Rapid Clinical Updates: Atrial Fibrillation Occurring During Acute Hospitalization-AHA Statement

AHA Statement

Pdf Summary

This American Heart Association scientific statement addresses atrial fibrillation (AF) occurring during acute hospitalization, termed acute AF—AF first detected or managed amid acute illness or hospitalization for another condition. Previously regarded as transient, evidence now reveals acute AF associates with high long-term recurrence risk, necessitating diligent acute and long-term management.<br /><br />The statement emphasizes a conceptual framework distinguishing substrates (structural/electrical atrial remodeling, scarring from chronic conditions or prior surgeries) and triggers (inflammation, autonomic tone shifts, electrolyte imbalances, procedural stress) provoking acute AF. Detecting acute AF relies on physical exam, ECG, and inpatient telemetry, and patient risk scores (e.g., CHA2DS2-VASc) help stratify monitoring intensity.<br /><br />Acute management requires a multipronged, individualized approach: identify and treat acute triggers; decide between rate control or rhythm control based on hemodynamic stability, patient tolerance, and stroke risk; and manage anticoagulation considering bleeding risk and procedural context. Hemodynamically unstable patients require immediate electrical cardioversion; stable patients may undergo rate control initially with consideration for delayed cardioversion. Pharmacological cardioversion (with agents like ibutilide, dofetilide, flecainide, amiodarone) or electrical cardioversion are options. Anticoagulation is guided by stroke risk (e.g., CHA2DS2-VASc ≥2 men, ≥3 women) and timing to minimize thromboembolism.<br /><br />Specific populations require tailored management: in critical illness, delay direct AF treatment unless hemodynamically unstable; COVID-19-associated AF entails assessing thrombotic risk; in hyperthyroidism, restore euthyroid status plus rate control; after cardiac or noncardiac surgery, manage bleeding risks, use prophylactic β-blockade or amiodarone post-cardiac surgery, and carefully time anticoagulation; and atrial flutter management parallels AF.<br /><br />Long-term follow-up is crucial due to high recurrence (up to 68% over 5 years). Heart rhythm monitoring after discharge—from intermittent ECGs to implantable loop recorders—guides management. Long-term anticoagulation decisions depend on individual stroke risk.<br /><br />Risk factor modification (weight loss, managing hypertension, diabetes, sleep apnea, alcohol reduction, exercise) is vital alongside rhythm management.<br /><br />The statement outlines ten key clinical practice points and identifies research gaps, notably optimal monitoring strategies, anticoagulation thresholds, risk stratification, and substrate-trigger interplay. Overall, multidisciplinary care personalized to patient substrates and acute conditions is advocated to manage acute AF effectively and mitigate long-term risks.

Keywords

acute atrial fibrillation

atrial fibrillation management

acute hospitalization

atrial remodeling

inflammation triggers

ECG monitoring

CHA2DS2-VASc score

rate control

rhythm control

anticoagulation therapy