Primary Atrial Fibrillation/Flutter (AF)

Before you start 

  • Whats the cause? – treating the precipitant often sorts the AF (adding B-Blockers to Sepsis can make things worse)
  • Stable or Unstable?  – Electricity vs. Drugs
  • less than 48hrs? – Rhythm vs. Rate control
  • CHADS-VASC vs. HASBLED – Anticoagulation
  • Arrhythmia Clinic – referral form attached tho the PDF


It’s essential any identifiable precipitant is treated, these include:

  • Haemodynamic stress: Valvular disease/Hypertension/LVD/Thrombus
  • Atrial ischemia: Ischaemic Heart Disease
  • Inflammation: Sepsis/Myocarditis/pericarditis
  • Noncardiovascular respiratory causes: PE/Pneumonia/Lung Cancer
  • Alcohol and drug use: Alcohol/Cocaine/Amphetamine
  • Endocrine disorders: Hyperthyroid/Diabetes/Phaeochromacytoma/Electrolyte prob.
  • Neurologic disorders: Subarachnoid Haemorrhage/Stroke
  • Genetic factors
  • Advancing age



***WPW with AF: Adenosine, Calcium channel blockers, Digoxin ALL precipitate VF/VT, Electrical Cardioversion is the preferred option***


To rhythm control or not: In the haemodynamically unstable patient Emergency DC Cardioversion (DCC) is the treatment of choice. But in the stable patient its not so clear, and should only be considered  in the ED if they fit the following due to the risk of precipitating a Stroke:

  • Clear onset within 24hrs of presentation
  • Clear onset between 24-48hr and CHADVASc 0-1
  • Recent onset & established on a DOAC and CHADVASc 0-1

The European Society of Cardiology, state that rhythm control is currently the main stay of management. It has been shown that the earlier the patient can be returned to sinus rhythm the less cardiac remodelling happens and its thought this reduces complications from AF. However, studies have not shown a survival advantage to rhythm control over rate control. Studies into whether rhythm control prevents complications of AF such as Stroke or MI are underway and projected to report in 2021. So currently if possible rhythm control should be our preferred option, however, we should consider the practicalities and patient choice.

Rhythm control – DCC or Drugs: DCC has been shown to restore rhythm quicker and more effectively than drugs (which work approximately 50% of the time). Our drug options are also limited. our available medications are:

  • Amiodarone –  is only recommended in patients with severe/moderate heart failure
  • Flecainide  – Only tablet medication available (as efficacious as IV but slower), and can induce Arrhythmia
    • NOT to be used in patients with structural heart disease
    • NOT useful in Atrial Flutter
    • Has it worked in the past? – they may have used “pill in the pocket” in the past successfully
    • ANY doubts involve Cardiology/Medicine
  • Rate Control – If neither of the above options are suitable for your patient the only other option is rate control

Discharge? – If all of following

  • No compromise
  • HR<110 for 2hr
  • No precipitants requiring admission

Refer to AF Clinic if new:  AF clinic Referral form

Consider Anticoagulation: CHADS-VASC vs HAS-BLED




PDF: Patient Info


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