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 7/5/23, 9:11 AM 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. January CT, Wann LS, Alpert JS, et al. 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 practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:e199. 2. Wyse DG, Van Gelder IC, Ellinor PT, et al. Lone atrial fibrillation: does it exist? J Am Coll Cardiol 2014; 63:1715. 3. Svennberg E, Friberg L, Frykman V, et al. Clinical outcomes in systematic screening for atrial fibrillation (STROKESTOP): a multicentre, parallel group, unmasked, randomised controlled trial. Lancet 2021; 398:1498. 4. Svendsen JH, Diederichsen SZ, H jberg S, et al. Implantable loop recorder detection of atrial fibrillation to prevent stroke (The LOOP Study): a randomised controlled trial. Lancet 2021; 398:1507. 5. US Preventive Services Task Force, Davidson KW, Barry MJ, et al. Screening for Atrial Fibrillation: US Preventive Services Task Force Recommendation Statement. JAMA 2022; 327:360. 6. Lyth J, Svennberg E, Bernfort L, et al. Cost-effectiveness of population screening for atrial fibrillation: the STROKESTOP study. Eur Heart J 2023; 44:196. 7. Lubitz SA, Atlas SJ, Ashburner JM, et al. Screening for Atrial Fibrillation in Older Adults at Primary Care Visits: VITAL-AF Randomized Controlled Trial. Circulation 2022; 145:946. https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 25/35 7/5/23, 9:11 AM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate 8. Perez MV, Mahaffey KW, Hedlin H, et al. Large-Scale Assessment of a Smartwatch to Identify Atrial Fibrillation. N Engl J Med 2019; 381:1909. 9. Diederichsen SZ, Haugan KJ, Kronborg C, et al. Comprehensive Evaluation of Rhythm Monitoring Strategies in Screening for Atrial Fibrillation: Insights From Patients at Risk Monitored Long Term With an Implantable Loop Recorder. Circulation 2020; 141:1510. 10. Jonas DE, Kahwati LC, Yun JDY, et al. Screening for Atrial Fibrillation With Electrocardiography: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2018; 320:485. 11. Christophersen IE, Yin X, Larson MG, et al. A comparison of the CHARGE-AF and the CHA2DS2-VASc risk scores for prediction of atrial fibrillation in the Framingham Heart Study. Am Heart J 2016; 178:45. 12. Marston NA, Garfinkel AC, Kamanu FK, et al. A polygenic risk score predicts atrial fibrillation in cardiovascular disease. Eur Heart J 2023; 44:221. 13. Bano A, Rodondi N, Beer JH, et al. Association of Diabetes With Atrial Fibrillation Phenotype and Cardiac and Neurological Comorbidities: Insights From the Swiss-AF Study. J Am Heart Assoc 2021; 10:e021800. 14. Echouffo-Tcheugui JB, Shrader P, Thomas L, et al. Care Patterns and Outcomes in Atrial Fibrillation Patients With and Without Diabetes: ORBIT-AF Registry. J Am Coll Cardiol 2017; 70:1325. 15. Sanna T, Diener HC, Passman RS, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014; 370:2478. 16. Noseworthy PA, Kaufman ES, Chen LY, et al. Subclinical and Device-Detected Atrial Fibrillation: Pondering the Knowledge Gap: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e944. 17. Healey JS, Connolly SJ, Gold MR, et al. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 2012; 366:120. 18. Walkey AJ, Benjamin EJ, Lubitz SA. New-onset atrial fibrillation during hospitalization. J Am Coll Cardiol 2014; 64:2432. 19. Tung P, Levitzky YS, Wang R, et al. Obstructive and Central Sleep Apnea and the Risk of Incident Atrial Fibrillation in a Community Cohort of Men and Women. J Am Heart Assoc 2017; 6. 20. Lavie CJ, Pandey A, Lau DH, et al. Obesity and Atrial Fibrillation Prevalence, Pathogenesis, and Prognosis: Effects of Weight Loss and Exercise. J Am Coll Cardiol 2017; 70:2022. https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 26/35 7/5/23, 9:11 AM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate 21. Wang TJ, Parise H, Levy D, et al. Obesity and the risk of new-onset atrial fibrillation. JAMA 2004; 292:2471. 