CONGRESS ABSTRACT

Background. Atrial fibrillation (AF) is the most prevalent arrhythmia in Emergency Room admission, especially in elderly patients. Last ESC Guideline (GL) suggest a new AF-CARE approach that includes the management of Comorbidity and risk factors, Avoid stroke and thromboembolism, Reduce symptoms by rate and rhythm control and Evaluation and dynamic reassessment. Objectives. In order to simplify the decision-making approach, an intra-hospital pathway was built in digital format, considering the clinical presentation, the various therapeutic options and the destination to the most appropriate ward. Birth sex is no more considered in the evaluation of the thrombotic risk. DOAC over VKAs (in eligible patients) are recommended when CHA2DS2-VA score ≥ 2 and should be considered with a score of 1. Moreover Amyloidosis or Hypertrophic Cardiomyopathy requires therapy regardless of CHA2DS2-VA score. Elective cardioversion without at least 3 weeks of anticoagulation or transesophageal echocardiography is no recommended if AF last longer than 24h. In patients with acute or worsening hemodynamic instability urgent electric cardioversion must be performed without delay even if the arrhythmia has been lasting for more than 24 hours. To control heart rate in the acute phase of AF, current GL suggest beta-blockers, Digoxin and Non-Dihydropyridine Calcium Channel Blockers; Amiodarone being the last option. When pharmaceutical Cardioversion is required, Flecainide, Propafenone and Vernakalant are recommend, excluding patients affected by Hypertrophic Cardiomyopathy, Coronary Artery Disease and Heart Failure with Reduced Ejection Fraction, who must be treated with Amiodarone. The entire protocol scheme can be divided into three columns: on the right, patients with a hemodynamic instability, on the left stable ones, and in the middle DOACs users. Patients on the left can wait up to 48 hours for a spontaneous sinus rhythm restoration. The final part of the flowchart highlights the strengthened indications for Catheter Ablation as first choice in patients with persistent AF. A further aim was to optimize patients’ selection, to achieve a more appropriate in-hospital destination, differentiating between stable and labile hemodynamic compensation patients. Conclusion. The proposed AF management pathway, is updated pursuant to the latest GL and aligns to the reality of a II level Emergency Department, and is available in a digital scheme.