Atrial Fibrillation 🫀

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📞 What to Ask on the Phone

  • Is the patient symptomatic (palpitations, chest pain, breathlessness, dizziness)?
  • Are there signs of haemodynamic instability? If so, escalate to senior immediately.
  • Duration of the arrhythmia (new onset vs known AF)?
  • Any previous episodes or cardioversions?
  • Is the patient anticoagulated? What is their current medication list?

🔍 Immediate Considerations

  • Assess vitals: BP, HR, O2 sats, RR, temperature
  • Identify red flags: chest pain, syncope, hypotension, pulmonary oedema
  • Review ECG and compare to any prior
  • Consider reversible causes: sepsis, PE, thyrotoxicosis, alcohol, electrolyte imbalance
  • On any rate/rhythm control medication already? Anticoagulated?

🧪 Initial Assessment

  • ECG – confirm AF, rate, and rule out other arrhythmias
  • Bloods: FBC, U&E, LFT, TFTs, CRP, Troponin if chest pain
  • CXR if concern for pulmonary oedema or infection
  • VBG if concerned re: lactic acidosis or electrolyte disturbance
  • ECHO if new-onset or considering cardioversion (may be outpatient)

🩹 Management

  • If haemodynamically unstable → heparinise & urgent DC cardioversion (call senior/cardiology/anaesthetics)
  • If stable, consult registrar and consider:
  • → Anticoagulation - Rivaroxaban 20mg PO OD, discuss with senior if CrCl <50. Consider aspirin if <48h onset and low stroke risk with cardioversion.
  • → Rate control with beta-blocker (e.g. bisoprolol 5mg PO stat). Give MgSO4 2g IV.
  • → Give IV metoprolol 2.5mg if no response to oral beta-blocker after 30 mins (repeat at 20 minutes if no response).
  • → Asthmatics: substitute with Verapamil 2mg IV & Diltiazem 120mg PO
  • Do not cardiovert unless duration & anticoagulation status are clear
  • If duration <48h and patient is low risk, consider rhythm control (discuss with senior)

✅ Actions for Interns

  • Document vitals, symptoms, and management clearly.
  • Ensure senior is aware of any new or unstable AF
  • Order or chase relevant investigations
  • Clarify and communicate anticoagulation plan
  • Arrange follow-up with cardiology or further workup if needed

CHA₂DS₂-VASc Score

Stroke risk assessment for atrial fibrillation

Risk Factors

Assessment Result

0
✅Low risk

HAS-BLED & ORBIT Scores

Bleeding risk assessment tools

HAS-BLED Score

💉
Risk Factors
HAS-BLED Result
0
Acceptable bleeding risk

ORBIT Score

⚖️
Risk Factors
ORBIT Result
0
Low bleeding risk
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