Sandbox/New Onset AF

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Mugilan Poongkunran M.B.B.S [2]

New Onset Atrial Fibrillation

Shown below is an algorithm depicting the management of patients with newly discovered atrial fibrillation based on the 2014 ACCF/AHA/HRS Guideline for the Management of Patients With Atrial Fibrillation.

Abbreviations: AF: Atrial fibrillation; BP: Blood pressure; DC: Direct current; EF: Ejection fraction; HR: Heart rate; SBP: Systolic blood pressure

New onset atrial fibrillation (Paroxysmal or persistent or permanent)

Stable: ❑ Asymptomatic OR ❑ Mild to moderate symptoms

Unstable: ❑ Hypotension ❑ Tachycardia ❑ Cold extremities ❑ Peripheral cyanosis ❑ Mottling ❑ Altered mental status ❑ Ongoing ischemia ❑ Decompensated heart failure

Does the patient require heart rate control therapy?

Does the patient has any symptoms and signs of pulmonary edema? ❑ Dyspnea ❑ Crackles ❑ Chest X-ray showing pulmonary edema

No (spontaneous cardioversion)

Yes

Yes

No

❑ Identify the underlying etiology and treat accordingly ❑ Proceed with anticoagulation strategy as shown below

❑ Proceed with the heart rate control strategy

Manage pulmonary edema: ❑ Initiate oxygen therapy ❑ High dose IV diuretics ❑ BP management ❑ SBP 85 - 100 mm Hg (dobutamine or milrinone) ❑ SBP < 85 mm Hg (dopamine and norepinephrine)

Immediate DC cardioversion

Did the patient achieve heart rate control goal: ❑ Resting HR <110 bpm in asymptomatic and EF > 40% patients ❑ Resting HR <80 bpm in symptomatic and EF < 40% patients

After initial pulmonary edema management proceed with DC cardioversion

Yes

No

Successful

Unsuccessful

❑ Identify the underlying etiology and treat accordingly ❑ Proceed with cardioversion strategy for initial symptomatic patients as shown below ❑ Proceed with anticoagulation strategy as shown below

❑ Identify the underlying etiology and treat accordingly ❑ Proceed with cardioversion strategy as shown below ❑ Proceed with anticoagulation strategy as shown below

Identify the underfying cause and treat accordingly

Repeat cardioversion: ❑ After adjusting the location of the electrodes and applying pressure over the electrodes OR ❑ After administration of an antiarrhythmic medication

Proceed with the anticoagulation strategy

References

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