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cardio.afib.core.v1PRODUCTION
cardio.afib.core.v1

Atrial fibrillation (rate / rhythm / anticoagulation)

cardiologyacutechronicadult
Hard-required inputs
0 / 7
Care setting:

Encounter flow

11/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm AF on ECG; differentiate paroxysmal / persistent / permanent — ESC 2024 classification

Inputs
1
Actions
0
Advance rule
Set
Advance when

AF documented

Patient inputs (12)

CHA₂DS₂-VA scoring + ablation candidacy

2024 ESC drops sex from CHA₂DS₂ baseline (CHA₂DS₂-VA)

RVR identification + rate control target — RACE II (Van Gelder NEJM 2010)

<48 h vs ≥48 h drives cardioversion AC strategy — ACC/AHA 2023

Confirm AF vs flutter / WPW pre-excited AF — ESC 2024

HD instability triggers DCCV — ACC/AHA 2023

DOAC dose adjustment (apixaban renal) — ARISTOTLE (Granger NEJM 2011)

CASTLE-AF — ablation Class I in HFrEF + AF

CHA₂DS₂-VA component + secondary prevention

Hyperthyroidism reversible AF trigger — ESC 2024

LA size, LVEF, valvular AF (mitral stenosis → warfarin) — ACC/AHA 2023

HAS-BLED modifiable factors — ESC 2024

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningpre_excited_af_wpw — ACC/AHA 2023
    AF in WPW (delta wave on baseline ECG, irregular wide-complex tachycardia) — ACC/AHA 2023
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghd_instability_in_af — ACC/AHA 2023
    AF with SBP <90 / pulmonary edema / ischemia — ACC/AHA 2023
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmajor_bleed_on_ac — ESC 2024
    Major bleeding (Hgb drop >2, transfusion, intracranial, GI requiring hospitalization) on DOAC or warfarin — ESC 2024
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehigh_chads_VA_no_ac — ESC 2024
    CHA₂DS₂-VA ≥2 with no AC prescribed — ESC 2024
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecryptogenic_stroke_screen_AF — ESC 2024
    Cryptogenic embolic stroke with no documented AF — 2024 ESC (PMID 39210723)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateablation_candidate_HFrEF — ESC 2024
    AF + HFrEF with persistent symptoms despite GDMT — CASTLE-AF (Marrouche NEJM 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

Integrated AF-CARE / ABC pathway — stepwise (2024 ESC AF-CARE PMID 39210723 / 2023 ACC/AHA PMID 38033089)
axis: afib_afcare_abc_stepwisestep 1 - Step 1 — [C] Comorbidity & risk-factor management (AF-CARE pillar C)
Selected step "Step 1 — [C] Comorbidity & risk-factor management (AF-CARE pillar C)" — All AF patients — addressed before/with anticoagulation per 2024 ESC AF-CARE (PMID 39210723); reversible-driver screen (thyrotoxic, alcohol, OSA, HF, valvular, post-op, PE)
  • risk-factor modification bundle
    first line
    lifestyle
    BP <130/80; weight loss ≥10% if BMI ≥27; OSA treatment; alcohol abstinence • lifestyle • ongoing
    triggers: all_AF_patients
    2024 ESC AF-CARE [C] (PMID 39210723); alcohol abstinence reduced AF recurrence HR 0.55 (0.36–0.84) over 6 mo — Voskoboinik NEJM 2020 (PMID 31893513)

outpatient playbook — drug actions (4)

