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Key Clinical Updates in Atrial Fibrillation

In patients with atrial fibrillation and no clinical risk factors (CHA2DS2-VASc score 0), there is no indication for anticoagulant or antithrombotic therapy. In general, unless there is an indication for antiplatelet therapy (CHD, peripheral vascular disease), patients with atrial fibrillation should not be prescribed aspirin for stroke prevention.

In patients with atrial fibrillation duration of greater than 48 hours (or unknown), a minimum of 3 weeks of anticoagulation or exclusion of left atrial thrombus by TEE pre-cardioversion is required. Anticoagulation should be continued for at least 4 weeks following cardioversion to prevent thromboembolism.

In patients with prior left atrial appendage occlusion, TEE is recommended to exclude device-related thrombus or peri-device leak which may prompt anticoagulant initiation.

Joglar J et al. Circulation. [PMID: 38033089]

ESSENTIALS OF DIAGNOSIS

  • Presents as an irregularly irregular heart rhythm on examination and ECG.

  • Prevention of stroke should be considered in all patients with risk factors for stroke (those with HF, hypertension, age 65 or older, diabetes mellitus, prior history of stroke or transient ischemic attack [TIA], or vascular disease).

  • Heart rate control with beta-blocker or calcium channel blockers generally required. Restoration of sinus rhythm with cardioversion, antiarrhythmic medications, or catheter ablation in symptomatic patients.

GENERAL CONSIDERATIONS

Atrial fibrillation is the most common chronic arrhythmia, with an estimated global prevalence of 50 million individuals. It occurs in rheumatic and other forms of valvular heart disease, dilated cardiomyopathy, hypertension, and CHD as well as in patients with no apparent cardiac disease; it may be the initial presenting sign in thyrotoxicosis, and this condition should be excluded with the initial episode. Atrial fibrillation often appears in a paroxysmal fashion before becoming the established rhythm. Pericarditis, chest trauma, thoracic or cardiac surgery, thyroid disorders, obstructive sleep apnea, or pulmonary disease as well as medications (beta-adrenergic agonists, inotropes, bisphosphonates, and certain chemotherapeutics) may cause attacks in patients with normal hearts. Acute alcohol excess and alcohol withdrawal (termed holiday heart) may precipitate atrial fibrillation. For regular, moderate drinkers, abstinence from alcohol reduces recurrences of atrial fibrillation by about 50%.

Atrial fibrillation is associated with a 2-fold risk of SCD, a 2.4-fold risk of stroke, and a 5-fold risk of HF. Atrial fibrillation increases the propensity for thrombus formation due to circulatory stasis in the left atrial appendage and consequent embolization, most devastatingly to the cerebral circulation. Untreated, the rate of stroke is approximately 5% per year. However, patients with significant obstructive valvular disease, chronic HF or LV dysfunction, diabetes mellitus, hypertension, or age over 75 years and those with a history of prior stroke or other embolic events are at substantially higher risk (up to nearly 20% per year in patients with multiple risk factors). In patients presenting with embolic stroke of unknown source (cryptogenic stroke), a substantial portion will have asymptomatic or “subclinical” atrial fibrillation detected with implantable loop recorders, allowing initiation of oral anticoagulation ...

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