FP Essentials Cardiovascular Disease PDF, 536, January 2024

FP Essentials ™ 536...

FP Essentials ™ 536 January 2024 Cardiovascular Disease Atrial Fibrillation and Atrial Flutter 7 Anticoagulation Therapy for Atrial Fibrillation 14 Other Common Arrhythmias 22 Inflammatory and Infectious Heart Conditions 29 www.aafp.org/fpe Downloaded from www.aafp.org/fpe. Copyright © 2024 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Barry D. Weiss, MD, FAAFP Leigh Ann Backer Darren Sextro Medical Editor Editorial Director Director, Journal Media Ryan D. Kauffman, MD, FAAFP, Andrea Harden Marilyn Harvey CCFP S. Jane Thomas Project Specialist Karl T. Rew, MD Senior Associate Editors Susi Cordill Kate Rowland, MD, FAAFP John Moessner Circulation Manager Associate Medical Editors Editorial Assistant Rebecca Harp S. Lindsey Clarke, MD, FAAFP Dave Klemm Senior Circulation Strategist Joel J. Heidelbaugh, MD, Art Coordinator FAAFP, FACG Frances Spitsnogle Robert C. Langan, MD, FAAFP Bret A. Taylor Circulation Specialist Brian Z. Rayala, MD, FAAFP Production Director Editorial Board Members Stacey Herrmann R. Shawn Martin Production Design Manager Executive Vice President and Chief Executive Officer Bryan Colley Margot Savoy, MD, MPH, FAAFP Randy Knittel Senior Vice President of Education, Senior Production Designers Inclusiveness, and Physician Well-Being Evan Palmer Senior Digital Production Specialist Cover illustration by Jonathan Dimes ISSN# 2159-3000 FP Essentials is indexed in MEDLINE and PubMed. Subscription Information American Academy of Family Physicians 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2680 Phone: 800-274-2237 Email: [email protected] Online: www.aafp.org/pubs/fpe/subscribe/subscription-management.html Other Contact Information Permission to reuse content: [email protected] Comments or suggestions for the editors: [email protected] Proposal submissions: www.aafp.org/pubs/fpe/authors.html  536 Cardiovascular Disease Authors Robert L. Gauer, MD Joel M. Guess, MD William Criswell, PharmD, BCPS Robert L. Gauer, MD, is a hospitalist for the Internal Carolina. He is an assistant professor at the School of Medicine Residency Program at Womack Army Med- Medicine at USUHS in Bethesda, Maryland. ical Center in Fort Liberty, North Carolina. He has a designation of focused practice in hospital medicine. He William Criswell, PharmD, BCPS, is an inpatient is an assistant professor at the School of Medicine at the clinical pharmacist for the Internal Medicine Residency Uniformed Services University of the Health Sciences Program at Womack Army Medical Center in Fort Lib- (USUHS) in Bethesda, Maryland. erty, North Carolina, where he also serves as a preceptor for the Clinical Pharmacy Residency Program. He is an Joel M. Guess, MD, is an internal medicine attending adjunct assistant professor at Campbell University College physician at the Internal Medicine Residency Program at of Pharmacy and Health Sciences in Buies Creek, North Womack Army Medical Center in Fort Liberty, North Carolina. Disclaimer: The views expressed herein are those of the author(s) and do not necessarily reflect the official policy of the Department of the Army, Department of Defense, or the US government. Disclosure: It is the policy of the AAFP that all individuals in a position to control CME content disclose any relationships with ineligible companies upon nomination/invitation of participation. Disclosure documents are reviewed for potential relevant financial relationships. If relevant financial relationships are identified, mitigation strategies are agreed to prior to confirmation of participation. Only those participants who had no relevant financial relationships or who agreed to an identified mitigation process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose. Gauer RL, Guess JM, Criswell W. Cardiovascular Disease. FP Essent. 2024;536:1-52. Gauer RL, Guess JM. Cardiovascular Disease: Atrial Fibrillation and Atrial Flutter. FP Essent. 2024;536:7-13. Criswell W, Gauer RL. Cardiovascular Disease: Anticoagulation Therapy for Atrial Fibrillation. FP Essent. 2024;536:14-21. Guess JM, Gauer RL. Cardiovascular Disease: Other Common Arrhythmias. FP Essent. 