Atrial fibrillation, or A-fib, is an increasingly common chronic condition seen in the primary care setting. Management is multifaceted and requires a team-based approach.
Risk for A-fib increases with age and is greater if there is a family history. Modifiable risk factors for A-fib are obesity, diabetes, hypertension, sleep apnea, and excessive caffeine or alcohol intake.
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“Managing these modifiable risk factors are critical to the long-term success in managing atrial fibrillation,” said Kent E. Morris, M.D., electrophysiologist with the Norton Heart & Vascular Institute Heart Rhythm Center.
“In practice that means making sure their blood pressure is within the acceptable range, making sure there is adequate control of diabetes, having a conversation about the benefits of weight reduction, and addressing screening for sleep apnea and treating it, if it’s indicated. It’s not a one-and-done conversation,” Dr. Morris said.
One of the challenges of A-fib is diagnosing it. As many as 30% to 50% of people may have A-fib at some point, and incidence of A-fib correlates simply with how long a patient is monitored. The longer a patient is monitored, the more episodes of A-fib a clinician will see.
“A palpitation can be a descriptor of a number of things, so trying to actually pinpoint what’s occurring when the patient has that symptom is one of the challenges to diagnosing A-fib,” Dr. Morris.
Dr. Morris recently discussed “Management of Atrial Fibrillation in Primary Care” on the continuing medical education podcast MedChat.
The classic symptom of A-fib is the so-called “fluttering” feeling in the chest, but many patients do not experience this. They may be asymptomatic or simply have shortness of breath or lack of energy during activities or exercise.
The best time to refer a patient for specialized care is at the time of diagnosis, according to Dr. Morris.
A-fib, including asymptomatic A-fib, increases the risk for stroke five-fold. Data from the past 15 years shows even a couple of minutes of A-fib is long enough for a thrombus to form, which has lowered the threshold to initiate anticoagulants.
Primary care providers should assess a patient’s risk for stroke using a scoring system called CHA2DS2-VASc. The CHA2DS2-VASc score, in combination with the duration and burden of A-fib, determines whether anticoagulation therapy should be initiated.
Newer, direct oral anticoagulants (DOACs) are now preferred over warfarin in most cases. Patients should still receive warfarin for anticoagulation if they have moderate or more mitral stenosis. Patients on dialysis also should receive warfarin or apixaban because of the pharmokinetics related to renal clearance of some of the DOAC medications.
Controlling symptoms is another important goal of managing A-fib in the primary care setting. This can involve rate control alone or rhythm control, which may include the use of medications or catheter ablation.
Untreated, rapid A-fib can lead to cardiomyopathy and congestive heart failure. There is a strong correlation between incidence of A-fib and advancing heart failure class, and newer data suggests patients with an early rhythm control strategy may do better, particularly in younger patients.
Overall, A-fib management in primary care involves a combination of risk assessment, anticoagulation therapy, heart rate control and symptom management.