It’s essential any Modifiable causes are treated, these include:

• • Haemodynamic stress: Valvular disease/Hypertension/LVD/Thrombus
  • Atrial ischemia: Ischaemic Heart Disease
  • Inflammation: Sepsis/Myocarditis/pericarditis
  • Noncardiovascular respiratory causes: PE/Pneumonia/Lung Cancer
  • Alcohol and drug use: Alcohol/Cocaine/Amphetamine
  • Endocrine disorders: Hyperthyroid/Diabetes/Phaeochromacytoma/Electrolyte prob.
  • Neurologic disorders: Subarachnoid Haemorrhage/Stroke
  • Genetic factors
  • Advancing age

2.0 ABC of AF

European Society of Cardiologyhas introduced the concept of the ABC of AF

• • Anticoagulation – AF increases stroke risk 5-fold
  • Better Symptom Control – Rate/Rhyme control (Haemodynamic instability = DCC)
  • Cardiovascular risk factors – Identification and treatment

2.1 Anticoagulation

AF increases the chance of Stroke by 5x (and those recently diagnosed are least likely be on any form of protection)

• ESC/NICE recommends using the CHADS-VASc to assess stroke risk and ORBIT to assess bleeding risk
• There are currently significant delays getting to “New AF” clinic as well as to GP’s, making assessment of Stroke risk in ED more important than ever

CHADS-VASc outcome recommendations

• • Males (0), Female (1) – No anticoagulation recommended
  • Males (1) – Consider anticoagulation (DOAC) in light of bleed risk
  • ALL (≥2) – Anticoagulation recommended (DOAC)- Trust DOAC guide,  NICE/CKS
  • Use Apixaban where first line, significantly cheaper. If using alternative please document reasons.

ORBIT outcome recommendations

• • Modifiable risks – Address ALL modifiable risk factors
  • Most will benefit from anticoagulation – but discuss personalised risk with patients

Contraindications to Anticoagulation inc:

• • Active serious bleeding (where the source should be identified and treated)
  • Associated comorbidities (e.g. severe thrombocytopenia <50 platelets/lL, severe anaemia under investigation, etc.)
  • Recent high-risk bleeding event such as intracranial haemorrhage (ICH).

2.2 Better Symptom Control

• • Haemodynamically STABLE patients: the 2020 ESC don’t recommend Rate vs Rhythm control as better as the initial treatment.EAST studyshowed early rhythm control improved outcomes, but early was defined as within 36 days of diagnosis.
  • Haemodynamically UNSTABLE patients: will require EMERGENCY DC Cardioversion.

Rates control:

• • First line:
    • β-Blocker
    • Non-dihydropyridine calcium channel blockers (Diltiazem/Verapamil) – esp. in Severe COPD/Asthma
  • Second Line:Consider adding in
    • Digoxin – however, digoxin alone is not effective in patients with increased sympathetic drive. Observational studies have associated digoxin use with excess mortality in AF patients)
    • Amiodarone can be useful as a last resort when heart rate cannot be controlled with combination therapy in patients who do not qualify for non-pharmacological rate control