2024;536:22-28. Gauer RL, Guess JM. Cardiovascular Disease: Inflammatory and Infectious Heart Conditions. FP Essent. 2024;536:29-38. Copyright © 2024 American Academy of Family Physicians. All rights reserved. Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium. 1 Foreword I was diagnosed with atrial fibrillation (AF) several years Other topics reviewed in this edition are several supra- ago. It was quite a surprise because I have been an exercise ventricular and ventricular rhythm disorders (Section maniac for my entire adult life and have healthy weight, Three), along with inflammatory disorders (pericar- lipid levels, and blood pressure. Only then did I learn that ditis and myocarditis) in Section Four, the latter hav- AF is common among people who participate in long-term ing received a lot of attention during the COVID-19 endurance exercise. Professional athletes have high rates pandemic. of AF, with some studies finding rates as high as 32% to I hope you will find the information in this edition to 63%.1 be as interesting and useful as I did. There is a lot to learn Thus, it was really interesting to work on this edition about these conditions. of FP Essentials. Sections One and Two are devoted to Barry D. Weiss, MD, FAAFP, Medical Editor various aspects of dealing with AF, including rate control, Professor, Department Family and Community Medicine rhythm control, ablation, and anticoagulation. It was good University of Arizona College of Medicine, Tucson to see that ablation is increasingly becoming a first-line 1. Turagam MK, Flaker GC, Velagapudi P, Vadali S, Alpert MA. Atrial treatment. In addition, the geriatrician in me was glad fibrillation in athletes: pathophysiology, clinical presentation, evaluation to see the authors point out the need for anticoagulation and management. J Atr Fibrillation. 2015;8(4):1309. in older adults with AF, who often do not receive that therapy because many physicians are hesitant to prescribe anticoagulation to older adults. However, the authors point out that older adults receive the most benefit from anticoagulation for AF. Learning Objectives Recommend ablation to manage paroxysmal, persistent, or permanent atrial fibrillation (AF) in patients who are symptomatic and intolerant of at least one antiarrhythmic drug, and consider ablation as a first-line treatment. Prescribe anticoagulants for patients with AF based on the CHA2DS2-VASc (Congestive heart failure, Hyper- tension, Age 75 years or older [doubled], Diabetes, prior Stroke or transient ischemic attack or thromboem- bolism [doubled], Vascular disease, Age 65-74 years, Sex category score. Consider anticoagulants for older adults with AF, rather than withholding them because of age-related con- cerns (eg, fall risk). If needed, refer patients for physical therapy to decrease fall risk. Discontinue and restart anticoagulants at appropriate times in patients with AF who undergo procedures that have bleeding risk. Be aware that frequent premature atrial contractions, previously considered benign, are a risk factor for developing AF. Summarize guideline-recommended drugs for acute pericarditis. Describe appropriate antibiotic prophylaxis before dental and other procedures for patients who have had prior infective endocarditis. 2  Contents Authors........................................... 1 SECTION FOUR Foreword.......................................... 2 Inflammatory and Infectious Heart Conditions..... 29 Learning Objectives............................... 2 Acute Pericarditis................................. 29 Pretest Questions................................. 4 Clinical Features, Differential Diagnosis, Pretest Answers................................... 5 Diagnostic Evaluation, Management, Prognosis, Key Practice Recommendations................... 6 Physical Activity Restrictions Myocarditis....................................... 33 SECTION ONE Clinical Presentation, Diagnostic Evaluation, Atrial Fibrillation and Atrial Flutter................. 7 Management, Prognosis, COVID-19–Related Atrial Fibrillation.................................. 7 Myocarditis Epidemiology, Classification, Risk Factors, Infective Endocarditis............................. 35 Screening, Presentation, Diagnosis, Management Clinical Presentation, Evaluation, Management, Atrial Flutter...................................... 