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New Onset Atrial Fibrillation

Matthew DeLaney, MD, Mizuho Morrison, DO, and Ryan Pedigo, MD
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When evaluating a patient with a-fib it is important to consider both rhythm control and also the associated risk of subsequent thrombosis. Even in patients who have brief episodes of a-fib there may be a significant risk of developing a thrombotic complication.

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Jason K. -

It seems like a broad statement to say that anyone with afib of (convincingly) less than 48 hours should be sent to the ED from UC in light of the RACE 7 ACWAS study, which basically says that cardioversion isn't necessarily the best step in new onset afib (without other indications for immediate cardioversion). It seems like in otherwise stable patients, a discussion with a cardiologist may save even new onset afib patients an ED visit.

Mike W., MD -

From Matt Delaney:

This is a great question. the RACE 7 ACWAS study seems to tell us that in most patients taking a wait and see approach for patients with a-fib is a reasonable option. When randomized to a cardioversion vs wait and see both groups had similar outcomes with the majority of patients being in NSR at 48 hours.
The issue in the UC is that most of the a-fib patients I see are symptomatic and don't really buy into the idea of going home to wait and see if they will spontaneously go out of a-fib. I think if a patient walks in with new onset a-fib and they are not tachycardic it would be reasonable to give them the option of going home. I agree with Jason that a discussion with a PCP or cardiologist would be a good step to ensure that they can get seen promptly in followup. I've had this discussion with a handful of patients and all of them wanted to have immediate cardioversion but again this is more patient preference than any evidence based recommendation.

Hope this helps,

DeLaney

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Off The Cuff Full episode audio for MD edition 169:22 min - 79 MB - M4AHippo Urgent Care RAP September 2019 Written Summary 681 KB - PDF

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