Rapid Clinical Updates: Atrial Fibrillation Occurring During Acute Hospitalization-Handout

Handout

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This rapid clinical update focuses on Acute Atrial Fibrillation (AF), emphasizing recent shifts in understanding and management. Acute AF refers to atrial fibrillation first detected or treated during an acute illness, replacing the older term “secondary” AF. It highlights that acute AF involves both acute triggers and underlying susceptibility, placing patients at high risk for long-term recurrence. In-hospital management centers on addressing the "3As": identifying acute triggers, controlling AF via rate or rhythm strategies, and initiating anticoagulation—with direct oral anticoagulants (DOACs) preferred.<br /><br />The relationship between AF and heart failure (HF) is emphasized, noting that AF, whether acute, postoperative, or chronic, is linked with HF admissions and poor outcomes. These conditions may share overlapping risk factors, and treating one aggressively often benefits the other.<br /><br />Regarding control strategies, although rate control has traditionally been favored, emerging evidence supports rhythm control as potentially preferable, especially for symptomatic patients. Transesophageal echocardiography (TEE) is recommended before electrical cardioversion unless the patient is already on adequate anticoagulation. A "wait-and-see" approach—attempting rate control for 48 hours before proceeding to cardioversion if necessary—is shown to be as effective as immediate cardioversion. Many patients with acute AF may spontaneously revert to normal rhythm with prompt modification of triggers.<br /><br />In summary, acute AF requires comprehensive inpatient management targeting triggers, rhythm/rate control, and anticoagulation. Its interplay with HF mandates integrated treatment, and evolving evidence supports flexible cardioversion timing and preference for rhythm control in symptomatic cases. Direct oral anticoagulants are the favored anticoagulant agents in this setting.

Keywords

Acute Atrial Fibrillation

AF management

acute triggers

rate control

rhythm control

direct oral anticoagulants

heart failure

transesophageal echocardiography

electrical cardioversion

wait-and-see approach