reversible causes'.) Cardiovascular risk factors Identifying and treating risk factors and comorbidities may help with AF symptoms and burden. Common risk factors and comorbidities that can lead to the development of AF include advanced age, hypertension, diabetes, obstructive sleep apnea, heart failure, and obesity. For most identified risk factors, we believe that treating the risk factor may reduce but not eliminate the likelihood of subsequent episodes of AF. A comprehensive description of risk factors for AF is discussed separately. (See "Epidemiology, risk factors, and prevention of atrial fibrillation", section on 'Chronic disease associations' and "Overview of established risk factors for cardiovascular disease".) Symptom and hemodynamic management Unstable patients In some hemodynamically unstable patients who manifest with signs or symptoms such as hypotension, altered mental status, or heart failure, we attempt ventricular rate control. Slowing of the ventricular rate will sometimes lead to spontaneous reversion to sinus rhythm. Rate control is usually performed with a beta blocker or calcium channel blocker (verapamil or diltiazem). This is discussed in detail separately. (See "Control of ventricular rate in patients with atrial fibrillation who do not have heart failure: Pharmacologic therapy".) For patients with AF and heart failure, ventricular rate control strategies are discussed separately. (See "The management of atrial fibrillation in patients with heart failure", section on 'Rate control in heart failure with reduced ejection fraction'.) If the patient remains hemodynamically unstable, emergency cardioversion should be performed, particularly if the hemodynamic compromise is due to an uncontrolled rapid ventricular rate and/or we believe that the lack of atrial contraction is impairing cardiac output. Emergent therapy with rate control and/or cardioversion for unstable patients is discussed separately. (See "Atrial fibrillation: Cardioversion", section on 'Unstable patients' and "Control of https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 13/35 7/6/23, 2:49 PM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate ventricular rate in patients with atrial fibrillation who do not have heart failure: Pharmacologic therapy", section on 'Determining urgency'.) Unless AF reverts spontaneously, a decision is made whether, when, and how cardioversion will be performed. Management of thromboembolic risk is a key consideration when cardioversion is considered. (See "Atrial fibrillation: Cardioversion" and "Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation".) If we decide to perform emergency cardioversion, the risk for a thromboembolic event needs to be considered. Most patients who will undergo cardioversion should be anticoagulated as soon as the decision is made to cardiovert or after assessment of their clinical thromboembolic risk based on their CHA DS -VASc score. Issues related to anticoagulation around the time of 2 2 cardioversion are discussed in detail separately. (See "Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation", section on 'AF duration less than 48 hours' and "Atrial fibrillation: Cardioversion" and "Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation".) Once the patient becomes hemodynamically stable, the remainder of the acute and long-term management is similar to that of stable patients. Stable patients For stable patients with new-onset AF who do not meet the above criteria for emergency management and in whom we have performed an evaluation, we try to accomplish the following in the outpatient setting: Evaluate the need to slow the ventricular rate. Discuss the possible need for cardioversion with the patient. If the patient is highly symptomatic or if there is new-onset AF even in the absence of symptoms, we usually attempt cardioversion. Among patients with new-onset AF, even if cardioversion is contemplated, it usually does not need to be performed urgently; the majority of these patients will spontaneously convert to sinus rhythm within 48 to 72 hours [33]. Among 1822 patients admitted to the hospital because of AF, 356 had an arrhythmia duration less than 72 hours. Sixty-eight percent of the patients with this short AF duration spontaneously reverted to sinus rhythm [33]. Two-thirds of those with spontaneous reversion had AF duration of less than 24 hours; AF duration less than 24 hours was the only predictor of spontaneous reversion. A detailed discussion of cardioversion, including reasons to not cardiovert, is found elsewhere. (See "Atrial fibrillation: Cardioversion" and "Management of atrial fibrillation: Rhythm control versus rate control", section on 'Summary and recommendations'.) https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 14/35 7/6/23, 2:49 PM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate The choice of electrical or pharmacologic cardioversion requires consideration of the efficacy and safety of the approach, comorbidities, stability, preferences of the patient, and comfort of the clinician to use one or the other approach. This issue is discussed in detail elsewhere. (See "Atrial