13 Prophylaxis Rate Control, Rhythm Control, Anticoagulation References........................................ 39 Resources......................................... 45 SECTION TWO Posttest Questions................................ 46 Anticoagulation Therapy for Atrial Fibrillation...... 14 Posttest Answers.................................. 49 Who Should Receive Anticoagulation Therapy...... 14 TABLES Persistent or Long-Standing Persistent AF, Paroxysmal AF 1. Event Rates Within Categories of Antiplatelet Therapy.............................. 15 CHA2DS2-VASc and HAS-BLED Scores......... 15 2. Comparison of Direct Oral Anticoagulation Oral Anticoagulants............................... 15 for AF......................................... 16 Warfarin, Direct Oral Anticoagulants 3. Perioperative Treatment of Patients Taking Special Populations............................... 17 Anticoagulants for AF.......................... 20 Poor Anticoagulation Candidates, Secondary AF, 4. Common Etiologies of Acute Pericarditis........ 30 Atrial High-Rate Episodes, Valvular Heart Disease, 5. Acute and Recurrent Pericarditis Chronic Kidney Disease, Acute Coronary Syndrome Management.................................. 32 and Percutaneous Coronary Intervention, Older 6. Common Etiologies of Myocarditis............. 33 Adults 7. Myocarditis Presentation and Perioperative Management........................ 19 Recommended Diagnostic Evaluation.......... 34 Warfarin, Direct Oral Anticoagulants 8. Recommended Antibiotic Management of Reversal.......................................... 19 Infective Endocarditis Based on Pathogen...... 37 Common Interactions............................. 21 FIGURES SECTION THREE 1. Electrocardiogram Showing Atrial Fibrillation... 8 Other Common Arrhythmias....................... 22 2. Atrial Fibrillation Management................. 10 Premature Atrial Contractions..................... 22 3. Electrocardiogram Showing Atrial Flutter....... 12 Risk Factors, Significance, Clinical Manifestations, 4. Management of Premature Ventricular Diagnosis, Management Complexes.................................... 25 Premature Ventricular Contractions................ 23 5. Electrocardiogram Showing Supraventricular Risk Factors, Significance, Clinical Manifestations, Narrow-Complex Tachycardia.................. 26 Evaluation, Management 6. Management of Supraventricular Tachycardia... 27 Supraventricular Tachycardia...................... 24 7. Electrocardiogram Showing Acute Pericarditis.. 31 Presentation, Diagnosis, Management Sinus Node Dysfunction.......................... 26 Risk Factors, Clinical Manifestations, Diagnosis, Management 3 Pretest Questions To assess your current knowledge of this FP Essentials topic, complete the pretest below and check your answers against the explanations provided at the end. Use the results to inform your study of this edition and prepare to com- plete the posttest, which appears later in the edition and online for CME credit. Each question has only one correct answer. 1. Which one of the following is true of the incidence of 4. Which one of the following is true of anticoagulation or risk factors for developing atrial fibrillation (AF)? in older adults with atrial fibrillation?  A. Lifetime risk is higher in socioeconomically  A. It typically should not be prescribed for patients disadvantaged groups. older than 85 years due to fall risk.  B. Nonmodifiable risk factors include female sex.  B. Its benefit for preventing stroke is greatest in  C. Heart failure is the most common chronic older adults. illness associated with AF.  C. Warfarin is the preferred anticoagulant because  D. Long-term high-intensity endurance exercise there has been limited testing of direct oral increases risk of developing AF. anticoagulants in older adults.  E. P revalence typically increases with age, but  D. Dabagatran is the preferred anticoagulant. declines in adults older than 80 years.  E. It appears to increase dementia risk. 2. An otherwise healthy young adult comes to the 5. Which one of following is true of premature atrial emergency department with dizziness. He is contractions (PACs)? hypotensive but alert and communicative. He reports  A. They most often occur in short runs of multiple no personal or family history of heart disease. beats. The electrocardiogram shows atrial fibrillation.  