22. Wynn GJ, Todd DM, Webber M, et al. The European Heart Rhythm Association symptom classification for atrial fibrillation: validation and improvement through a simple modification. Europace 2014; 16:965. 23. Krahn AD, Klein GJ, Kerr CR, et al. How useful is thyroid function testing in patients with recent-onset atrial fibrillation? The Canadian Registry of Atrial Fibrillation Investigators. Arch Intern Med 1996; 156:2221. 24. European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery, Camm AJ, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010; 31:2369. 25. Lip GYH. The ABC pathway: an integrated approach to improve AF management. Nat Rev Cardiol 2017; 14:627. 26. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373. 27. Yoon M, Yang PS, Jang E, et al. Improved Population-Based Clinical Outcomes of Patients with Atrial Fibrillation by Compliance with the Simple ABC (Atrial Fibrillation Better Care) Pathway for Integrated Care Management: A Nationwide Cohort Study. Thromb Haemost 2019; 119:1695. 28. Pastori D, Pignatelli P, Menichelli D, et al. Integrated Care Management of Patients With Atrial Fibrillation and Risk of Cardiovascular Events: The ABC (Atrial fibrillation Better Care) Pathway in the ATHERO-AF Study Cohort. Mayo Clin Proc 2019; 94:1261. 29. Proietti M, Romiti GF, Olshansky B, et al. Improved Outcomes by Integrated Care of Anticoagulated Patients with Atrial Fibrillation Using the Simple ABC (Atrial Fibrillation Better Care) Pathway. Am J Med 2018; 131:1359. 30. Guo Y, Lane DA, Wang L, et al. Mobile Health Technology to Improve Care for Patients With Atrial Fibrillation. J Am Coll Cardiol 2020; 75:1523. 31. Pastori D, Farcomeni A, Pignatelli P, et al. ABC (Atrial fibrillation Better Care) Pathway and Healthcare Costs in Atrial Fibrillation: The ATHERO-AF Study. Am J Med 2019; 132:856. https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 27/35 7/5/23, 9:11 AM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate 32. Alkhouli M, Friedman PA. Ischemic Stroke Risk in Patients With Nonvalvular Atrial Fibrillation: JACC Review Topic of the Week. J Am Coll Cardiol 2019; 74:3050. 33. Danias PG, Caulfield TA, Weigner MJ, et al. Likelihood of spontaneous conversion of atrial fibrillation to sinus rhythm. J Am Coll Cardiol 1998; 31:588. 34. Martinez KA, Hurwitz HM, Rothberg MB. Qualitative Analysis of Patient-Physician Discussions Regarding Anticoagulation for Atrial Fibrillation. JAMA Intern Med 2022; 182:1260. 35. Israel CW, Gr nefeld G, Ehrlich JR, et al. Long-term risk of recurrent atrial fibrillation as documented by an implantable monitoring device: implications for optimal patient care. J Am Coll Cardiol 2004; 43:47. 36. Page RL, Wilkinson WE, Clair WK, et al. Asymptomatic arrhythmias in patients with symptomatic paroxysmal atrial fibrillation and paroxysmal supraventricular tachycardia. Circulation 1994; 89:224. 37. Voskoboinik A, Kalman JM, De Silva A, et al. Alcohol Abstinence in Drinkers with Atrial Fibrillation. N Engl J Med 2020; 382:20. 38. Abed HS, Wittert GA, Leong DP, et al. Effect of weight reduction and cardiometabolic risk factor management on symptom burden and severity in patients with atrial fibrillation: a randomized clinical trial. JAMA 2013; 310:2050. 39. Pathak RK, Middeldorp ME, Lau DH, et al. Aggressive risk factor reduction study for atrial fibrillation and implications for the outcome of ablation: the ARREST-AF cohort study. J Am Coll Cardiol 2014; 64:2222. 40. Garnvik LE, Malmo V, Janszky I, et al. Physical activity, cardiorespiratory fitness, and cardiovascular outcomes in individuals with atrial fibrillation: the HUNT study. Eur Heart J 2020; 41:1467. 41. Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016; 37:2315. 