Slide 1: Patient presenting with shortness of breath…what’s the rhythm? Hint: where are the p waves?

Slide 2: Tachycardia + narrow complex + irregularly irregular + no p waves = atrial fibrillation (with rapid ventricular response). Did you know? Afib is the most common arrhythmia in the general population! Vitals are stable…what are your treatment options?

Slide 3: Treatment options. First line…beta blockers (ie metoprolol) – be cautious, especially with IV formulation, in decompensated heart failure OR nondihydropyridine CCBs (ie diltiazem) – avoid altogether in decompensated heart failure. If critically ill or unstable, consider amiodarone or electrical cardioversion!

Slide 4: Data dive. AFFIRM trial: rate control is not inferior to rhythm control. RACE II trial: HR < 110 bpm is not inferior to < 80 bpm. CASTLE-AF trial: catheter ablation > meds in specific populations. Bottom line: titrate medications to improve symptoms and refer to cardiologist for a discussion of rhythm control strategy in the outpatient setting.

Slide 5: And don’t forget to consider anticoagulation. CHA2DS2-VASC = Congestive heart failure, Hypertension, Age ≥ 65 or ≥ 75, Diabetes, Stroke/TIA, Vascular disease, Sex Category (F). Score ≥ 2 in men and ≥ 3 in women: oral anticoagulation recommended. Score ≥ 1 in medn and ≥ 2 in women: oral anticoagulation considered. Aspirin is no longer recommended for this population.


  • January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019 Jul 9;140(2):e125-e151. Epub 2019 Jan 28. PMID 30686041.

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