  1. 1. DOAC by CHA₂DS₂-VA ≥2
    rxcui 1364430
    Apixaban 5 mg BID (2.5 if 2 of: ≥80 yo / ≤60 kg / Cr ≥1.5) OR rivaroxaban 20 mg / edoxaban 60 mg / dabigatran 150 BID • PO • BID/daily
    trigger: CHA₂DS₂-VA ≥2 (men) / ≥3 (women) — ESC 2024 simplifies to ≥2 for both sexes (CHA₂DS₂-VA)
    DOACs preferred over warfarin in non-valvular AF — ESC 2024
  2. 2. rate control
    rxcui 221124
    Metoprolol succinate 25–200 mg daily OR diltiazem ER 120–360 mg daily • PO • daily
    trigger: Rate control strategy — RACE II (Van Gelder NEJM 2010 PMID 20231232) lenient HR <110
    BB first if CAD/HFrEF; non-DHP CCB if BB-intolerant — 2023 ACC/AHA (PMID 38033089)
  3. 3. antiarrhythmic for early rhythm control
    rxcui 4441
    Flecainide 50–150 mg BID (no SHD) OR amiodarone 200–400 mg daily after load (SHD/HFrEF) • PO • BID/daily
    trigger: Symptomatic + AF ≤12 mo OR HFrEF — EAST-AFNET 4 (Kirchhof NEJM 2020 PMID 32865375)
    EAST-AFNET 4 composite HR 0.79 (0.66–0.94) + CASTLE-AF (Marrouche NEJM 2018 PMID 29385358)
  4. 4. risk-factor modification
    Weight loss 10%, BP <130/80, OSA treatment, alcohol <3 drinks/wk • lifestyle • ongoing
    trigger: All AF patients — ESC 2024
    LEGACY 2014 — durable AF-free survival improvement

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Palpitations / irregular pulse — ESC 2024; ECG / monitor showing AF — ESC 2024; Dyspnea or fatigue from RVR — ACC/AHA 2023.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Atrial fibrillation (rate / rhythm / anticoagulation)** (cardio.afib.core.v1).
Phenotype framing: Paroxysmal vs persistent vs long-standing persistent vs permanent; valvular vs non-valvular — ESC 2024
Scope: Confirm AF on ECG; differentiate paroxysmal / persistent / permanent — ESC 2024 classification

No severity triggers fired against current inputs.

Plan

Regimen axis: **Integrated AF-CARE / ABC pathway — stepwise (2024 ESC AF-CARE PMID 39210723 / 2023 ACC/AHA PMID 38033089)** — step "Step 1 — [C] Comorbidity & risk-factor management (AF-CARE pillar C)".
1. risk-factor modification bundle BP <130/80; weight loss ≥10% if BMI ≥27; OSA treatment; alcohol abstinence lifestyle ongoing (lifestyle, first line) — 2024 ESC AF-CARE [C] (PMID 39210723); alcohol abstinence reduced AF recurrence HR 0.55 (0.36–0.84) over 6 mo — Voskoboinik NEJM 2020 (PMID 31893513)

Setting playbook (outpatient) — Confirm AF, assess CHA₂DS₂-VA + HAS-BLED, choose rate vs early rhythm control with comorbidity-aware drug selection, and address risk-factor modifiers (LEGACY)
2. DOAC by CHA₂DS₂-VA ≥2 Apixaban 5 mg BID (2.5 if 2 of: ≥80 yo / ≤60 kg / Cr ≥1.5) OR rivaroxaban 20 mg / edoxaban 60 mg / dabigatran 150 BID PO BID/daily — CHA₂DS₂-VA ≥2 (men) / ≥3 (women) — ESC 2024 simplifies to ≥2 for both sexes (CHA₂DS₂-VA) (DOACs preferred over warfarin in non-valvular AF — ESC 2024)
3. rate control Metoprolol succinate 25–200 mg daily OR diltiazem ER 120–360 mg daily PO daily — Rate control strategy — RACE II (Van Gelder NEJM 2010 PMID 20231232) lenient HR <110 (BB first if CAD/HFrEF; non-DHP CCB if BB-intolerant — 2023 ACC/AHA (PMID 38033089))
4. antiarrhythmic for early rhythm control Flecainide 50–150 mg BID (no SHD) OR amiodarone 200–400 mg daily after load (SHD/HFrEF) PO BID/daily — Symptomatic + AF ≤12 mo OR HFrEF — EAST-AFNET 4 (Kirchhof NEJM 2020 PMID 32865375) (EAST-AFNET 4 composite HR 0.79 (0.66–0.94) + CASTLE-AF (Marrouche NEJM 2018 PMID 29385358))
5. risk-factor modification Weight loss 10%, BP <130/80, OSA treatment, alcohol <3 drinks/wk lifestyle ongoing — All AF patients — ESC 2024 (LEGACY 2014 — durable AF-free survival improvement)