B. They are most common in adolescents. Which one of the following is the most appropriate  C. Breakthrough PACs can occur with beta treatment for this patient? blockers, which increase risk by slowing the  A. Synchronized direct current cardioversion. heart.  B. Intravenous diltiazem.  D. They have been shown in multiple trials to be  C. Infusion of short-acting beta blocker. ineffectively treated with catheter ablation.  D. Emergency ablation.  E. F  requent PACs are associated with an increased risk of developing atrial fibrillation. 3. W  hich one of the following is true of anticoagulation for patients with atrial fibrillation (AF) and valvular 6. Which one of the following is true of premature heart disease? ventricular contractions (PVCs)?  A. Apixaban is preferred for patients with  A. They are uncommon in otherwise healthy mechanical heart valves. individuals.  B. Rivaroxaban is preferred for patients with  B. They can be treated with ablation when left bioprosthetic valves who develop AF ventricular dysfunction is also present. postoperatively.  C. There is no association between PVCs and  C. Warfarin is preferred for patients with moderate developing cardiomyopathy. to severe mitral stenosis.  D. They cause syncope and presyncope in most  D. Direct oral anticoagulants are not effective patients. in patients with AF and native valvular heart  E. T  hey can be effectively managed with disease. dihydropyridine calcium channel blockers. 4  7. Which one of the following is the most common 8. Which one of the following drug regimens is cause of pericarditis in the United States? considered first-line therapy for acute pericarditis?  A. Viral infections.  A. Colchicine and prednisone.  B. Autoimmune conditions.  B. Colchicine plus aspirin and prednisone.  C. Drugs (eg, chemotherapy drugs).  C. Colchicine plus nonsteroidal anti-  D. Metabolic conditions. inflammatory drugs (ie, aspirin or ibuprofen or  E. V  accination adverse effects. indomethacin).  D. Prednisone plus indomethacin.  E. Indomethacin. Pretest Answers Question 1: The correct answer is D. Question 5: The correct answer is E. In general, regular physical activity decreases the risk of Although premature atrial contractions (PACs) were developing atrial fibrillation (AF) by up to 46% in older previously considered benign, there is increasing recog- adults. However, patients who engage in long-term high- nition that frequent PACs are associated with develop- level endurance exercise (eg, marathon runners, cross- ing atrial fibrillation along with its potential outcomes of country skiers, long-distance cyclists) have a twofold to stroke and death. See page 22. fivefold increased risk for AF. See page 8. Question 6: The correct answer is B. Question 2: The correct answer is A. Patients with premature ventricular contractions and Immediate synchronized direct current cardioversion left ventricular dysfunction at presentation and those is recommended for patients with atrial fibrillation and who develop left ventricular dysfunction during clinical hemodynamic instability (eg, hypotension). See page 9. follow-up should be referred to an electrophysiologist for possible ablation. See page 24. Question 3: The correct answer is C. Warfarin is preferred for atrial fibrillation in patients with Question 7: The correct answer is A. moderate to severe mitral stenosis. See page 18. In high-resource countries, viral infections are the most common cause of pericarditis. See page 29 and Table 4. Question 4: The correct answer is B. Analysis of data from large studies, including individuals Question 8: The correct answer is C. 85 years or older, show that benefits of anticoagulation Colchicine plus nonsteroidal anti-inflammatory drugs for atrial fibrillation are greatest in older adults, reducing (ie, aspirin or ibuprofen or indomethacin) is the recom- risk of thromboembolic events by 32% (4.3% per year mended first-line treatment for acute pericarditis. See with anticoagulation vs 6.3% per year without antico- page 31 and Table 5. agulation), with similar risks of major bleeding compared with those in patients taking antiplatelet therapy or no anticoagulation. See page 19. 