42. Schmitt J, Duray G, Gersh BJ, Hohnloser SH. Atrial fibrillation in acute myocardial infarction: a systematic review of the incidence, clinical features and prognostic implications. Eur Heart J 2009; 30:1038. 43. Garg RK, Jolly N. Acute myocardial infarction secondary to thromboembolism in a patient with atrial fibrillation. Int J Cardiol 2007; 123:e18. https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 28/35 7/5/23, 9:11 AM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate 44. Belkouche A, Yao H, Putot A, et al. The Multifaceted Interplay between Atrial Fibrillation and Myocardial Infarction: A Review. J Clin Med 2021; 10. 45. Crenshaw BS, Ward SR, Granger CB, et al. Atrial fibrillation in the setting of acute myocardial infarction: the GUSTO-I experience. Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries. J Am Coll Cardiol 1997; 30:406. 46. Eldar M, Canetti M, Rotstein Z, et al. Significance of paroxysmal atrial fibrillation complicating acute myocardial infarction in the thrombolytic era. SPRINT and Thrombolytic Survey Groups. Circulation 1998; 97:965. 47. Goldberg RJ, Seeley D, Becker RC, et al. Impact of atrial fibrillation on the in-hospital and long-term survival of patients with acute myocardial infarction: a community-wide perspective. Am Heart J 1990; 119:996. 48. Leong DP, Eikelboom JW, Healey JS, Connolly SJ. Atrial fibrillation is associated with increased mortality: causation or association? Eur Heart J 2013; 34:1027. 49. Corley SD, Epstein AE, DiMarco JP, et al. Relationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study. Circulation 2004; 109:1509. 50. Pedersen OD, Bagger H, Keller N, et al. Efficacy of dofetilide in the treatment of atrial fibrillation-flutter in patients with reduced left ventricular function: a Danish investigations of arrhythmia and mortality on dofetilide (diamond) substudy. Circulation 2001; 104:292. 51. Conen D, Chae CU, Glynn RJ, et al. Risk of death and cardiovascular events in initially healthy women with new-onset atrial fibrillation. JAMA 2011; 305:2080. 52. Andersson T, Magnuson A, Bryngelsson IL, et al. All-cause mortality in 272,186 patients hospitalized with incident atrial fibrillation 1995-2008: a Swedish nationwide long-term case-control study. Eur Heart J 2013; 34:1061. 53. Benjamin EJ, Wolf PA, D'Agostino RB, et al. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation 1998; 98:946. 54. Stewart S, Hart CL, Hole DJ, McMurray JJ. A population-based study of the long-term risks associated with atrial fibrillation: 20-year follow-up of the Renfrew/Paisley study. Am J Med 2002; 113:359. 55. Chen LY, Sotoodehnia N, B kov P, et al. Atrial fibrillation and the risk of sudden cardiac death: the atherosclerosis risk in communities study and cardiovascular health study. JAMA Intern Med 2013; 173:29. 56. Marijon E, Le Heuzey JY, Connolly S, et al. Causes of death and influencing factors in patients with atrial fibrillation: a competing-risk analysis from the randomized evaluation of long- https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 29/35 7/5/23, 9:11 AM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate term anticoagulant therapy study. Circulation 2013; 128:2192. 57. Vermond RA, Crijns HJ, Tijssen JG, et al. Symptom severity is associated with cardiovascular outcome in patients with permanent atrial fibrillation in the RACE II study. Europace 2014; 16:1417. 58. Papanastasiou CA, Theochari CA, Zareifopoulos N, et al. Atrial Fibrillation Is Associated with Cognitive Impairment, All-Cause Dementia, Vascular Dementia, and Alzheimer's Disease: a Systematic Review and Meta-Analysis. J Gen Intern Med 2021; 36:3122. 59. Kim D, Yang PS, Yu HT, et al. Risk of dementia in stroke-free patients diagnosed with atrial fibrillation: data from a population-based cohort. Eur Heart J 2019; 40:2313. 