Non-pharmacologic actions:
- Cardiology / EP referral for ablation discussion if symptomatic on AAD or HFrEF — CASTLE-AF (Marrouche NEJM 2018)
- OSA evaluation if STOP-BANG ≥3 — ESC 2024
- Alcohol counselling — ESC 2024
- Weight-loss program — ESC 2024
- Cardiac rehab if structural heart disease — ACC/AHA 2023
- Smoking cessation — ESC 2024

AVOID / contraindication checks:
- DOAC_avoid_mechanical_valve — 2023 ACC/AHA (PMID 38033089)
- DOAC_avoid_mitral_stenosis_rheumatic_mod_severe — 2023 ACC/AHA
- DOAC_avoid_APS_triple_positive — 2024 ESC
- DOAC_dose_adjust_renal_per_label — ENGAGE/ROCKET AF/ARISTOTLE labels
- Edoxaban_avoid_CrCl_above_95 — ENGAGE AF TIMI 48 (PMID 24251359)
- Flecainide_propafenone_avoid_structural_HD — 2024 ESC
- Non_DHP_CCB_avoid_HFrEF — 2023 ACC/AHA
- WPW_pre excited_AF_AVOID_AVN_blockers_use_procainamide_or_DCCV — 2023 ACC/AHA

Monitoring

Regimen monitoring:
- creatinine q6-12 months on DOAC (more frequent if CrCl <60) — 2024 ESC
- INR q4 weeks warfarin at steady state — 2023 ACC/AHA
- ECG at each visit for QTc on AAD (hold sotalol/dofetilide if QTc >500 ms) — 2023 ACC/AHA
- TFT + LFT q6 months on amiodarone — 2023 ACC/AHA
- reassess CHA₂DS₂-VA + HAS-BLED + RFM at every visit (AF-CARE [E] dynamic reassessment) — 2024 ESC

Setting (outpatient) monitoring:
- INR q4 weeks if warfarin; creatinine q6–12 mo if DOAC — ESC 2024
- ECG at each visit; AAD-specific (QTc) monitoring — ACC/AHA 2023
- Echo q1–2 years — ESC 2024
- TSH q6 mo on amiodarone — ACC/AHA 2023

Follow-up plan: Risk-factor modification (LEGACY): BP, weight, OSA screen (STOP-BANG), alcohol; vaccination
- Close-out criterion: follow-up scheduled with RFM plan

Monitoring phase: INR if warfarin; periodic creatinine for DOAC; rhythm/rate symptom diary — ESC 2024

Disposition

Current setting: outpatient — Confirm AF, assess CHA₂DS₂-VA + HAS-BLED, choose rate vs early rhythm control with comorbidity-aware drug selection, and address risk-factor modifiers (LEGACY)

Disposition criteria:
- Stable on AC + rate or rhythm control → q6–12 month visits — ESC 2024
- Newly symptomatic / new HF / breakthrough → q4–6 week titration — ACC/AHA 2023
- Ablation candidate → EP referral — CASTLE-AF (Marrouche NEJM 2018)

Escalation triggers (move to higher acuity):
- New stroke / TIA → switch to AC (if not already), reassess regimen, consider LAA closure for AC contraindication — ESC 2024
- Major bleed → reverse, address modifiable factors, LAA closure if cannot resume AC — ESC 2024
- Symptomatic refractory to AAD → ablation — CABANA (Packer JAMA 2019)

Patient Action Plan

**AF anticoagulation + bleed/falls action plan — ESC 2024**
Personalised values: CHA2DS2_VA_score, HAS_BLED_score, AC_drug, reversal_agent_pathway.

**Doing well — AC adherent, no bleed, controlled rhythm/rate** (green):
Triggers:
- No bleeding signs (no melena, hematemesis, hematuria, severe bruising)
- No new neurologic symptoms
- Rate controlled / asymptomatic
Actions:
- Continue AC every day — never skip even on travel
- Continue rate / rhythm med
- Annual physician visit + labs
- Carry medical alert / AC card

**Caution — minor bleed, missed dose, falls, palpitations** (yellow):
Triggers:
- Easy bruising or minor nosebleed lasting >10 min
- Missed AC dose >1
- Falls or near-falls
- New persistent palpitations or fatigue
Actions:
- Resume AC at next dose; do NOT double up
- Apply pressure for bleeding; ice for bruise
- Schedule fall-prevention review + bone density
- Call provider within 24–48 h
Contact provider when:
- Bleeding does not stop with pressure within 15 min
- Multiple missed doses or AC discontinuation
- New symptoms (chest pain, weakness, SOB)

