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cardio.atrial_flutter.alcohol-related.v1

Alcohol-related atrial flutter ("Holiday Heart Syndrome")

cardiologyacuteadult
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11/12 authored

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Detailed

Alcohol-related atrial flutter = trigger-identifiable + modifiable arrhythmia in (typically) structurally normal heart. Acute focus: rate control + cardioversion + alcohol cessation; Long-term focus: AUD treatment + lifestyle modification per LEGACY (PMID 25788534) + abstinence per ALCOHOL-AF (PMID 31893513). Route to cardio.atrial_flutter.v1 for acute rate/rhythm + AC decisions

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Holiday Heart syndrome framed

Patient inputs (17)

Holiday Heart Syndrome described in any age but especially young/middle-aged binge drinkers; CHA2DS2-VASc + age-related bleed risk for AC decision

Female sex = +1 CHA2DS2-VASc; alcohol metabolism + pregnancy considerations; AUDIT-C cutoff differs (≥3 female vs ≥4 male)

Flutter RVR HR >120 increases hemodynamic risk + symptom burden; rate control target HR 80-110

AST/ALT/GGT for chronic alcohol use + cirrhosis screen; LFT abnormalities affect AC choice (warfarin vs DOAC; severe cirrhosis Child-Pugh C contraindicates DOAC)

Quantify binge (>5 drinks/day in 1 day = NIAAA threshold) vs chronic heavy use (>14 drinks/wk male / >7 drinks/wk female); AUDIT-C score; document last drink + amount; relate to flutter onset timing

Confirm flutter morphology (typical CTI vs atypical) + rate; rule out concomitant AF; QT for medication risk

TTE to rule out structural substrate (alcoholic cardiomyopathy if chronic; LA dilation; LV dysfunction) — distinguishes pure Holiday Heart from substrate-driven flutter requiring different long-term plan

Hypomagnesemia + hypokalemia common in binge drinkers (vomiting + poor intake); replete to Mg ≥2.0 + K ≥4.0 — required for rhythm stability + cardioversion success

Hyperthyroidism + flutter overlap; mandatory screen in new-onset flutter per ACC/AHA 2024

Rule out ACS-related flutter; demand ischemia possible with rapid rate; alcoholic cardiomyopathy may have chronic troponin elevation

SBP <90 with flutter RVR → DCCV indication; permissive HTN (alcohol withdrawal can elevate BP) requires careful titration

CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol revised) score for withdrawal risk + severity; CIWA >15 = severe withdrawal needing benzodiazepine protocol; affects flutter management timing (severe withdrawal can perpetuate flutter)

CHA2DS2-VASc for AC indication; Holiday Heart self-limited <24-48 h may not require chronic AC if isolated, but cardioversion-eligibility window + uncertainty often drive 4-wk post-CV AC per ACC/AHA 2024

HAS-BLED for AC bleed-risk; alcohol use disorder elevates bleed risk (varices, GIB, falls, head injury); influences CV/AC strategy

AUDIT-C (Alcohol Use Disorders Identification Test - Consumption) brief 3-item screen; ≥4 male / ≥3 female = positive screen; ≥8 = severe AUD; drives brief intervention + referral pathway (SBIRT)

eGFR for DOAC dosing; alcohol use disorder + renal dysfunction common

Document acute intoxication for trigger correlation; level >300 mg/dL with severe withdrawal expected if chronic heavy drinker

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Severity triggers (5)