fibrillation: Cardioversion", section on 'Electrical versus pharmacologic cardioversion'.) Determine the need for acute and long-term anticoagulant therapy. Discuss the cause (if known) and natural history of AF. (See 'Sequelae' below.) Consider consultation with a cardiologist. Reasons to consult a cardiologist include the need for cardioversion or the need to treat with antiarrhythmic drugs or catheter ablation. (See 'Management setting' above.) Schedule follow-up. (See 'Long-term management' below.) LONG-TERM MANAGEMENT Early follow-up Follow-up after an episode of acute AF is necessary to evaluate the safety and efficacy of rate or rhythm control, patient adherence with anticoagulant and antiarrhythmic therapy, need for continued therapies for AF, to discuss any strategies to reduce AF recurrence, and to assess the functional status of the patient. For many patients, a one-week follow-up visit, or as soon as possible if one week is not realistic for a particular patient, is a reasonable strategy. This early return is particularly important for patients started on antiarrhythmic drug therapy to assess safety, efficacy, and side effects that can be specific to their therapy. (See "Antiarrhythmic drugs to maintain sinus rhythm in patients with atrial fibrillation: Recommendations".) Prevention of thromboembolism Following initial pre- and postcardioversion anticoagulation, the decision to continue long-term anticoagulation following a single reversible incident is debatable, and the decision is highly individualized based on the presumed future risk of recurrent AF in that individual (vis a vis CHA DS -VASc score). It is also reasonable to take 2 2 an observational approach following a reversible cause of AF involving clinical follow-up of symptoms and ambulatory monitoring for surveillance for possible recurrence. (See "Atrial fibrillation in adults: Selection of candidates for anticoagulation".) Anticoagulation shared-decision making The shared decision-making between patients and providers includes benefits versus risks of taking anticoagulation and tradeoffs between warfarin and DOAC; providers should also be prepared to address patients https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 15/35 7/6/23, 2:49 PM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate questions about out-of-pocket costs, as failure to do so could lead to patient harm. A qualitative study of 37 recorded clinical encounters showed that providers rarely are prepared to adequately address patient questions related to medication cost [34]. Among patients with AF, thrombus in the left atrial appendage is the primary source for thromboemboli. (See "Hemodynamic consequences of atrial fibrillation and cardioversion to sinus rhythm", section on 'Atrial stunning'.) A subset of patients who require long-term anticoagulation may be unable to take it due to high bleeding risk or poor adherence. In such patients, occlusion of the left atrial appendage may be considered. After left atrial appendage occlusion, patients are required to be on short-term anticoagulation. Left atrial appendage occlusion is described in detail separately. (See "Atrial fibrillation: Left atrial appendage occlusion".) AF recurrence Continuous cardiac monitoring studies have shown that approximately 90 percent of patients with AF have recurrent episodes of AF [35]. However, up to 90 percent of episodes are not recognized by the patient [36], and asymptomatic episodes lasting more than 48 hours are not uncommon, occurring in 17 percent of patients in a study that used continuous ECG monitoring to detect AF [35]. The latter study also showed that 40 percent of patients had episodes of AF-like symptoms in the absence of AF. (See "Paroxysmal atrial fibrillation", section on 'Natural history'.) Some methods to reduce AF recurrence and/or burden including the following: Alcohol reduction Alcohol is a modifiable risk factor for AF, and among people who consume an excessive amount of alcohol, reduction and abstinence appear to decrease the risk of recurrent AF and time in AF. (See "Epidemiology, risk factors, and prevention of atrial fibrillation", section on 'Alcohol'.) In one study, 140 symptomatic patients with paroxysmal or persistent AF who were in sinus rhythm at baseline and who consumed 10 or more standard drinks per week (about 120 g of pure alcohol) were randomly assigned to alcohol abstention or usual alcohol consumption [37]. After six months, patients underwent comprehensive rhythm monitoring. Patients assigned to abstinence had: Greater reduction in their alcohol intake from 16.8 to 2.1 standard drinks per week, while those in the usual consumption group reduced their consumption from 16.4 to 13.2 per week. https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 16/35 7/6/23, 2:49 PM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate Lower rates of recurrent AF (53 versus 73 percent of the two groups). Recurrence of AF was also delayed in the abstinence group, and the AF burden was significantly lower. Weight loss and physical activity Among patients with AF, both of these measures can lead to healthy cardiac remodeling [38] and reduce