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Background

• Ectopic atrial rhythm originating from abnormal foci near pulmonary veins
• Variable AV nodal conduction and ventricular rate (75-125 BPM)
• Classification: Paroxysmal, persistent, or permanent
• Risk factors: Age > 80, hypertension (HTN), coronary artery disease (CAD), atrial abnormalities, hyperthyroidism
• Triggers: Alcohol (EtOH), increased catecholamines (infection, surgery, pain)
• Symptoms: Asymptomatic or symptomatic (palpitations, presyncope, dyspnea)

Complications of Atrial Fibrillation

• Tachyarrhythmia-induced cardiomyopathy: Dilated cardiomyopathy from prolonged tachycardia
• Embolic events: Stroke, mesenteric ischemia, limb ischemia, etc.

Diagnosis

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Management of New Onset Atrial Fibrillation

Step 1: Rate control (if necessary)

• Beta-blocker or calcium channel blocker (CCB)
• Goal: HR 110-120 BPM

Step 2: Cardioversion (if still in AF after rate control)

• Preferred method: DC electrical cardioversion
• Drug options: Flecainide, propafenone, or ibutilide
  • Anticoagulation required for at least 3 weeks or AF developed within the last 48 hr

Step 3: If in RVR: IV beta-blockers, CCB, Digoxin, or amiodarone

Step 4: Chronic therapy

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Chronic Therapy

Rate Control

• Goal HR: < 85 BPM (symptomatic), < 110 BPM (asymptomatic)
• Drug choice: Beta-blocker (e.g., metoprolol), alternative options: CCB, digoxin

Rhythm Control

• Indication: < 65 years old, symptomatic patients requiring restoration of sinus rhythm
• Medications: Flecainide, propafenone, sotalol (if CAD present), amiodarone (if CHF present)

Anticoagulation

Indications assessed using CHA2DS2-VASc score

• DOAC (dabigatran, rivaroxaban, apixaban)
• Warfarin (INR 2-3)

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Compare to risk of Bleeding with Anticoagulation using HASBLED

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Surgical Intervention for Atrial Fibrillation

• Pulmonary vein isolation for severe cases