Rapid Clinical Updates: Challenging Inpatient Scenarios in Atrial Fibrillation-Slides

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This clinical update addresses challenging inpatient scenarios in atrial fibrillation (AF), focusing on acute management, stroke prevention, and individualized care in complex patients. Acute AF frequently occurs during hospitalization for acute illnesses, sepsis, or surgery, often as a first episode with high recurrence rates (30-75% over 5 years depending on context). Identification and treatment of precipitating factors (e.g., sepsis, electrolyte imbalance) and continuous cardiac monitoring are critical for early stabilization and recurrence detection.<br /><br />For hemodynamically unstable patients, urgent synchronized electrical cardioversion with concurrent anticoagulation is indicated. Stable patients typically undergo rate control as first-line treatment using beta blockers or calcium-channel blockers, with rhythm control reserved for specific indications like persistent symptoms or heart failure. Early rhythm control has demonstrated cardiovascular benefits, reducing events such as stroke and heart failure hospitalization, as reflected in trials like EAST-AFNET 4.<br /><br />Stroke prevention relies on thromboembolic risk assessment via CHA2DS2-VASc, though this tool is less validated in acutely ill hospitalized patients. Direct oral anticoagulants (DOACs) are preferred over warfarin except in mechanical valves or rheumatic mitral stenosis. In acute AF during severe illness (e.g., sepsis), immediate anticoagulation is not routinely recommended due to uncertain stroke risk and heightened bleeding risk; reassessment after illness resolution guides long-term therapy. Shared decision-making is emphasized, especially for patients with concurrent bleeding and limited life expectancy, where individualized strategies balance stroke prevention against bleeding risk and quality of life.<br /><br />Additional topics covered include management of concomitant coronary artery disease requiring PCI, anticoagulation around cardioversion, left atrial appendage occlusion indications, and the importance of post-discharge follow-up for arrhythmia and risk factor management. Falls should not automatically preclude anticoagulation, especially with safer agents like apixaban. Overall, the update stresses evidence-based, patient-centered care incorporating the latest guideline recommendations for managing AF in complex inpatient settings.

Keywords

atrial fibrillation

acute management

stroke prevention

hemodynamic instability

electrical cardioversion

rate control

rhythm control

CHA2DS2-VASc score

direct oral anticoagulants

patient-centered care