AF burden [38,39] and cardiovascular mortality [40,41]: In one study, 150 patients with symptomatic AF and a body mass index in the 2 overweight or greater range ( 25 kg/m ) were randomized to a weight management intervention or general lifestyle advice [38]. After 15 months, participants assigned the intervention showed a greater reduction in weight compared with the general lifestyle advice group (14.3 versus 3.6 kg). The intervention group also had a greater reduction in AF symptom burden (11.8 versus 2.6 points), symptom severity scores (8.4 versus 1.7 points), number of AF episodes (2.5 fewer versus no change), and cumulative AF duration (692-minute decline versus 419-minute increase). Echocardiographic cardiac remodeling parameters also improved in the intervention versus control group (ie, reduction in interventricular septal thickness [1.1 and 0.6 mm] and reduction in left 2 atrial area [3.5 and 1.9 cm ]). In a nonrandomized intervention study, 149 patients undergoing a catheter ablation for symptomatic AF were offered a three-month cardiovascular risk factor management 2 program [39]. Patients had a body mass index of 27 kg/m plus at least one additional cardiovascular risk factor. Sixty-one patients opted for the risk factor management intervention and 88 did not (the control group). On follow-up, patients who chose the intervention lost weight, whereas the control group gained weight (-13.2 versus +1.5 kg). The intervention group had a mean systolic blood pressure reduction, whereas the control group had a blood pressure increase (-34.1 versus 20.6). Control of dyslipidemia was higher in the intervention compared with control group (46 versus 17 percent). More patients in the control group experienced AF recurrence (32.9 versus 9.7 percent; hazard ratio [HR] 2.6; 95 %CI, 1.7-4.0) compared with the intervention group. Among patients with AF, physical activity may lower cardiovascular mortality [40,41]. (See 'Benefit of physical activity' below.) Rate or rhythm control Once ventricular rate control is achieved, a decision regarding the long-term management (rhythm versus rate control) of AF should be made; this decision depends on many factors. These are discussed in detail separately. (See "Management of atrial fibrillation: Rhythm control versus rate control".) The following points should be kept in mind irrespective of the strategy chosen: https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 17/35 7/6/23, 2:49 PM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate Both strategies can fail in the short and long term. Consequently, many patients need to be reconsidered for the alternate strategy as the natural history of their disease progresses. All patients with AF, irrespective of strategy chosen/rhythm, should have their thromboembolic risk assessed and be managed accordingly. (See "Atrial fibrillation in adults: Selection of candidates for anticoagulation".) For patients who are managed with a rhythm-control strategy, rate control is necessary due to the possibility of recurrence of AF. The advantages and disadvantages of rhythm and rate control, and subgroups of patients for whom one or the other is preferred, are discussed in greater detail separately. (See "Management of atrial fibrillation: Rhythm control versus rate control".) A rhythm-control strategy uses either antiarrhythmic drug therapy, percutaneous catheter ablation, and/or a surgical procedure. Electrical cardioversion may be necessary to restore sinus rhythm. Antiarrhythmic medications are generally started before cardioversion and continued to maintain sinus rhythm (in the event of AF recurrence). (See "Atrial fibrillation: Surgical ablation", section on 'Maze procedure' and "Atrial fibrillation: Catheter ablation", section on 'Efficacy'.) The decision regarding which of the above rhythm-control methods to pursue is discussed in detail separately. (See "Maintenance of sinus rhythm in atrial fibrillation: Catheter ablation versus antiarrhythmic drug therapy".) Among patients undergoing cardiac surgery for another reason (eg, mitral valve or coronary artery bypass surgery), surgical ablation to control refractory AF can be done during the same procedure. Several surgical techniques have been developed for the control of refractory AF and maintenance of sinus rhythm. These surgical procedures appear effective at eliminating or reducing the frequency of AF in a high percentage of patients. For patients who are at high risk for stroke, long-term anticoagulation is still continued. This is discussed in detail separately. (See "Atrial fibrillation: Surgical ablation".) A rate-control strategy generally uses drugs that slow conduction across the atrioventricular node such as beta blockers, nondihydropyridine calcium channel blockers, or digoxin. Atrioventricular junction ablation with pacemaker placement is used in patients with persistent tachycardia, hemodynamic instability, and poorly tolerated and/or highly symptomatic AF, in whom rate control has not been successful. These approaches to ventricular rate control in AF are discussed in detail separately. (See "Control of ventricular rate in patients with