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What should be done when atrial fibrillation first presents 

What should be done when atrial fibrillation first presents
Chapter:
What should be done when atrial fibrillation first presents
Source:
Management of Atrial Fibrillation (Oxford Cardiology Library): A Practical Approach
Author(s):

James A. Reiffel

DOI:
10.1093/med/9780199686315.003.0002

Current estimates suggest that over 6 million patients in the United States have atrial fibrillation (AF). Worldwide these numbers are dramatically higher. For each of these patients, there was a first episode. Most often AF presents symptomatically; however, it may be detected incidentally. The presentation dictates much of what is done at the initial encounter, aside from the considerations of anticoagulation and rate control. Asymptomatic, incidentally detected AF requires rate control therapy and anticoagulation for the same indications as symptomatic AF. However, it does not necessitate urgent evaluation, hospitalization, or rhythm control. In the symptomatic patient with new-onset AF, the first determination is whether or not urgent cardioversion is required (ischaemia, haemodynamic instability, rapid pre-exciatation). If so it should proceed without delay. This should be followed by an initial patient evaluation focused upon: any past symptoms; the patient’s reliability as to accurately detecting the AF onset; the patient’s compliance with medication and follow-up instructions; whether there are co-morbid disorders mandating or contraindicating anticoagulation and/or that might affect antiarrhythmic treatment decisions; whether there is evidence of underlying sinus node or conduction system disease; and whether there are any identifiable precipitants. With this information the encounter can then proceed to the initiation of rate control and anticoagulation, determination of in- versus out-patient management, determination as to the need for, timing of, and approach to non-urgent or elective cardioversion, elimination of precipitants, and what additional diagnostic tests might be required in the days following this first encounter.

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