Approach to acute arrhythmia management in atrial fibrillation

Atrial fibrillation is a common reason for presentation to general practitioners or emergency departments, and frequently occurs in hospitalised patients. Approximately 50% of atrial fibrillation episodes spontaneously terminate within 24 hoursCapucci, 1992Jordaens, 1997.

If a precipitant of the atrial fibrillation episode is identified, treating this can help manage the atrial fibrillation. Atrial fibrillation precipitated by an acute event (eg sepsis, surgery) often resolves with time. However, these patients are at an increased risk of thromboembolic events, and of recurrent atrial fibrillation in the longer term. Data about the long-term management of these patients (particularly whether to continue oral anticoagulation) are limited.

In addition to identifying any precipitating factors for acute atrial fibrillation and treating relevant comorbidities (see Comorbidities and precipitating factors of atrial fibrillation), the management strategy also depends on the following factors:

• the patient’s haemodynamic state—see Atrial fibrillation with haemodynamic instability and Atrial fibrillation in haemodynamically stable patients
• the duration of the atrial fibrillation episode—see Atrial fibrillation lasting less than 48 hours and patient is haemodynamically stable and Atrial fibrillation lasting longer than 48 hours and patient is haemodynamically stable
• the patient’s thromboembolic risk—see Stroke and bleeding risk assessment for atrial fibrillation
• the resources available to the clinician for monitoring the patient, providing procedural sedation and performing electrical cardioversion
• the patient’s preference for approach to management.

There are 2 available methods for initial arrhythmia management of a patient with atrial fibrillation.

• Rhythm control (electrical or pharmacological cardioversion, or via catheter ablation)—to attempt to restore and maintain sinus rhythm; this is reasonable in patients who are more symptomatic, have a reduced left ventricular ejection fraction that might be due to atrial fibrillation, or if rate control was not effective. See Acute rhythm control for more information.
• Rate control—to prevent haemodynamic deterioration by controlling ventricular rate; this is a reasonable approach in patients who are symptomatic or who have a high ventricular rate (regardless of symptoms). See Rate control and Urgent rate control for more information.

Detailed discussion of the relative merits of rhythm control and rate control is beyond the scope of this text.

For patients diagnosed with recent-onset atrial fibrillation (less than 12 months from diagnosis) and concomitant cardiovascular conditions, referral for an early rhythm control strategy (electrical or pharmacological cardioversion, or catheter ablation) is associated with a lower risk of death from cardiovascular causes or strokeKirchhof, 2020.

Discuss treatment with the patient and explain that atrial fibrillation is a dynamic condition, so treatment may vary over time and will require regular review. Document and communicate to the patient’s wider multidisciplinary team of healthcare professionals whether rate or rhythm control, or a combination approach, has been selectedNHFA CSANZ Atrial fibrillation guideline working group, 2018.