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Home | Articles | Cardiac | Management of Acute AF

Management of Acute AF

Last updated 3rd December 2020

Last Updated on 27th March 2015 by Chris Isles

Rate Control

  1. When patients present acutely with AF, the fibrillation may arise de novo, or be provoked by an intercurrent illness such as a chest infection, or be longstanding with acceleration of ventricular rate provoked by the intercurrent illness.
  2. The initial clinical strategy is likely to be one of rate control. Rhythm control is unlikely to be effective in the presence of intercurrent illness or if the AF is longstanding.
  3. In this common clinical situation, there are two treatment goals. One is to treat the precipitating illness; the other is to improve control of ventricular rate, using drugs which slow conduction through the AV node.

Rhythm Control

  1. Emergency electrical cardioversion, without delaying to achieve anticoagulation, is indicated if life-threatening haemodynamic instability caused by new-onset AF
  2. Consider pharmacological or electrical cardioversion for new-onset AF of duration <48 hours if there are no provoking factors eg chest infection.
  3. If pharmacological cardioversion has been chosen offer:
    • flecainide or amiodarone if there is no evidence of structural or CHD
    • amiodarone if there is evidence of structural or CHD.
  4. In AF >48 hours or uncertain duration who may be benefit from rhythm control, delay electrical cardioversion until they have been anticoagulated for a minimum of 3 weeks. During this period offer rate control as appropriate.

Antithrombotic Therapy

  1. The issues are whether patients need heparin in the short term and warfarin long term.
  2. NICE recommend heparin for new-onset atrial fibrillation at presentation and that heparin be continued until a full risk assessment has been made. We use dalteparin (Fragmin) for this purpose. See section on Low Molecular Weight Heparin for dosing information. 
  3. Oral anticoagulation is then indicated if sinus rhythm not restored within 48 hours and CHA2DS2 VASc Score ≥2 or if considered that patient will benefit from rhythm control with view to DC cardioversion in 3-4 weeks time.
  4. The risk of stroke in the first week of new onset AF in a patient who has no obvious precipitating factors, is otherwise well, is suitable for rate control and has a CHA2DS2 VASc score of 2 is actually quite low (a fraction of 1%) and so an alternative and acceptable strategy for such patients is not to give heparin but to start warfarin 2mg daily and send them home for an INR check with GP in a weeks time.

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