/AFL (refer to Figure 2 in the original guideline document):

• For emergency department (ED) patients: Screen for early cardioversion in the ED (refer to Figure 4 in the original guideline document).
• Administer rate controlling agents as indicated (refer to Table 4 in the original guideline document) – [I, B].
  • Electrophysiology (EP) consult for uncontrolled rate despite adequate trial of rate controlling agents.
• Consider the appropriateness of a rhythm control strategy (refer to Table 3 in the original guideline document) – [I, B].
  • If rhythm control strategy is appropriate/desired, consult EP and start immediate anticoagulation (refer to Figure 3 in the original guideline document).
• Consider anticoagulation based on CHA₂DS₂-VAS_c score (refer to Table 2 and Figure 3 in the original guideline document) – [I, A].
  • The choice of anticoagulant will depend on the patient's clinical circumstances and renal function (refer to Figure 3 in the original guideline document).
  • Obtain Neurology consult prior to initiation of anticoagulation for patients with recent ischemic stroke within the prior two weeks.
  • Patients with valvular disease and those requiring concomitant treatment with dual antiplatelet therapy should be anticoagulated with warfarin.
  • Target-specific oral anticoagulants are preferred over warfarin in many cases.

Definitions:

Levels of Evidence

1. Randomized controlled trials
2. Controlled trials, no randomization
3. Observational trials
4. Opinion of expert panel

Strength of Recommendation

1. Generally should be performed
2. May be reasonable to perform
3. Generally should not be performed

The following algorithms are provided in the original guideline document:

• Acute management of UNSTABLE atrial fibrillation and atrial flutter (AF/AFL)
• Acute management of STABLE atrial fibrillation and atrial flutter with rapid ventricular response
• Management of anticoagulation therapy in atrial fibrillation and atrial flutter
• Emergency department screening for early cardioversion of atrial fibrillation and atrial flutter

An algorithm titled "Management of acute atrial fibrillation/flutter after thoracic surgery" is also provided in Appendix C in the original guideline document.

The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).

Conclusions were based on prospective randomized clinical trials (RCTs) if available, to the exclusion of other data; if RCTs were not available, observational studies were admitted to consideration. If no such data were available for a given link in the problem formulation, expert opinion was used to estimate effect size.

It is hoped that standardization of care will result in improved patient outcomes, shorter length of hospital stay, lower readmission rates, and overall cost savings for the system.

Note from the University of Michigan Health System (UMHS) and the National Guideline Clearinghouse (NGC): The following guidance was current as of May 2014. Because UMHS occasionally releases minor revisions to its guidance based on new information, users may wish to consult the original guideline document 

Note from NGC: The following key points summarize the content of the guideline. Refer to the full text of the original guideline document for detailed information on each of the screening procedures.

The strength of recommendation (I-III) and levels of evidence (A-D) are defined at the end of the "Major Recommendations" field.

Key Points

Clinical Presentation

Patients presenting with palpitations, irregular pulse, chest pain, dyspnea, fatigue, lightheadedness, syncope, cardio-embolic disease and new or recurrent heart failure should be evaluated for atrial fibrillation/atrial flutter (AF/AFL). While AF may be asymptomatic and found incidentally, AFL is usually highly symptomatic.

Diagnosis

Electrocardiogram (ECG) is essential in the diagnosis of AF/AFL. The initial evaluation is summarized in Table 1 in the original guideline document and should include:

• Physical exam
• Laboratory evaluation: complete blood count (CBC), basic metabolic profile, magnesium, thyroid-stimulating hormone, and cardiac enzymes as indicated
• Imaging: chest X-ray, echocardiogram
• Continuous telemetry monitoring in the hospital

Treatment

Initial treatment of AF/AFL depends on hemodynamic stability.

Unstable AF/AFL (refer to Figure 1 in the original guideline document):

• Begin resuscitation and consider other conditions contributing to instability.
• If instability due to AF/AFL - immediate direct current cardioversion.

Stable AF/AFL (refer to Figure 2 in the original guideline document):

• For emergency department (ED) patients: Screen for early cardioversion in the ED (refer to Figure 4 in the original guideline document).
• Administer rate controlling agents as indicated (refer to Table 4 in the original guideline document) – [I, B].
  • Electrophysiology (EP) consult for uncontrolled rate despite adequate trial of rate controlling agents.
• Consider the appropriateness of a rhythm control strategy (refer to Table 3 in the original guideline document) – [I, B].
  • If rhythm control strategy is appropriate/desired, consult EP and start immediate anticoagulation (refer to Figure 3 in the original guideline document).
• Consider anticoagulation based on CHA₂DS₂-VAS_c score (refer to Table 2 and Figure 3 in the original guideline document) – [I, A].
  • The choice of anticoagulant will depend on the patient's clinical circumstances and renal function (refer to Figure 3 in the original guideline document).
  • Obtain Neurology consult prior to initiation of anticoagulation for patients with recent ischemic stroke within the prior two weeks.
  • Patients with valvular disease and those requiring concomitant treatment with dual antiplatelet therapy should be anticoagulated with warfarin.
  • Target-specific oral anticoagulants are preferred over warfarin in many cases.