5 Key Practice Recommendations These key learning points summarize the consensus- and evidence-based recommendations included in this edition. The sources listed here for each statement recommend that physicians perform or implement these actions directly in a clinical setting. 1. Refer patients with atrial fibrillation (AF) and hemo- Source: ESC, reference 2 dynamic instability for immediate synchronized Website: https://academic.oup.com/eurheartj/ direct current cardioversion. article/42/5/373/5899003 Evidence rating: SORT C Sources: European Society of Cardiology (ESC), 5. Prescribe colchicine plus nonsteroidal anti-inflam- American Heart Association (AHA)/American College matory drugs as first-line treatment for patients with of Cardiology (ACC)/Heart Rhythm Society (HRS), acute pericarditis. Canadian Cardiovascular Society (CCS)/Canadian Evidence rating: SORT C Heart Rhythm Society (CHRS), references 2, 5, 7 Source: ESC, reference 155 Websites: https://academic.oup.com/eurheartj/ Website: https://www.ncbi.nlm.nih.gov/pmc/ article/42/5/373/5899003 articles/PMC7539677/ https://www.sciencedirect.com/science/article/pii/ S0735109714017409 6. For patients with suspected infective endocarditis, https://onlinecjc.ca/article/S0828-282X(20)30991-0/ administer antibiotics promptly after obtaining blood fulltext cultures. Antibiotics should cover staphylococci, streptococci, and enterococci. 2. Consider catheter ablation in patients with parox- Evidence rating: SORT C ysmal or persistent AF who are symptomatic and Sources: ESC, StatPearls, references 193, 201 unable to tolerate at least one antiarrhythmic drug. Websites: https://academic.oup.com/eurheartj/ Evidence rating: SORT B article/36/44/3075/2293384 Source: ESC, reference 2 https://www.ncbi.nlm.nih.gov/books/NBK542162/ Website: https://academic.oup.com/eurheartj/ article/42/5/373/5899003 Strength of Recommendation Taxonomy 3. Prescribe beta blockers or nondihydropyridine calcium channel blockers (verapamil or diltiazem) as (SORT) the preferred drugs for rate control in paroxysmal, persistent, and permanent AF in patients without Evidence significant left ventricular dysfunction or decompen- Rating Definition sated heart failure. A Recommendation based on consistent and Evidence rating: SORT C good-quality patient-oriented evidence.a Sources: AHA/ACC/HRS, CCS/CHRS, references 5, 7 Websites: https://www.sciencedirect.com/science/ B Recommendation based on inconsistent or article/pii/S0735109714017409 limited-quality patient-oriented evidence.a https://onlinecjc.ca/article/S0828-282X(20)30991-0/ C Recommendation based on consensus, fulltext usual practice, opinion, disease-oriented evidence,a or case series for studies 4. Prescribe oral anticoagulants (warfarin or direct oral of diagnosis, treatment, prevention, or anticoagulants) for stroke prevention in patients screening. with AF with significant stroke risk (ie, men with a aPatient-oriented evidence measures outcomes that matter to CHA2DS2-VASc [Congestive heart failure, Hyper- patients: morbidity, mortality, symptom improvement, cost reduction, tension, Age 75 years or older [doubled], Diabetes, and quality of life. Disease-oriented evidence measures intermedi- prior Stroke or transient ischemic attack or throm- ate, physiologic, or surrogate end points that may or may not reflect boembolism [doubled], Vascular disease, Age 65 improvement in patient outcomes (eg, blood pressure, blood chemis- try, physiologic function, pathologic findings). to 74 years, Sex category] score of 2 or greater and From Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation women with a score of 3 or greater), assuming no taxonomy [SORT]: a patient-centered approach to grading evidence in excessive bleeding risk. the medical literature. Am Fam Physician. 