Acute Atrial Fibrillation: What we do.

In this podcast we go on the patient journey, of a 61 yo patient who presents at 11pm at night with an irregularly irregular pulse, at a rate of 167 bpm and a complaint of palpitations.

How do you manage these patients?

1. Who to Cardiovert and who not to
2. Active vs Wait and See + can we predict who will cardiovert?
3. Drugs vs Electricity
4. Pads Placement
5. What Energy To Use?
6. Should We anticoagulate?
7. Some Scores that might change your practice

References

1.  Botto G L et al. Presence and duration of atrial fibrillation detected by continuous monitoring: crucial implications for the risk of thromboembolic events. J Cardiov Electrophysiol 2009;20:241-8
2. Cotter P E et al. Incidence of Atrial Fibrillation detected by implantable loop recorders in unexplained stroke. Neurology 2013;80: 1546-50
3. Healey J S etal. Subclinical Atrial Fibrillation and the risk of Stroke. NEJM 2012;266:120-129

4. Ip J et al. Multicenter randomised study of anticoagulation guided remote rhythm monitoring in patients with implantable cardiaoverter-defibrillator and CRT-D devices: Rationale, design and clinical characteristics of the initially enrolled cohort. Am Heart J 2009;188:364-70.

5. Boriani G et al. Device-detected atrial fibrillation and risk for stroke: an analysis of >10,000 patients from the SOS AF project (Stroke prevention Strategies based on Atrial Fibrillation information from implanted devices. Europ Heart J 2014;35:508-516.
6. Sposato L et al. Very short paroxysm account for more than half of the cases of atrial fibrillation detected after stroke and TIA: A Systematic review and Meta- Analysis. Int J Stroke. 2015;10:801-7
7. Gladstone D J et al. Atrial fibrillation in patients with cryptogenic stroke. NEJM 2014; 26:2467-2477.
8. Daoud EG et al. Temporal relationship of atrial tachyarrhythmias, cardiovascular events and systemic emboli based on stored device data: a subgroup analysis of trends. Heart Rhythm 2011; 8:1416-23

9. Palomaki A et al. Strokes after cardioversion of atrial fibrillation- The FibStroke Study. Int J Card 2016;203:269-273

10. Johansson AK, et al. Is one month treatment with dabigatran before cardioversion of atrial fibrillation sufficient to prevent thromboembolism? Europace. 2015;17:1514-1517.

11.  Hendrika A van den Ham et al. Major bleeding in users of direct oral anticoagulants in atrial fibrillation: A pooled analysis of results from multiple population-based cohort studies. Pharmacoepidemiol Drug Saf. . 2021 Oct;30(10):1339-1352.

12.  Lopes RD, et al. Rationale and design of the Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation (ARTESiA) trial. Am Heart J. 2017;189:137–145

13. Keith A A. et al. GARFIELD-AF risk score for mortality, stroke, and bleeding within 2 years in patients with atrial fibrillation. Europ Heart Jour - Quality of Care and Clinical Outcomes (2022) 8, 214–227
14. Pluymaekers N et al. Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation. NEJM 2019;380:1499-1508
15. Niederdockl J et al. Predicting Spontaneous Conversion to sinus rhythm in symptomatic atrial fibrillation: The ReSinus score. Eurpo J Int Med. 2021;83:45-53
16. Stiell IG et al. Electrical Versus Pharmacological Cardioversion for Emergency Department Patients with Acute Atrial Fibrillation (RAFF2): A Partial Factorial Randomised Trial. Lancet 2020. PMID: 32007169
17. Schmidt A S. Antero-Lateral Versus Anterior-Posterior Electrode Position for Converting Atrial Fibrillation. Circulation. 2021;144:1995–2003. 
18. Glover B M, et al Biphasic Energy Selection for transthoracic cardioversion of atrial fibrillation. The BEST AF Trial. Heart. 2008 Jul;94(7):884-7