Definitions:

Levels of Evidence

1. Randomized controlled trials
2. Controlled trials, no randomization
3. Observational trials
4. Opinion of expert panel

Strength of Recommendation

1. Generally should be performed
2. May be reasonable to perform
3. Generally should not be performed

The following algorithms are provided in the original guideline document:

• Acute management of UNSTABLE atrial fibrillation and atrial flutter (AF/AFL)
• Acute management of STABLE atrial fibrillation and atrial flutter with rapid ventricular response
• Management of anticoagulation therapy in atrial fibrillation and atrial flutter
• Emergency department screening for early cardioversion of atrial fibrillation and atrial flutter

An algorithm titled "Management of acute atrial fibrillation/flutter after thoracic surgery" is also provided in Appendix C in the original guideline document.

The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).

Conclusions were based on prospective randomized clinical trials (RCTs) if available, to the exclusion of other data; if RCTs were not available, observational studies were admitted to consideration. If no such data were available for a given link in the problem formulation, expert opinion was used to estimate effect size.

It is hoped that standardization of care will result in improved patient outcomes, shorter length of hospital stay, lower readmission rates, and overall cost savings for the system.

Note from the University of Michigan Health System (UMHS) and the National Guideline Clearinghouse (NGC): The following guidance was current as of May 2014. Because UMHS occasionally releases minor revisions to its guidance based on new information, users may wish to consult the original guideline document 

Note from NGC: The following key points summarize the content of the guideline. Refer to the full text of the original guideline document for detailed information on each of the screening procedures.

The strength of recommendation (I-III) and levels of evidence (A-D) are defined at the end of the "Major Recommendations" field.

Key Points

Clinical Presentation

Patients presenting with palpitations, irregular pulse, chest pain, dyspnea, fatigue, lightheadedness, syncope, cardio-embolic disease and new or recurrent heart failure should be evaluated for atrial fibrillation/atrial flutter (AF/AFL). While AF may be asymptomatic and found incidentally, AFL is usually highly symptomatic.

Diagnosis

Electrocardiogram (ECG) is essential in the diagnosis of AF/AFL. The initial evaluation is summarized in Table 1 in the original guideline document and should include:

• Physical exam
• Laboratory evaluation: complete blood count (CBC), basic metabolic profile, magnesium, thyroid-stimulating hormone, and cardiac enzymes as indicated
• Imaging: chest X-ray, echocardiogram
• Continuous telemetry monitoring in the hospital

Treatment

Initial treatment of AF/AFL depends on hemodynamic stability.

Unstable AF/AFL (refer to Figure 1 in the original guideline document):

• Begin resuscitation and consider other conditions contributing to instability.
• If instability due to AF/AFL - immediate direct current cardioversion.

Stable AF/AFL (refer to Figure 2 in the original guideline document):

• For emergency department (ED) patients: Screen for early cardioversion in the ED (refer to Figure 4 in the original guideline document).
• Administer rate controlling agents as indicated (refer to Table 4 in the original guideline document) – [I, B].
  • Electrophysiology (EP) consult for uncontrolled rate despite adequate trial of rate controlling agents.
• Consider the appropriateness of a rhythm control strategy (refer to Table 3 in the original guideline document) – [I, B].
  • If rhythm control strategy is appropriate/desired, consult EP and start immediate anticoagulation (refer to Figure 3 in the original guideline document).
• Consider anticoagulation based on CHA₂DS₂-VAS_c score (refer to Table 2 and Figure 3 in the original guideline document) – [I, A].
  • The choice of anticoagulant will depend on the patient's clinical circumstances and renal function (refer to Figure 3 in the original guideline document).
  • Obtain Neurology consult prior to initiation of anticoagulation for patients with recent ischemic stroke within the prior two weeks.
  • Patients with valvular disease and those requiring concomitant treatment with dual antiplatelet therapy should be anticoagulated with warfarin.
  • Target-specific oral anticoagulants are preferred over warfarin in many cases.

Definitions:

Levels of Evidence

1. Randomized controlled trials
2. Controlled trials, no randomization
3. Observational trials
4. Opinion of expert panel

Strength of Recommendation

1. Generally should be performed
2. May be reasonable to perform
3. Generally should not be performed

The following algorithms are provided in the original guideline document:

• Acute management of UNSTABLE atrial fibrillation and atrial flutter (AF/AFL)
• Acute management of STABLE atrial fibrillation and atrial flutter with rapid ventricular response
• Management of anticoagulation therapy in atrial fibrillation and atrial flutter
• Emergency department screening for early cardioversion of atrial fibrillation and atrial flutter

An algorithm titled "Management of acute atrial fibrillation/flutter after thoracic surgery" is also provided in Appendix C in the original guideline document.

The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).

Conclusions were based on prospective randomized clinical trials (RCTs) if available, to the exclusion of other data; if RCTs were not available, observational studies were admitted to consideration. If no such data were available for a given link in the problem formulation, expert opinion was used to estimate effect size.

It is hoped that standardization of care will result in improved patient outcomes, shorter length of hospital stay, lower readmission rates, and overall cost savings for the system.