Scope and Target Population:
This guideline addresses first detected episode and recurrent (paroxysmal, persistent and permanent) atrial fibrillation and atrial flutter in the adult population that present in primary care, emergency room, and the inpatient settings. The scope includes stabilization, assessment, labeling (classification), treatment and patient education.

This document is not intended to replace the comprehensive ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation, which the interested provider is encouraged to review.

Clinical Highlights and Recommendations:
There are five key steps in the management of patients with atrial fibrillation or atrial flutter (SALT-E): stabilize, assess, label, treat and educate.

After confirming the diagnosis of atrial fibrillation or atrial flutter with a 12-lead electrocardiogram:

Stabilize

• Assess for hemodynamic instability (hypotension, myocardial ischemia, uncompensated congestive heart failure, altered mental status or end-organ dysfunction).
  
• Treat hemodynamic instability with emergent direct current cardioversion and obtain an emergent cardiology or internal medicine consult.
  
• Establish adequate rate control.
Assess

• Assess for potentially reversible causes and for comorbidities of atrial fibrillation/atrial flutter.
  
• Hypertension is one of the most common causes of atrial fibrillation. In addition, hypertension is one of the most common risk factors for thromboembolic complications associated with atrial fibrillation. Treatment for hypertension should be initiated early.
Label

• Label (classify) patients into one of three categories:
  
  • First Detected Episode, Duration Known greater than or equal to 48° or Duration Unknown
    
  • Recurrent atrial fibrillation
    
    • Paroxysmal
      
    • Persistent
      
    • Permanent
  • Recurrent atrial flutter
  Treatment options are determined by these three categories.
Treat
First Detected Episode, Duration Known > 48 hours or Duration Unknown

• Patients with stable atrial fibrillation or atrial flutter with duration greater than 48 hours or duration unknown require appropriate anticoagulation (international normalized ratio greater than or equal to 2.0) for three weeks prior to electrical cardioversion or use of antiarrhythmics/chemical cardioversion.
Recurrent atrial fibrillation

• Patients with paroxysmal, persistent or permanent atrial fibrillation require assessment for chronic anticoagulation (risk of thromboembolism compared with risk of bleeding) and adequate rate control.
  
• Patients with persistent symptoms despite adequate rate control may require intermittent cardioversion, antiarrhythmic agents and/or electrophysiology consultation.
Recurrent atrial flutter

• Patients with recurrent atrial flutter should be referred for an electrophysiology consultation.
Educate
Patient education is a critical component in the management of all patients with atrial fibrillation/atrial flutter. Patients who have experienced one or more episodes of atrial fibrillation should be taught to periodically monitor their pulse and have a plan for treatment if they detect an irregular pulse.

Priority Aims

1. Increase the percentage of adult patients (age 18 years and older) who are accurately diagnosed with atrial fibrillation/flutter.
   
2. Improve the consistency of anticoagulation therapy in adult patients (age 18 years and older) with non-valvular paroxysmal, persistent or permanent atrial fibrillation/flutter.
   
3. Improve rate control in adult patients (age 18 years and older) with permanent atrial fibrillation.
   
4. Increase the percentage of adult patients (age 18 years and older) with a confirmed diagnosis of atrial fibrillation/atrial flutter who, along with their family, have received education around atrial fibrillation/flutter and anticoagulation therapy.
   
5. Reduce the percentage of patient harm associated with the use of anticoagulation therapy.
   
6. Increase the percentage of adult patients (age 18 years and older) with a confirmed diagnosis of atrial fibrillation/flutter, receiving dietary monitoring.
   
7. Increase the percentage of adult patients (age 18 years and older) with a confirmed diagnosis of atrial fibrillation/flutter who have a medication communication/reconciliation plan throughout the continuum of care.

Additional Background
This guideline follows closely the American College of Cardiology and the American Academy of Family Physician guidelines. Areas of divergence from other clinical practice guidelines are TEE and rhythm vs. rate control. The purpose of this guideline is to provide primary care with a guideline that outlines areas for systems improvement for the diagnosis and treatment of atrial fibrillation in primary care.

A Fib is a common arrhythmia and an important independent risk factor for stroke. The prevalence of A Fib increases from 0.5% for the 50- to 59-year-old age group to 8.8% in the 80- to 89-year-old age group. Symptoms vary from none to severe disabling palpitations, dyspnea and syncope. Patients with A Fib have a mortality rate double that of control subjects. The attributable risk of embolic stroke from A Fib increases from 1.5% per year for the 50- to 59-year-old age group to nearly 30% per year for the 80- to 89-year-old age group, and increases substantially in the presence of other cardiovascular conditions.