Mount Carmel Health Partners Clinical Guidelines Atrial Fibrillation

Mount Carmel Emergency Department Protocol for Early Cardioversion of Hemodynamically Stable Atrial Fibrillation Signs and/or symptoms of new onset or recurrent atrial fibrillation (Afib) Consider differential Dx for Afib: PE, CHF, hyperthyroid, alcohol withdrawal, valvular disease, infection, etc. Evaluate and treat associated conditions as indicated Consider complete blood count (CBC) Consider basic metabolic profile (BMP) Thyroid stimulating hormone(TSH) if new diagnosis INR if on warfarin Echo if no recent echo and possible to obtain OR can get as an outpatient No Excluded from Pathway: •Known history of intracardiac thrombus •Unclear duration of AFib or >48 hours of AFib while not on anticoagulation •CHA2DS2-VASC score ≥ 5 •Signs of heart failure •Known Ejection Fractur(EF) <30% •Angina •Acute MI within 4 weeks •Stroke/TIA within 3 months •Cr clearance <30 •Other comorbid conditions that require admission Appropriate for Cardioversion (CV) Preferred approach is procedural sedation + DC CV · Consider chemical CV if refusing DC CV or not candidates for procedural sedation in patients refusing DC CV. Min 4 hour observation period Yes Hospital Admission or Rate Control Strategy With Close Follow-up · Yes, Cardioversion 120-360 Joules (synchronized) No Rate Control Strategy Desired – Permanent atrial fibrillation, Anticoagulation contraindicated, Asymptomatic or minimally symptomatic Sinus Rhythm · Observe 1-2 hrs · Prescribe oral anticoagulant · Early PCP F/U · Afib clinic F/U DISCHARGE Initiate anticoagulation (AC), if indicated Administer Rate Controlling Meds Expert consult, as needed Continued AF Symptomatic or not rate controlled ADMIT Rate Control (HR<100) and minimal symptoms · Monitor 1-2 hrs, ambulate · Home AC and rate control meds · Afib clinic · Early PCP F/U DISCHARGE AFib - 2 Continued AF Symptomatic or not rate controlled ADMIT Rate Control (HR<100) and minimal symptoms · Monitor 1-2 hrs, ambulate · Home AC and rate control meds · Afib clinic · Early PCP F/U DISCHARGE

Mount Carmel Health Partners Clinical Guidelines Atrial Fibrillation | Page 2