Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Unstable → synchronized cardioversion + anticoagulation plan.
- Stable → rate control (β‑blocker/CCB) ± amiodarone (HFrEF).
- Rhythm control if symptoms persist or new onset; TEE if ≥48 h/unknown duration.
- Start/continue anticoagulation per CHA₂DS₂‑VASc; address triggers (sepsis, alcohol, thyroid).
Clinical Synopsis & Reasoning
Rapid AF can cause hypotension, ischemia, or heart failure. Stabilize ABCs; if unstable, perform synchronized cardioversion. If stable, choose rate control (β‑blocker or nondihydropyridine CCB; amiodarone if LV dysfunction/hypotension) versus rhythm control based on duration and comorbidities, and address anticoagulation using CHA₂DS₂‑VASc and bleeding risk.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| 12‑lead ECG and telemetry | Diagnosis | Irregularly irregular rhythm; exclude pre‑excitation | QT/QRS monitoring |
| Electrolytes, TSH, troponin, echo (selected) | Etiology/complications | Hypo‑K/Mg, thyrotoxicosis, structural heart disease | Guide therapy |
| Stroke risk/bleed risk scores (CHA₂DS₂‑VASc, HAS‑BLED) | Anticoagulation | Risk stratification | Shared decision |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Instability or organ dysfunction | High risk | ICU; escalate care |
| Failure of first-line therapy | Refractory | Advance pathway; consult subspecialists |
| Severe comorbidity/pregnancy/immunosuppression | Higher risk | Lower threshold to admit |
| Poor follow-up access | Safety | Prefer observation/admission |
| Diagnostic uncertainty with red flags | Missed diagnosis risk | Serial exams and monitoring |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Diltiazem IV bolus/infusion or Metoprolol IV | AV nodal blockade | Minutes | Rate control in stable patients | Avoid diltiazem in decompensated HFrEF |
| Amiodarone IV (if rate control failure or HFrEF) | Antiarrhythmic | Hours | Rate/rhythm in LV dysfunction | Monitor QT/LFTs |
| Electrical cardioversion (unstable) or TEE‑guided cardioversion (≥48 h or unknown duration) | Rhythm control | Immediate/Hours | Restore sinus rhythm | Anticoagulation per guideline |
| Anticoagulation: DOACs preferred; heparin bridge if needed | Stroke prevention | Hours‑days | Based on CHA₂DS₂‑VASc | Adjust for renal function |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- AHA/ACC/HRS AF management guideline — Link