Scope and Target Population:
This guideline addresses first detected episode and recurrent (paroxysmal, persistent, and permanent) atrial fibrillation (A Fib) and atrial flutter (A Flutter) in the adult population who 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 guideline, 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 A Fib or A Flutter ("SALT-E"): stabilize, assess, label, treat and educate

After confirming the diagnosis of A Fib or A Flutter with a 12-lead ECG:
Stabilize

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

Assess

• Assess thromboembolic potential and risk for bleeding.
  
• Hypertension is one of the primary causes and comorbidities for A Fib. Treatment for hypertension should be initiated early.
  
• Assess for potentially reversible causes of A Fib/A Flutter, comorbidities.

Label

• Label (classify) patients into one of three categories:
  
  - First Detected Episode, Duration Known > 488 or Duration Unknown
  - Recurrent A Fib
• Paroxysmal
  
• Persistent
  
• Permanent
  
  - Recurrent A Flutter

Treatment options are determined by these four categories.

Treat
First Detected Episode, Duration Known > 48 hours or Duration Unknown

• Patients with stable A Fib or A Flutter with duration greater than 48 hours or duration unknown require appropriate anticoagulation (INR greater than or equal to 2.0) for three weeks prior to electrical cardioversion or use of antiarrhythmics/chemical cardioversion.

Recurrent A Fib

• Patients with paroxysmal, persistent or permanent A Fib 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 A Flutter

• Patients with recurrent A Flutter should be referred for an electrophysiology consultation.

Educate
Patient education is a critical component in the management of all patients with A Fib/A Flutter. Patients who have experienced one or more episodes of A Fib 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 patients age 18 years and older who are accurately diagnosed with A Fib.
   
2. Improve the consistency of anticoagulation in patients with paroxysmal, persistent or permanent A Fib/Flutter.
   
3. Improve rate control in patients with permanent A Fib.
   
4. Increase the percentage of patients with A Fib/Flutter who receive patient education.

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.