**Medical alert — major bleed or stroke symptoms** (red):
Triggers:
- Severe / life-threatening bleed (vomiting blood, melena, severe nosebleed, intracranial)
- Sudden severe headache, vision change, slurred speech, weakness, numbness
- Trauma with significant bleeding or head injury
- Sudden severe palpitations + chest pain or syncope
Actions:
- Call 911 / go to ED immediately
- Bring AC name + last dose time + reversal agent card
- Apply pressure to external bleeding while awaiting EMS
- Do NOT take additional AC doses
Contact provider when:
- Any red zone symptom — ED is the destination, not the office

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] AF in WPW (delta wave on baseline ECG, irregular wide-complex tachycardia) — ACC/AHA 2023
- [LIFE_THREATENING] AF with SBP <90 / pulmonary edema / ischemia — ACC/AHA 2023
- [LIFE_THREATENING] Major bleeding (Hgb drop >2, transfusion, intracranial, GI requiring hospitalization) on DOAC or warfarin — ESC 2024

Citations

- 2023 ACC/AHA/ACCP/HRS AF Guideline (Joglar, PMID 38033089/38043043) + 2024 ESC/EACTS AF Guidelines (Van Gelder, PMID 39210723) — AF-CARE/ABC pathway; supplemented by RE-LY / ROCKET-AF / ARISTOTLE / ENGAGE AF-TIMI 48 / Hart 2007 meta / AFFIRM / RACE II / EAST-AFNET 4 / CASTLE-AF / CABANA / EARLY-AF / STOP-AF First / PROTECT-AF / PREVAIL / PRAGUE-17 / Voskoboinik / LOOP / STROKESTOP. DEPTH-PASS-2 2026-05-16: purged 3 stale/SUSPECTED_FABRICATION PMIDs (29668288 IMPACT-unconfirmed, 29766750 POINT-not-AF, 23900119 REDUCE-not-AF); 27797306 PIONEER-AF-PCI dropped (triple-therapy belongs to STEMI sibling). All 22 below verified via PubMed MCP get_article_metadata 2026-05-16. [PMID:38033089](https://pubmed.ncbi.nlm.nih.gov/38033089/)
- Cited evidence (PMID 38043043) [PMID:38043043](https://pubmed.ncbi.nlm.nih.gov/38043043/)
- Cited evidence (PMID 39210723) [PMID:39210723](https://pubmed.ncbi.nlm.nih.gov/39210723/)
- Cited evidence (PMID 39716733) [PMID:39716733](https://pubmed.ncbi.nlm.nih.gov/39716733/)
- Cited evidence (PMID 19717844) [PMID:19717844](https://pubmed.ncbi.nlm.nih.gov/19717844/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2023 ACC/AHA/ACCP/HRS AF Guideline (Joglar, PMID 38033089/38043043) + 2024 ESC/EACTS AF Guidelines (Van Gelder, PMID 39210723) — AF-CARE/ABC pathway; supplemented by RE-LY / ROCKET-AF / ARISTOTLE / ENGAGE AF-TIMI 48 / Hart 2007 meta / AFFIRM / RACE II / EAST-AFNET 4 / CASTLE-AF / CABANA / EARLY-AF / STOP-AF First / PROTECT-AF / PREVAIL / PRAGUE-17 / Voskoboinik / LOOP / STROKESTOP. DEPTH-PASS-2 2026-05-16: purged 3 stale/SUSPECTED_FABRICATION PMIDs (29668288 IMPACT-unconfirmed, 29766750 POINT-not-AF, 23900119 REDUCE-not-AF); 27797306 PIONEER-AF-PCI dropped (triple-therapy belongs to STEMI sibling). All 22 below verified via PubMed MCP get_article_metadata 2026-05-16. — PMID:38033089
  • Cited evidence (PMID 38043043) — PMID:38043043
  • Cited evidence (PMID 39210723) — PMID:39210723
  • Cited evidence (PMID 39716733) — PMID:39716733
  • Cited evidence (PMID 19717844) — PMID:19717844