The pitfalls relating to AF can be identified into three main areas:

Misdiagnosis of AF
  • Where doubt exists a long rhythm strip is required
  • Remember the faster the rate the more regular AF will look
  • AF is always irregularly irregular
  • AF may co-exist with bundle branch block. This can cause confusion with ventricular tachycardias
  • The possibility of multi-focal atrial tachycardia and atrial flutter should always be considered
  • Patients with AF secondary to an underlying medical condition may not benefit for rate or rhythm control as they have been shown to have a nearly 6 fold increase in adverse event rate
Mistreatment of AF
  • Digoxin does not sufficiently limit AV nodal conduction when there is significant sympathetic discharge
    • It should only be used as monotherapy in sedentary patients
  • The greatest AF associated risks arise from thromboembolic complications including stroke
  • Failure to assess and treat the stroke risk is a significant error
  • Any patient with a known or suspected accessory pathway and an irregular rhythm should not be treated with any AV blocking agent including adenosine and beta blockers
  • Patients with accessory pathways are at risk of sudden death if AF occurs
  • Amiodarone is toxic. Wherever possible long term use should be avoided
Failure to assess and treat an individual’s stroke risk

Most of the morbidity and mortality associated with AF is due to the thromboembolic complications of clot breaking off from the left atrial appendage. In consequence, the most important treatment decision in most patients concerns the assessment and, where appropriate, treatment of this risk.


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