60. Moffitt P, Lane DA, Park H, et al. Thromboprophylaxis in atrial fibrillation and association with cognitive decline: systematic review. Age Ageing 2016; 45:767. Topic 1022 Version 82.0 https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 30/35 7/5/23, 9:11 AM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate GRAPHICS 12 lead ECG of atrial fibrillation The 12 lead ECG shows atrial fibrillation. The QRS complex is narrow, P waves are absent, and the baseline between successive QRS complexes shows irregular coarse "fibrillatory waves." The QRS complexes occur at irregularly irregular intervals. Reproduced with permission by Samuel Levy, MD. Graphic 64217 Version 2.0 https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 31/35 7/5/23, 9:11 AM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate Clinical risk factors for stroke, transient ischemic attack, and systemic embolism in the CHA DS -VASc score 2 2 (A) The risk factor-based approach expressed as a point based scoring system, with the acronym CHA DS -VASc (NOTE: maximum score is 9 since age may contribute 0, 1, or 2 points) 2 2 CHA DS -VASc risk factor Points 2 2 Congestive heart failure +1 Signs/symptoms of heart failure or objective evidence of reduced left ventricular ejection fraction Hypertension +1 Resting blood pressure >140/90 mmHg on at least 2 occasions or current antihypertensive treatment Age 75 years or older +2 Diabetes mellitus +1 Fasting glucose >125 mg/dL (7 mmol/L) or treatment with oral hypoglycemic agent and/or insulin Previous stroke, transient ischemic attack, or thromboembolism +2 Vascular disease +1 Previous myocardial infarction, peripheral artery disease, or aortic plaque Age 65 to 74 years +1 Sex category (female) +1 (B) Adjusted stroke rate according to CHA DS -VASc score 2 2 CHA DS -VASc score Patients Stroke and 2 2 (n = 73,538) thromboembolism event rate at 1-year follow-up (%) 0 6369 0.78 1 8203 2.01 2 12,771 3.71 3 17,371 5.92 4 13,887 9.27 5 8942 15.26 https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 32/35 7/5/23, 9:11 AM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate 6 4244 19.74 7 1420 21.50 8 285 22.38 9 46 23.64 CHA DS -VASc: Congestive heart failure, Hypertension, Age ( 75; doubled), Diabetes, Stroke (doubled), Vascular disease, Age (65 to 74), Sex. 2 2 Part A from: Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial brillation developed in collaboration with EACTS. Europace 2016; 18(11):1609-1678. By permission of Oxford University Press on behalf of the European Society of Cardiology. Copyright 2016 Oxford University Press. Available at: www.escardio.org/. Graphic 83272 Version 29.0 https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 33/35 7/5/23, 9:11 AM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate Atrial fibrillation increases mortality in men and women Among 5209 subjects in the Framingham Heart Study, the mortality after a 10-year follow-up was higher in both men and women, aged 55 to 74, who had atrial fibrillation (AF) compared to those without AF (p <0.001) A similar relationship was seen in subjects between the ages of 75 and 94 (not shown). Data from Benjamin EJ, Wolf PA, D'Agostino RB, et al. Circulation 1998; 98:946. Graphic 71640 Version 2.0 https://www.uptodate.com/contents/atrial-fibrillation-overview-and-management-of-new-onset-atrial-fibrillation/print 34/35 7/5/23, 9:11 AM Atrial fibrillation: Overview and management of new-onset atrial fibrillation - UpToDate Contributor Disclosures Kapil Kumar, MD No relevant financial relationship(s) with ineligible companies to disclose. Peter J Zimetbaum, MD Consultant/Advisory Boards: Abbott Medical [Lead extraction]. All of the relevant financial relationships listed have been mitigated. Nisha Parikh, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. 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