2004;69:548-556. Evidence rating: SORT C 6  SECTION ONE Atrial Fibrillation and Atrial Flutter Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in adults, with lifetime rates of 21% to 33%. There are numerous risk factors, including older age, hypertension, coronary disease, obstructive sleep apnea, diabetes, and others. Patients engaging in lifelong high-endurance exercise also have increased risk. Some organi- zations recommend screening; others do not. However, many patients identify AF themselves using mobile cardiac monitoring devices, some of which accurately detect the arrhythmia. Patients with AF with hemodynamic instabil- ity are treated with immediate synchronized cardioversion. Treatment options for stable patients include scheduled cardioversion, rhythm control with pharmacotherapy, catheter ablation, and rate control with pharmacotherapy. Catheter ablation is increasingly used as first-line therapy, with up to 80% of patients remaining AF-free after one or two ablation treatments, an outcome superior to that with pharmacotherapy. Patients with AF should receive anticoagulation based on the CHA2DS2-VASc (Congestive heart failure, Hypertension, Age 75 years or older [dou- bled], Diabetes, prior Stroke or transient ischemic attack or thromboembolism [doubled], Vascular disease, Age 65 to 74 years, Sex category) score, and also before and immediately after ablation or cardioversion. It is uncertain whether long-term anticoagulation is needed after successful ablation. Atrial flutter (AFL) is the second most com- mon sustained supraventricular arrhythmia. Patients with AFL are at risk of developing AF, and many recommen- dations for managing AFL are similar to those for AF. The preferred management for AFL is catheter ablation, with success rates exceeding 90%. NOTE: New guidelines for the diagnosis and manage- for heart failure, hospitalization, thromboembolic events, ment of atrial fibrillation (AF) from the American College cognitive impairment, depression, impaired quality of of Cardiology/American Heart Association/American life, and overall mortality.1 Despite medical advances, College of Clinical Pharmacy/Heart Rhythm Society preventing AF and its complications remains challenging. (see Resources) were released just before this edition of FP Essentials went to press. They are not reflected in this EPIDEMIOLOGY text, but there are three important changes to note: (1) The prevalence of AF in adults worldwide is estimated a new AF classification system that includes risk factor to be between 2% and 4%.2 In the United States, AF stages; (2) endorsement of two additional validated stroke currently affects approximately 3 to 6 million adults, prediction tools (ie, ATRIA, GARFIELD-AF); and (3) and this number is expected to reach 6 to 16 million by recommendation as reasonable to initiate anticoagulation 2050 as the population ages.3 The Atherosclerosis Risk in for patients with device-detected atrial high-rate episodes Communities Study (ARIC) showed the incidence of AF without overt AF, based on rhythm duration and calcu- increases with age and is higher among White individu- lated stroke risk. als and those of lower socioeconomic status.4 However, lifetime risk is lower in socioeconomically disadvan- Case 1. KS, a 55-year-old with long-standing hypertension taged groups, possibly because of their overall shorter and diabetes, comes to your office because of palpitations lifespans.3 and mild exertional dyspnea. Electrocardiogram results reveal atrial fibrillation with an average heart rate of 80 to CLASSIFICATION 90 beats/min. Atrial fibrillation is classified based on duration of epi- sodes.2,5 Paroxysmal AF terminates spontaneously or with Atrial Fibrillation treatment within 7 days. Persistent AF is continuously Atrial fibrillation (AF), the most common sustained sustained for more than 7 days. Long-standing persistent cardiac arrhythmia in adults, is characterized by chaotic AF is continuous for more than 12 months. Permanent AF atrial activity with no distinguishable P waves, and ven- refers to the situation in which patients, in joint deci- tricular contractions indicated by irregular QRS com- sion with their clinician, have opted to no longer pursue plexes (Figure 1). Patients with AF have increased risks rhythm control. 