atrial fibrillation who do not have heart failure: Pharmacologic therapy" and "Atrial fibrillation: Atrioventricular node ablation".) https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 18/35 7/6/23, 2:49 PM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate Most patients who present with AF will require slowing of the ventricular rate to improve symptoms. (See "Control of ventricular rate in patients with atrial fibrillation who do not have heart failure: Pharmacologic therapy".) Long-term follow-up Patients with paroxysmal, persistent, longstanding persistent, or permanent AF will need periodic care and occasional urgent evaluation during the natural history of their disease. (See 'Classification and terminology' above.) We suggest routine follow-up every 12 months in stable patients and sooner if there are changes in symptoms. Patients on high-risk antiarrhythmic therapy, such as dofetilide or sotalol, are often seen every six months. These patients may need to be under the care of a cardiologist and/or electrophysiology specialist for management of antiarrhythmic medications. From time to time, patients should be monitored for the following: Efficacy and safety of antithrombotic therapy (international normalized ratio for patients on warfarin and creatinine clearance for patients on antiarrhythmic therapy and other newer anticoagulants). Functional status, including change in symptoms (history). Efficacy and safety of antiarrhythmic drug therapy (eg, ECG, assessment of renal and hepatic function). (See "Antiarrhythmic drugs to maintain sinus rhythm in patients with atrial fibrillation: Recommendations".) Efficacy of rate control (history, ECG, and extended Holter monitoring if variability in heart rate is suspected). (See "Control of ventricular rate in patients with atrial fibrillation who do not have heart failure: Pharmacologic therapy".) In active patients with AF, we use stress testing to gauge adequacy of heart rate control in AF during exercise. Insufficient heart rate control in AF is a major factor for exercise intolerance in AF. (See "Ambulatory ECG monitoring".) Laboratory testing We obtain a complete blood count, serum electrolytes, and assessment of renal function, particularly in patients for whom a nonvitamin oral anticoagulant might be started. We do not order troponin unless acute ischemia is suspected. Clinical or subclinical hyperthyroidism is present in less than 5 percent of patients with AF [23]. A thyroid-stimulating hormone and free T4 levels should be obtained in all patients with a first episode of AF, or in those who develop an increase in AF frequency. (See "Epidemiology, risk factors, and prevention of atrial fibrillation", section on 'Hyperthyroidism'.) https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 19/35 7/6/23, 2:49 PM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate SEQUELAE Myocardial infarction Myocardial infarction has been shown to occur as a result of a coronary artery thromboembolism resulting from AF [42,43]. However, large studies of this sequelae of AF are lacking. Also, myocardial infarction from demand ischemia (also called type 2 myocardial infarction) can also result from AF, usually in the setting of a rapid ventricular rate. (See "Diagnosis of acute myocardial infarction", section on 'Comparing type 1 and 2 myocardial infarction'.) Whereas tachyarrhythmias have been shown to account for about 25 percent of type 2 myocardial infarction [44], studies specifically studying AF and type 2 myocardial infarction are lacking. In patients with a recent myocardial infarction, the subsequent development of AF increases mortality [45,46]. This effect is primarily due to associated risk factors such as heart failure and cardiogenic shock and not due to AF itself [46,47]. Mortality AF and mortality AF is an independent risk factor for mortality across a wide age range and in both males and females, but the evidence is insufficient to establish AF as a cause of excess mortality rather than just a marker of high risk [48]. Rhythm-control trials among patients with AF suggest that those in sinus rhythm had lower mortality compared with those in AF [49,50]. In a secondary analysis of the randomized controlled AFFIRM trial of rhythm versus rate control in AF, the presence of sinus rhythm was associated with a significant reduction in mortality (hazard ratio [HR] 0.54; 95% CI 0.42-0.70) [49]. A similar benefit from being in sinus rhythm (relative risk 0.44; 95% CI 0.4-0.64) was noted in a separate trial of dofetilide in patients with reduced left ventricular function [50]. Strength of association Observational cohort studies have also shown that AF is associated with increased mortality [51-54]. In a post-hoc analysis of the Women's Health Study of 34,772 women with a median age of 53 who were free of AF, 2.9 percent developed AF at a median follow-up of 15.4 years [51]. New-onset AF was associated with a significantly increased adjusted risk of all-cause, cardiovascular, and noncardiovascular mortality (HR 2.14, 95% CI 1.64-2.77; HR 4.18, 95% CI 2.69-6.51; and HR 1.66, 95% CI 1.19- 2.30, respectively). Adjustment for nonfatal cardiovascular