New 2023 AHA Atrial Fibrillation Guidelines

Written by Caitlin Nicholson

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This article outlines the updated 2023 guidelines for diagnosis and management of atrial fibrillation. Continue reading for ways to incorporate them into your emergency medicine practice.

A few ways to deal with being irregularly irregular…

• Acute Management in the unstable patient
  The first step in managing patients in Afib with RVR in the ED is recognizing patients who need emergency direct current cardioversion (DCCV). The guidelines continue to recommend prompt synchronized DCCV for patients who are hemodynamically unstable.
• Acute management of the stable patient
  The safety of DCCV as a rhythm control option in non-anticoagulated patients with Afib duration <48 hours has been called into question. Recommendations are weak (class 2b) to use DCCV, without prior transesophageal echo to rule out thrombus, in patients with CHA₂DS₂-VASc score 0-1 and symptom duration <12 hours. They also recommend electrical over pharmacologic cardioversion, “when the patient is able to tolerate sedation, desires more immediate rhythm conversion, or has failed or not met candidacy for pharmacologic cardioversion,” using at least 200J biphasic energy for initial shock. Anterior-posterior pad placement is preferred for obese patients and patients with longer duration AFib. However, we covered a study from late 2021 that found anterolateral pad placement was superior in elective DCCV of all-comers with biphasic energy.
• Pharmacologic Cardioversion
  Pharmacologic cardioversion is recommended in stable patients or in patients in whom electrical DCCV cannot be performed. In patients with normal LV function, IV amiodarone or ibutilide can be used, with procainamide being a second-tier recommendation. In patients with heart failure with reduced ejection fraction (HFrEF, EF <40%), they recommend IV amiodarone.
• Rate Control in the stable patient (see figure)
  The strongest recommendation for pharmacologic rate control of the stable patient in Afib with RVR is beta blockers or nondihydropyridine calcium channel blockers. If these are ineffective, the guidelines recommend treating with digoxin (+/- magnesium), and finally IV amiodarone. In patients with known LV systolic dysfunction, nondihydropyridine calcium channel blockers have been deemed harmful.
• Thromboembolism Prevention
  CHA₂DS₂-VASc continues to be useful for assessing thromboembolic risk and determining therapy for patients with AFib. Patients with risk greater than or equal to 2% per year should be on anticoagulation to prevent stroke and systemic thromboembolism. Additional risk factors not included in CHA₂DS₂-VASc include higher AF burden/longer duration, persistent/permanent AF versus paroxysmal, obesity, hypertrophic cardiomyopathy, poorly controlled hypertension, eGFR <45mL/min, proteinuria, enlarged LA volume or diameter. Direct oral anticoagulants are recommended over warfarin unless a patient has CKD stage 3.

How will this change my practice?
Given the new recommendations, I will consider going directly to DCCV in select, stable patients who are safe for sedation. This is a fast and effective way to get someone quickly out of atrial fibrillation. But I will have a low threshold to involve cardiology to perform TEE before DCCV if there is any doubt about Afib duration or thromboembolic risk. I will continue to use amiodarone for pharmacologic cardioversion and beta-blockers for rate control. Regarding thromboembolic risk, I will expand my considerations outside of the CHA₂DS₂-VASc risk assessment.

Source
2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2023 Nov 30. doi: 10.1161/CIR.0000000000001193. Online ahead of print.

Edited by Clay Smith