7 CARDIOVASCULAR DISEASE Figure 1. Electrocardiogram Showing Atrial Fibrillation Note: The heart rate is 86 beats/min. The ventricular rate is irregular. There are no P waves associated with QRS complexes, and fibrillation waves are seen in lead V. Image courtesy of Robert L. Gauer, MD. In addition, although not a formal classification, subclin- exercise (eg, marathon runners, cross-country skiers, ical or device-detected AF refers to asymptomatic AF epi- long-distance cyclists) have a twofold to fivefold increased sodes detected on cardiac monitoring devices in patients risk for AF.10,11,12,13 Such intense exercise results in struc- without previously known AF.2 Terms no longer recom- tural myocardial changes, greater oxidative stress, and a mended include lone AF, valvular AF (now recognized as heightened inflammatory response predisposing patients moderate or severe mitral stenosis), and chronic AF. to AF. Secondary AF occurs in patients with identifiable precip- RISK FACTORS itants, such as sepsis, alcohol intoxication, use of stimu- Nonmodifiable risk factors for AF include advancing age, lant drugs (eg, cocaine, methamphetamines), pulmonary male sex, White race, and genetics (eg, sequence variances embolus, thyrotoxicosis, inflammatory heart conditions, of potassium, sodium, and non-ion channel genes).6 Of and acute myocardial infarction. It also occurs after cardiac these, age is the most significant risk factor. The prevalence and noncardiac surgery.14 Drugs known to precipitate AF of AF is less than 1% in individuals younger than 50 years, include bisphosphonates (eg, alendronate, zoledronic acid), 4% by age 65 years, and 12% in those 80 years or older.7 bronchodilators, antipsychotics (ie, chlorpromazine, clozap- Hypertension and coronary heart disease are the most ine, olanzapine, quetiapine), amiodarone (which induces common chronic illnesses associated with AF. Other con- thyrotoxicosis), adenosine, and ivabradine (Corlanor).15 ditions associated with increased AF risk include valvular heart disease, heart failure, increased left atrial size, hyper- SCREENING trophic cardiomyopathy, congenital heart disease, venous Current guidelines recommend AF screening only within thromboembolic disease, obstructive sleep apnea, obesity, the context of an established clinical encounter. For chronic obstructive pulmonary disease, diabetes, chronic example, the 2020 Canadian Cardiovascular Society (CCS) kidney disease, and smoking.2,3,8,9 and European Society of Cardiology (ESC) AF guidelines In general, regular physical activity decreases the risk of recommend opportunistic screening for AF in patients 65 developing AF by up to 46% in older adults.10 However, years or older during medical encounters, and the ESC patients who engage in long-term high-level endurance also recommends considering electrocardiogram (ECG) 8  SECTION ONE screening in patients 75 years or older and in those having (NT-proBNP) level, and inflammatory markers (ie, high risk for stroke.2,7 The U.S. Preventive Services Task C-reactive protein, erythrocyte sedimentation rate) should Force (USPSTF) concluded there is insufficient evidence to be obtained as clinically indicated. Imaging should include assess the balance of benefits and harms of screening for AF a chest x-ray if pulmonary edema is suspected or to detect in adults 50 years or older.16 cardiomegaly) and an echocardiogram (to assess atrial size, However, health consciousness among the general popu- left ventricular systolic function, and valvular anatomy lation coupled with direct-to-consumer advertisement have and function, as well as to assess for atrial thrombus). substantially increased awareness of AF and its associated These tests can be obtained on a nonurgent basis in stable medical complications. Patients are using mobile health patients.2,5,7 technologies designed to detect asymptomatic AF.17,18,19 Computed tomography pulmonary angiography can Of these, single-lead ECG smartphone apps and smart be considered if there is concern for pulmonary embolus, watches have the highest sensitivities (92%-99%) and because symptoms of AF with RVR, (dyspnea, chest pain, specificities (76%-100%), with smartphone apps consid- syncope/near syncope, tachycardia) can mimic those of ered the most accurate.20 In a study of smartwatch and pulmonary embolus.25 Cardiac stress testing is appropriate fitness band electronics wearers, 0.5% of 419,297 smart after the patient is stabilized, if there is a concern for isch- watch app users received an irregular pulse notification, emic heart disease.5,7 