events such as myocardial infarction, stroke, or heart failure lowered these risks, but incident AF remained https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 20/35 7/6/23, 2:49 PM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate significantly associated with all types of mortality (HR 1.7, HR 2.57, HR and 1.42, respectively). Sex difference Several observational studies have suggested that the association between AF and death is greater in women with AF compared with men [52,53]. In a retrospective study of 272,186 patients with incidental AF at the time of hospitalization and 544,344 matched AF-free controls, the adjusted relative risk of death with AF was higher in females compared with males across all age categories (2.15 versus 1.76 for those <65 years, 1.72 versus 1.36 for those ages 65 to 74 years, and 1.44 versus 1.24 for those 75 to 85 years) [52]. In 621 participants in the Framingham Heart Study, having AF led to an almost doubling of the risk of death in both men and women (adjusted odds ratio 1.9 for women and 1.5 for men) ( figure 1) [53]. This sex difference in the association between AF and mortality was also shown in a separate study of 15,000 men and women [54]. Cause of excess mortality In participants with AF in the Framingham Heart Study, both heart failure and stroke contributed to the excess mortality [53]. In addition, in an observational study of over 20,000 individuals in two cohorts, incident AF was associated with an increased risk of sudden cardiac death (HR 2.47; 95% CI 1.95-3.13) as well as nonsudden cardiac death (HR 2.98; 95% CI 2.52-3.53) [55]. The specific causes of death, as well as their frequency and predictors, were evaluated using follow-up data from the RE-LY trial comparing dabigatran with warfarin [56]. Among 18,113 randomized patients with a median follow-up of two years, the annual mortality rate was 3.84 percent. Cardiac deaths (sudden cardiac death and progressive heart failure) accounted for 37.4 percent of these; stroke and hemorrhagic death accounted for 9.9 percent. Predictors of mortality in patients with AF In the RE-LY trial , the strongest independent clinical predictors of cardiac death were heart failure, intraventricular conduction delay on an ECG, and prior myocardial infarction [56]. In a post-hoc analysis of the RACE II trial, the risk of cardiovascular morbidity and mortality was highest in those with the greatest symptom burden as assessed with the Toronto AF Severity Scale [57]. This finding was driven by the increased rate of heart failure hospitalizations. Benefit of physical activity As in the general population, among patients with AF, physical activity can significantly reduce cardiovascular mortality [40,41]. (See "The benefits and risks of aerobic exercise", section on 'Mortality'.) In a prospective Danish study of over 1100 individuals with AF, metabolic equivalents were used to estimate cardiorespiratory fitness, and patients were followed for up to nine years for mortality outcomes. This study observed that each one-metabolic equivalent task higher was https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 21/35 7/6/23, 2:49 PM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate associated with a lower risk of all-cause mortality (HR 0.88; 95% CI 0.81-0.95) and cardiovascular disease mortality (HR 0.85; 95% CI 0.76-0.95) [40]. Patients meeting European Society of Cardiology physical activity recommendations had a lower risk of cardiovascular mortality compared with inactive patients (HR 0.54; 95% CI 0.34-0.86) [41]. Stroke and silent cerebral ischemia Stroke Stroke is the most frequent major complication of AF; this topic is discussed in detail separately. (See "Atrial fibrillation in adults: Use of oral anticoagulants" and "Atrial fibrillation in adults: Selection of candidates for anticoagulation".) (Related Pathway(s): Atrial fibrillation: Anticoagulation for adults with atrial fibrillation.) Silent cerebral ischemia Silent cerebral ischemia occurs in a patient who has specific lesions on imaging studies in the absence of clinical complaints or findings. Among patients with AF, these lesions are relatively common; this is discussed in detail separately. (See "Stroke in patients with atrial fibrillation", section on 'Silent cerebral infarction'.) Cognitive impairment and dementia AF increases the risk of cognitive impairment, all- cause dementia, vascular dementia, and Alzheimer's disease [58,59]. It is uncertain whether anticoagulation protects against dementia [59,60]. This is discussed in detail separately. (See "Risk factors for cognitive decline and dementia", section on 'Atrial fibrillation'.) Heart failure AF is a risk factor for new-onset heart failure. This is discussed separately. (See "The management of atrial fibrillation in patients with heart failure", section on 'Epidemiology'.) SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Atrial fibrillation" and "Society guideline links: Arrhythmias in adults".) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. th th The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more th th sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 22/35 7/6/23, 2:49 PM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) Basics topics (see "Patient education: Atrial fibrillation (The Basics)" and "Patient education: Medicines for atrial fibrillation (The Basics)" and "Patient education: Coping with high drug prices (The Basics)" and "Patient education: Heart failure and atrial fibrillation (The Basics)") Beyond the Basics topics (see "Patient education: Atrial fibrillation (Beyond the Basics)" and "Patient education: Coping with high prescription drug prices in the United States (Beyond the Basics)") SUMMARY AND RECOMMENDATIONS Background Atrial fibrillation (AF) is the most common cardiac arrhythmia that can have adverse consequences related to a reduction in cardiac output (symptoms) and atrial and atrial appendage thrombus formation (stroke and peripheral embolization) ( waveform 1). Classification Patients are classified as having paroxysmal, persistent, longstanding persistent, or permanent AR. Other classifications include subclinical or occult AF. (See 'Classification and terminology' above.) Screening We do not screen asymptomatic patients for AF. There is no sufficient evidence that screening for AF will substantially detect more AF or protect against cardiac events. Electrocardiograms (ECGs) do not appear more effective than pulse palpation at AF detection. (See 'Screening' above.) Presentation and Evaluation A new diagnosis of AF can present in a variety of ways; sometimes the patient has symptoms of AF and other times it is picked up incidentally. (See 'Common scenarios' above.) Essential information from the patient's symptoms and past medical history, physical examination, electrocardiogram (ECG), and a transthoracic echocardiogram (TTE) should be obtained at the time of diagnosis and periodically during the course of the disease. Additional laboratory testing, such as thyroid stimulating hormone assay, and ambulatory https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 23/35 7/6/23, 2:49 PM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate ECG monitoring may be necessary. (See 'History and physical examination' above and 'Laboratory testing' above.) Initial steps in all patients It is important to decide whether the patient should be managed as an outpatient or in the emergency room or acute hospital setting. When deciding, we take the patient's presentation, symptom burden, and associated conditions into consideration. (See 'Management setting' above.) Other initial steps for all patients include consideration of antithrombotic therapy, treatment of potentially reversible triggers of AF, and cardiovascular risk factor management. (See 'Initial management' above.) (Related Pathway(s): Atrial fibrillation: Anticoagulation for adults with atrial fibrillation.) Acute symptom management Symptom management starts with rate control of acute AF episodes and early decision-making regarding the need for cardioversion. Unstable patients In some hemodynamically unstable patients, ventricular rate control can be attempted; slowing of the ventricular rate sometimes leads to spontaneous reversion to sinus rhythm. If rate control does not work and the patient remains hemodynamically unstable, we pursue cardioversion; if we decide to perform emergency cardioversion, the risk for a thromboembolic event needs to be considered. (See "Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation", section on 'AF duration less than 48 hours'.) Stable patients For stable patients, usually in the nonacute care setting, we discuss the need for possible cardioversion, need for acute and long-term anticoagulant therapy, the cause (if known), and natural history of AF. (See 'Sequelae' above.) We consider consultation with a cardiologist. Reasons to consult a cardiologist include the need for cardioversion or the need to treat with antiarrhythmic drugs or catheter ablation. (See 'Management setting' above.) Long-term management Follow-up after an episode of acute AF is necessary to evaluate the safety and efficacy of rate or rhythm control, patient adherence with anticoagulant and antiarrhythmic therapy, need for continued therapies for AF, to discuss any strategies to reduce AF recurrence, and to assess the functional status of the patient. Lifestyle modification with reducing alcohol consumption, weight reduction, and increasing physical https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 24/35 7/6/23, 2:49 PM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate activity can reduce AF burden and decrease recurrence. (See 'Long-term management' above.) Sequelae In the absence of a reversible precipitant, AF is typically recurrent. AF is associated with increased risk of mortality, stroke, silent cerebral ischemia, cognitive impairment, dementia, and heart failure. Physical activity and higher cardiorespiratory fitness may protect against mortality in AF. (See 'Sequelae' above.) ACKNOWLEDGMENT The UpToDate editorial staff acknowledges Alan Cheng, MD, who contributed to an earlier version of this topic review. Use of UpToDate is subject to the Terms of Use. REFERENCES 1. 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