Atrial Fibrillation and Flutter Guide

I. Initial Evaluation

History

  • Symptoms: Palpitations, fatigue, dizziness, chest discomfort, dyspnea, syncope
  • Onset: Sudden vs gradual; known triggers (e.g., alcohol binge, infection, hyperthyroidism)
  • History: Prior AF/flutter, structural heart disease, heart failure, hypertension, thyroid disease

Physical Exam

  • Vitals: Irregularly irregular pulse (AF), rapid HR; stable vs unstable signs
  • Cardiac: Irregular rhythm in AF; sawtooth conduction in flutter may have regular or variable conduction
  • Signs of underlying causes: CHF signs, thyromegaly, murmurs

II. Diagnostic Workup

EKG

  • Atrial Fibrillation: Irregularly irregular rhythm, absence of P waves, fibrillatory baseline

  • Atrial flutter: Sawtooth flutter waves (esp. leads II, III, aVF), often with 2:1 or variable conduction

Labs

  • Electrolytes (K⁺, Mg²⁺)
  • TSH/Free T4 (hyperthyroidism evaluation)
  • Troponin if ischemia suspected
  • CBC, CMP to evaluate underlying or precipitating causes

Imaging

  • Chest X-ray: Evaluate for CHF
  • Echo: Assess for left atrial enlargement, valvular disease, LV function

III. Classification

TypeDescription
Paroxysmal AFTerminates spontaneously within 7 days
Persistent AFPersists >7 days or requires cardioversion
Long-standing persistent AFContinuous AF >12 months
Permanent AFDecision made to accept and not pursue rhythm control

IV. Treatment

Acute Management

  • If unstable (hypotension, ischemia, pulmonary edema): Immediate synchronized cardioversion
  • Rate control (stable): IV diltiazem or beta-blocker (e.g., metoprolol)
    • Diltiazem full dose is 0.25mg/kg IV. This can be broken down into 10-15mg IV pushes.
      • Repeat dosing until desired HR is achieved (usually aim for less than 105 bpm)
      • Metoprolol can be given in doses from 2.5mg to 5mg IV pushes
      • Consider diltiazem drip if the patient is requiring multiple (>3 IV pushes) without sustained response
  • Consider digoxin 250mcg IV if hypotensive or arrhythmia is refractory (esp. in CHF)
  • Anticoagulation considerations based on duration & risk factors

Anticoagulation

  • Calculate CHA₂DS₂-VASc score
  • Initiate anticoagulation (DOACs preferred) if score ≥2 (male) or ≥3 (female)
  • For AF >48h or unknown duration: Anticoagulate ≥3 weeks before or use TEE-guided strategy before cardioversion

Rhythm Control

  • Electrical cardioversion if appropriate (stable + anticoagulated)
    • This may be done on an inpatient basis (or through a cardiology clinic) once a TEE has confirmed no atrial thrombus is present
  • Pharmacologic cardioversion options: Amiodarone, flecainide, propafenone (consider contraindications)
  • Referral to EP for ablation in recurrent symptomatic AF/flutter

V. Disposition Planning

ScenarioDispositionNotes
New-onset AF/flutter, stable, rate controlled, CHA₂DS₂-VASc indicates low riskDischarge with outpatient cardiology follow-upStart anticoagulation if indicated, arrange follow-up
Persistent rapid AF/flutter, unstable, or evidence of end-organ damage or high CHA₂DS₂-VASc riskAdmit to telemetry, PCU or ICUInitiate IV therapy, possible cardioversion, continuous monitoring

VI. Red Flags / Escalation Triggers

  • Hemodynamic instability (SBP <90 mmHg)
  • Chest pain with dynamic ECG changes suggestive of ischemia
  • Acute heart failure with pulmonary edema
  • Signs of stroke or TIA
  • Pre-excitation (WPW) with wide complex irregular tachycardia

✅ Discharge Checklist

  • Stable rate & rhythm with clear follow-up plan
  • Initiated anticoagulation if indicated
  • Patient educated on symptoms, medications, when to return
  • Follow-up with primary care or cardiology scheduled

References

  1. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update on the Management of Patients With Atrial Fibrillation. Circulation. 2019;140(2):e125–e151. https://doi.org/10.1161/CIR.0000000000000665

Additional Keywords: A-fib, Afib, A-flutter, Aflutter, RVR, Rapid Ventricular Response