Electrophysiologic studies are recom- 34% of whom were confirmed to have AF on subsequent mended if the diagnosis is in question or in patients with cardiac monitoring.21 Another study of wearable smart evidence of preexcitation (Wolff-Parkinson-White [WPW] devices showed similar results, with a 92% positive pre- syndrome, in which ECGs show short PR intervals and dictive value for detecting AF with wearable photopleth- sloped upstroke of QRS complexes). ysmography devices (which use infrared light to detect variations in volume of blood circulation).22 MANAGEMENT Wrist-worn photoplethysmography has been found to The overall approach to AF is summarized in Figure 2. be cost-effective compared with pulse palpation and ECG Options vary depending on patient stability and on screening.23 However, AF detected by any of these devices whether rate or rhythm control treatment is used. Anti- should be confirmed with a 12-lead ECG or ambulatory coagulation also often is required. Some aspects of antico- monitor. agulation therapy for AF are discussed in this section and reviewed in depth in Section Two. PRESENTATION Unstable AF. Immediate synchronized direct current The presentation of patients with AF varies, ranging from cardioversion (DCCV) is recommended for patients with asymptomatic to hemodynamic instability. The most AF and hemodynamic instability (eg, hypotension ).2,5,7 common symptoms include rapid heart rate, palpitations, After cardioversion, these patients are at increased risk of fatigue, lightheadedness, and dyspnea. Rapid heart rates can embolic stroke if not previously receiving anticoagula- cause chest pain, syncope, hypotension, and heart failure.1 tion.2,7,26 If patients at high risk for decompensation are Prolonged undiagnosed AF, particularly with sustained receiving care in a medical facility with limited resources, heart rates greater than 110 beats/min, can lead to AF-me- they should be referred to the emergency department for diated cardiomyopathy with heart failure symptoms.24 treatment and stabilization; factors conferring high risk of decompensation include low-normal blood pressure, sus- DIAGNOSIS tained RVR, presyncopal symptoms, ischemic chest pain, A 12-lead ECG is recommended to identify AF (with or evidence of heart failure. or without a rapid ventricular rate [RVR]) and assess for In patients for whom treatment is less urgent, rapid other abnormalities, including ischemia, preexcitation, control of heart rate often requires use of intravenous multifocal atrial tachycardia, and conduction disorders.2,7 nondihydropyridine calcium channel blockers (diltiazem Recommended laboratory studies include a basic meta- and verapamil) or beta blockers.2,5,7,26 A meta-analysis bolic panel, complete blood cell count, coagulation studies comparing intravenous diltiazem with metoprolol in AF (prothrombin time; baseline level should be obtained to with RVR found that diltiazem had more rapid action, inform consideration of anticoagulation), cardiac biomark- along with higher efficacy and less effect on systolic blood ers (troponin level), a lipid panel, hemoglobin A1c level, pressure than metoprolol, with no significant differences in and thyroid function studies.2,7 adverse effects.27 However, diltiazem is a negative inotrope Additional testing, such as urine toxicology, eth- that can worsen heart failure. It should not be used in anol level, N-terminal pro-brain natriuretic peptide patients with acute decompensated heart failure or known 9 CARDIOVASCULAR DISEASE heart failure with an ejection fraction of 40% or less.5,7,28,29 Rate control vs rhythm control is a key management Amiodarone or digoxin is recommended in that situation.7 decision in AF and has been studied extensively. Rate con- Stable AF. Most patients with AF are relatively stable trol uses drugs, whereas rhythm control options include even in the presence of RVR. They can be treated without electrical cardioversion, drugs, and ablation. hospitalization or emergency department care. Older studies, specifically the AFFIRM (Atrial Patient with AF Is the patient hemo- Yes DCCV dynamically unstable? No Discussion of rate vs rhythm control Rate control Rhythm controla What is the ejection fraction? Duration of AF TEEb ≥40%