Atrial Fibrillation: Management of Acute Atrial Fibrillation and Atrial Flutter in Non-Pregnant Hospitalized Adults [2014 new]

[2014 new]

Introduction to this self-study CME activity


Atrial fibrillation (AF) and atrial flutter (AFL) are the most common sustained arrhythmias in the U.S., affecting 2.5 million adults with the majority of patients over the age of 65. AF/AFL is associated with numerous comorbidities including hypertension, coronary artery disease, heart failure, and valvular heart disease. The cost of direct care of patients with AF in the U.S. is an estimated $6.65 billion annually, the majority of which is attributed to hospitalizations due to rapid ventricular response, heart failure, and stroke. There are over 150 admissions to the UMHS annually with the principle diagnosis of new-onset AF, and there are many more than that for recurrent or chronic atrial fibrillation.


Electrocardiogram (ECG) is essential in the diagnosis of AF/AFL. The initial evaluation is summarized in Table 1 and should include:

  • Physical exam
  • Laboratory evaluation: CBC, basic metabolic profile, magnesium, thyroid-stimulating hormone, and cardiac enzymes as indicated
  • Imaging: Chest X-ray, echocardiogram
  • Continuous telemetry monitoring in the hospital


Initial treatment of AF/AFL depends on hemodynamic stability:

Unstable AF/AFL (Figure 1)

  • Begin resuscitation and consider other conditions contributing to instability
  • If instability due to AF/AFL - immediate direct current cardioversion

Stable AF/AFL (Figure 2):

  • For ED patients: Screen for early cardioversion in the Emergency Department (Figure 4)
  • Administer rate controlling agents as indicated (Table 4) – [I, B]
    • EP consult for uncontrolled rate despite adequate trial of rate controlling agents
  • Consider the appropriateness of a rhythm control strategy (Table 3) – [I, B]
    • If rhythm control strategy is appropriate/desired, consult EP and start immediate anticoagulation (Figure 3)
  • Consider anticoagulation based on CHA2DS2-VASc score (Table 2, Figure 3) – [I, A].
    • The choice of anticoagulant will depend on the patients clinical circumstances and renal function (Figure 3)
    • Obtain Neurology consult prior to initiation of anticoagulation for patients with recent ischemic stroke within the prior two weeks
    • Patients with valvular disease and those requiring concomitant treatment with dual antiplatelet therapy should be anticoagulated with warfarin
    • Target-specific oral anticoagulants are preferred over warfarin in many cases



Participants in this CME activity will understand and be able to implement evidence-based cost-effective clinical strategies for the diagnosis and treatment of atrial fibrillation (AF) and atrial flutter (AFL)in adult, non-pregnant patients.


This self-study activity is appropriate for physicians in Emergency Medicine, Family Medicine, Cardiology, Internal Medicine, Neurology, Pharmacy, Radiology, and other health care providers participating in inpatient or ambulatory care of patients with suspected gallbladder related diseases.


Team Leaders

  • Jeffrey M. Rohde, MD
    Internal Medicine
  • Thomas C. Crawford, MD

Team Members

  • Sarah E. Hartley, MD
    Internal Medicine
  • Sarah Hanigan, PharmD
    Pharmacy Services
  • Jules Lin, MD
    Thoracic Surgery
  • Lewis B. Morgenstern, MD
    Neurology (Stroke)
  • F. Jacob Seagull, PhD
    Medical Education
  • David M. Somand, MD
    Emergency Medicine
  • David H. Wesorick, MD
    Internal Medicine


  • James B. Froehlich, MD

Author Disclosures

Neither the team lead, the team members, nor the consultants have financial relationships with commercial companies whose products are discussed in this CME activity.

Other Acknowledgements

UMHS Guidelines Oversight Team

Literature Search Services

  • Taubman Medical Library

Production of Internet Format and Website Maintenance

  • Ellen Patrick-Dunlavey, MA

CME Accreditation and Credit Designation

The University of Michigan Medical School is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Michigan Medical School designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This CME activity was prepared for release in April 2015 with credit available through March 2018. The activity was reviewed in April 2018 and availability of credit extended through May 2021. Continuation of credit from that date depends on a thorough review of the content currency and accuracy.

Method of Participation

  1. View the web pages. You may print the self-study text to read off-line.
  2. Complete the on-line learning assessment test with a score of 70% or higher.  After you initially take the test, the test will be immediately electronically scored. 
    If fewer than 70% of the questions are answered correctly, the questions that were not answered correctly will be noted in red.  Review the CME content related to those topics and retake the test.
    If 70% or more of the questions are answered correctly, the correct and incorrect answers for all questions will be shown along with explanations of the basis for the correct answer.  The link to register and receive credit is shown at the end of the items and explanations. 
  3. Complete the electronic credit request and activity evaluation.  An electronic certificate of participation will be provided immediately.
  4. Print the certificate of participation for your personal records.