Mount Carmel Health Partners Clinical Guidelines Atrial Fibrillation
Atrial Fibrillation Clinical Guideline
Patient presents with signs and/or
symptoms of possible a-fib or atrial
flutter (See Table C)
Evaluation
Treatment
Quick Guide
• Atrial fibrillation (AF) is usually a symptom of another
underlying cause. It is rarely a primary arrhythmia.
• AF can be managed through rhythm control or rate control.
• Most AF patients should have long-term anticoagulation, even
if restored to sinus rhythm, depending on their stroke risk.
• The best anticoagulation strategies are based on factors
specific to each patient.
• Consider early referral to a cardiologist:
- for AF ablation which is critical for a successful outcome
(normal sinus rhythm)
- if the patient has failed medication or cannot tolerate an
antiarrhythmic medication.
Pursue pharmacologic
rhythm control. Consider
cardiology input.
(see Table G)
No
Is the patient
unstable?
(See Table D)
No
Perform history,
physical, and ECG
Are there any
reasons to not pursue
rhythm control?
(see Table B)
No
Is AF definitely known to be <48
hours and no
history of mitral stenosis or
prosthetic valves and no history
of TIA, stroke, or
thromboembolism?
(see Table F)
Is TEE
available?
Unsuccessful
Consider starting
antiarrhythmic if
patient has
structural heart
disease Load with
antiarrhythmic and
achieve therapeutic
anticoagulation, then
reattempt DC
cardioversion
Ongoing follow-up:
• Monitor INR If warfarin
is prescribed
• Evaluate and manage
any side effects (see
medication tables)
• Reconsider rhythm
control
Was second
attempt
successful?
No
Yes
One month
anticoagulation post DC cardioversion
(see Table F)
No
Therapeutic
anticoagulation x
4 weeks pre-
cardioversion; initiate
rate control if
symptomatic or heart
rate is >100
Successful
Chronic anticoagulation
(see Table I)
Yes
TEE before
cardioversion;
includes DC
cardioversion or
pharmacologic
Yes
Pursue chronic rate
control (see Table H)
Yes
Electrical (DC) cardioversion
Is immediate DC
cardioversion
available?
Yes
No
Send to ED with EMS
transport if possible
Yes
Follow-up: re-evaluate in 1 month for ongoing treatment including
chronic anticoagulation; determine ongoing follow-up schedule including
INR and evaluate need for continued antiarrhythmia medication
Yes
Is a
thrombus
present?
No
Does AF
reoccur or did
cardioversion
fail?
Yes
Follow up with
cardiologist
October 2017