AHA Statement on AF During Acute Hospitalization: Key Points

Chyou JY, Barkoudah E, Dukes JW, et al., on behalf of the American Heart Association Acute Cardiac Care and General Cardiology Committee, Electrocardiography and Arrhythmias Committee, and Clinical Pharmacology Committee of the Council on Clinical Cardiology; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular and Stroke Nursing; and Stroke Council.
Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association. Circulation 2023;Mar 13:[Epub ahead of print].

The following are key points to remember about a Scientific Statement from the American Heart Association (AHA) on atrial fibrillation (AF) occurring during acute hospitalization:

  1. Acute AF is described as AF identified in the setting of acute care or acute illness; AF may be detected or managed for the first time during acute hospitalization for another clinical condition.
  2. Of note, acute AF is common and not benign. Acute AF is associated with high risks of long-term AF recurrence, warranting close clinical attention during acute hospitalization, at transition of care, and over long-term follow-up.
  3. A schema of substrates and triggers can be useful for evaluation and management of AF occurring during acute hospitalization. AF after cardiac surgery is a distinct type of acute AF.
  4. Management of AF occurring during hospitalization requires a multifaceted approach. Vital components of management include identification and treatment of triggers, selection, and implementation of rate and/or rhythm control, and management of therapeutic anticoagulation.
  5. An acute rate or rhythm control strategy should be individualized and patient’s capacity to tolerate the risk of the strategy should be factored including potential rapid rates or atrioventricular (AV) dyssynchrony.
  6. Immediate direct current cardioversion is the treatment of choice for those with hemodynamic instability. Rhythm control can be considered for patients unable to attain clinically adequate rate control despite optimal use of AV nodal blocking agents and management of acute triggers. Of note, hemodynamic monitoring and thromboembolic prophylaxis are warranted for both electrical and pharmacologic cardioversion.
  7. Indication for anticoagulation is based on substrate, with feasibility and timing for anticoagulation based on the patient’s bleeding risk and considerations of the acute clinical condition. General considerations for anticoagulation for patients with AF are based on substrates, with CHA2DS2-VASc score of ≥2 for men or ≥3 for women as an accepted indication for anticoagulation in the absence of contraindications and significant bleeding risks.
  8. Given the high risks of AF recurrence in patients with acute AF, clinical follow-up and extended heart rhythm monitoring are important to optimize longer-term management.
  9. Overall management of acute AF addresses substrates and triggers using the 3As of acute management: Acute triggers, AF rate/rhythm management, and Anticoagulation. The 2As and 2Ms of long-term management are: AF rate/rhythm management, Anticoagulation, Monitor heart rhythm, and Modification of lifestyle and risk factors.
  10. Aggressive risk factor modification and lifestyle interventions should be pursued for all patients with acute AF, in tandem with long-term AF management strategies. Patients with acute AF benefit from close multidisciplinary care collaborations, allowing appropriate treatments tailored to the patient’s underlying substrates and acute conditions.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Cardiac Surgical Procedures, Critical Illness, Electric Countershock, Hemodynamics, Hemorrhage, Hospitalization, Life Style, Risk Factors, Secondary Prevention, Thromboembolism

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