Top Things to Know: AF Occurring During Acute Hospitalization

Published: March 13, 2023

  1. Acute atrial fibrillation (AF) is defined as AF detected in the setting of acute care or acute illness including AF occurring during acute hospitalization. This includes acute AF detected or managed for the first time during acute hospitalization for another condition.
  2. Acute AF is associated with high risks of long-term AF recurrence, warranting clinical attention during acute hospitalization, at transition of care, and over long-term follow-up.
  3. A framework of substrates and triggers can be useful for evaluation and management of AF occurring during acute hospitalization. AF after cardiac surgery is a distinct type of acute AF.
  4. Management of AF occurring during hospitalization requires a multipronged approach. Key components of management include identification and treatment of triggers, selection, and implementation of rate and/or rhythm control, and management of anticoagulation.
  5. An acute rate or rhythm control strategy should be individualized and weighed against the patient’s capacity to tolerate the risk of the strategy including potential rapid rates or atrioventricular dyssynchrony.
  6. In hemodynamically unstable patients, immediate direct current cardioversion is the treatment of choice. Rhythm control can also be considered for patients unable to attain clinically adequate rate control despite optimal use of atrioventricular nodal blocking agents and management of acute triggers. Hemodynamic monitoring and thromboembolic prophylaxis are warranted for both electrical and pharmacologic cardioversion.
  7. Indication for anticoagulation is based on substrate, with feasibility and timing for anticoagulation based on patient’s bleeding risk and contextual considerations of the acute condition.
  8. Given the high risks of AF recurrence in patients with acute AF, clinical follow-up and extended heart rhythm monitoring are important to tailor longer-term management.
  9. Overall management of acute AF addresses substrates and triggers using the 3As of acute management: Acute triggers, AF rate/rhythm management, and Anticoagulation. The 2As and 2Ms of long-term management are: AF rate/rhythm management, Anticoagulation, Monitor heart rhythm, and Modification of lifestyle and risk factors.
  10. Patients with acute AF benefit from close interdisciplinary care collaborations, allowing appropriate treatments tailored to patient’s underlying substrates and acute conditions.


Chyou JY, Barkoudah E, Dukes JW, Goldstein LB, Joglar JA, Lee AM, Lubitz SA, Marill KA, Sneed KB, Streur MM, Wong GC, Gopinathannair R; on behalf of the American Heart Association Acute Cardiac Care and General Cardiology Committee, Electrocardiography and Arrhythmias Committee, and Clinical Pharmacology Committee of the Council on Clinical Cardiology; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular and Stroke Nursing; and Stroke Council. Atrial fibrillation occurring during acute hospitalization: a scientific statement from the American Heart Association [published online ahead of print March 13, 2023]. Circulation. doi: 10.1161/CIR.0000000000001133