Atrial Fibrillation Guideline Check-In
Hey Team,
We had an interesting shift with quite a few people with atrial fibrillation. Coincidentally, there was an article published this week in Annals of EM that compared the 5 recent clinical guidelines on atrial fibrillation as they apply to emergency medicine.
Source: Atzema, C. L., Cox, J. L., Cheung, C. C., Coll-Vinent, B., Benjamin, E. J., Jackevicius, C. A., & Vinson, D. R. (2026). Comparing Guidelines for Atrial Fibrillation: Focus on Emergency Medicine. Annals of emergency medicine, S0196-0644(25)01291-0. Advance online publication.[pubmed]
1. Stroke Prevention
Actionable takeaway
Use one validated stroke risk tool consistently and document it.
DOACs are first-line for nearly all eligible AF/AFL patients.
Aspirin has no role in AF stroke prevention, except when treating vascular disease alone.
ED Pearl
Guideline differences mainly reflect how sex is handled, not whether anticoagulation is needed.
If a patient qualifies by any endorsed tool and has no major bleeding red flags, starting a DOAC in the ED is appropriate.
2. DOAC prescribing
Actionable takeaway
Before prescribing, ask three questions:
Prior major bleeding?
On antiplatelet therapy?
Platelets <100 or hemoglobin <8?
No to all three → prescribe 14–30 days of a DOAC and arrange follow-up.
Yes to any → defer and arrange specialty or rapid outpatient follow-up.
ED Pearl
You do not need a bleeding risk score to decide.
When dosing or interactions are unclear, deferring initiation is guideline-supported.
3. Cardioversion
Actionable takeaway
Unstable AF → immediate electrical cardioversion regardless of anticoagulation.
Stable AF → cardioversion eligibility now depends on duration, stroke risk, and valvular status, not a blanket 48-hour cutoff.
When cardioverting, administer a DOAC at the time of cardioversion, then continue 4 weeks in most patients.
ED Pearl
Evidence is low quality across all guidelines, but risk tolerance has narrowed.
If AF duration is unclear or >24 hours, avoid cardioversion unless imaging excludes atrial thrombus.
4. Rhythm control
Actionable takeaway
New AF (<1 year) benefits from early rhythm-control strategies, even if not cardioverted in the ED.
Refer newly diagnosed AF patients for cardiology or EP follow-up.
ED Pearl
Your role is not to perform ablation, but to start the pathway.
5. Rate control
Actionable takeaway
Accept a resting HR <100–110.
First-line: β-blocker or diltiazem/verapamil if EF preserved.
Avoid CCBs in decompensated HFrEF.
Use digoxin or amiodarone in hypotension or acute HF.
ED Pearl
Treat the underlying trigger first in secondary AF.
Over-aggressive rate control can worsen shock physiology.
6. Discharge Planning
Actionable takeaway
Before discharge, ensure:
DOAC prescription if indicated (14–30 days).
Follow-up within 1 week if new meds were started.
Referral for rhythm-control discussion within 12 months of diagnosis.
ED Pearl
Anticoagulation without follow-up is unsafe.
Withholding anticoagulation when clearly indicated is also risky
Cheers,
Dillon