5 need judgement
  • informationallife_threateningsevere_withdrawal_ciwa_15_with_aflutter_persistence
    Patient with severe alcohol withdrawal (CIWA-Ar >15) + persistent atrial flutter despite rate control attempts — sympathetic surge from withdrawal perpetuates arrhythmia
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghemodynamic_instability_with_aflutter_post_binge
    Atrial flutter with SBP <90 + lactate elevation OR syncope OR chest pain in post-binge patient — emergent rate/rhythm control required
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrence_with_continued_drinking
    Patient develops recurrent atrial flutter after initial Holiday Heart episode despite (or due to) continued drinking — failure of abstinence intervention
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereholiday_heart_vs_structural_substrate_distinction
    Echo reveals LV dysfunction, LA dilation >4.5 cm, or other structural disease in patient initially presenting with apparent Holiday Heart — actually structural-substrate flutter masquerading as Holiday Heart
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaudit_c_high_score_with_outpatient_referral_failure
    Patient with AUDIT-C ≥8 (severe AUD) fails outpatient AUD treatment engagement (no-shows, relapses, naltrexone non-adherence) → escalation to higher level of care needed
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Alcohol-related atrial flutter ("Holiday Heart") — acute rate/rhythm + electrolyte repletion + alcohol cessation/SBIRT + lifestyle modification per LEGACY pathway — ACC/AHA 2024 (PMID 38753446) + ALCOHOL-AF (PMID 31893513)
axis: aflutter_alcohol_related_holiday_heart_pathway
Selected axis "Alcohol-related atrial flutter ("Holiday Heart") — acute rate/rhythm + electrolyte repletion + alcohol cessation/SBIRT + lifestyle modification per LEGACY pathway — ACC/AHA 2024 (PMID 38753446) + ALCOHOL-AF (PMID 31893513)" by default fallback (first axis)
  • metoprolol_tartrate
    first line
    beta_blocker
    5 mg IV q5min × 3 then 25-50 mg PO BID • IV/PO • IV q5min × 3 → PO BID
    triggers: flutter_RVR_holiday_heart, no_HFrEF_decompensation
    AVN slowing for flutter; preferred over non-DHP CCB if alcoholic cardiomyopathy suspected (any LV dysfunction); ACC/AHA 2024 (PMID 38753446) Class I rate control
    rxcui 203191
  • metoprolol_succinate
    first line
    beta_blocker
    25-50 mg PO daily • PO • daily
    triggers: transition_to_PO_after_acute, long_term_rate_control
    Once-daily formulation for outpatient transition; ACC/AHA 2024
    rxcui 866427
  • diltiazem
    first line
    non_dhp_ccb
    0.25 mg/kg IV bolus then 5-15 mg/h infusion OR 30-60 mg PO QID • IV/PO • continuous IV / QID PO
    triggers: BB_contraindicated_or_intolerant, no_significant_LV_dysfunction
    Alternative AVN blocker; AVOID if EF <40 or alcoholic CMP — can worsen HF; ACC/AHA 2024 Class I
    rxcui 3443
  • apixaban
    first line
    DOAC_factor_Xa
    5 mg BID (2.5 mg BID if 2 of: ≥80 yr, ≤60 kg, Cr ≥1.5) • PO • BID
    triggers: cardioversion_planned_or_completed, cha2ds2vasc_>=2, recurrent_alcohol_aflutter
    4-wk post-CV AC mandatory per ACC/AHA 2024 (PMID 38753446); long-term AC if CHA2DS2-VASc ≥2; ARISTOTLE foundational (PMID 21870978); DOAC preferred over warfarin in non-valvular flutter
    rxcui 1364430
  • rivaroxaban
    first line
    DOAC_factor_Xa
    20 mg with food (15 mg if CrCl 15-50) • PO • once daily
    triggers: cardioversion_planned_or_completed, apixaban_unavailable
    ROCKET-AF reference; alternative DOAC
    rxcui 1114195
  • dabigatran
    first line
    DOAC_direct_thrombin
    150 mg BID (110 mg BID if ≥80 yr or higher bleed risk; avoid CrCl <30) • PO • BID
    triggers: cardioversion_planned_or_completed, idarucizumab_reversal_preference
    RE-LY reference; idarucizumab available for emergent reversal — useful in alcohol-related patients with elevated falls/GIB risk
    rxcui 1037045
  • warfarin
    comorbidity specific
    vitamin_K_antagonist
    5 mg daily; INR target 2-3 • PO • daily
    triggers: mechanical_valve, severe_renal_failure_CrCl_<15, cost_constraint, severe_cirrhosis_DOAC_contraindicated
    Cirrhosis Child-Pugh C contraindicates DOACs (apixaban can be used in Child-Pugh B with caution); warfarin alternative if DOAC contraindicated; INR monitoring challenging in heavy drinkers
    rxcui 11289
  • magnesium_sulfate
    first line
    electrolyte_replacement
    2-4 g IV over 15-30 min then 1-2 g IV q4-6h to Mg ≥2.0 • IV • q4-6h until repleted
    triggers: hypomagnesemia, rhythm_instability, pre_cardioversion
    Hypomagnesemia common in binge drinkers; Mg repletion supports rhythm stability + cardioversion success; ACC/AHA 2024 supportive measure
    rxcui 6585
  • potassium_chloride
    first line
    electrolyte_replacement
    40-80 mEq PO/IV over 4 h to K ≥4.0; max 10 mEq/h IV peripheral • PO/IV • until repleted
    triggers: hypokalemia, rhythm_instability
    Hypokalemia common from binge + emesis; K repletion reduces ectopy + supports rhythm stability
    rxcui 8591
  • lorazepam
    comorbidity specific
    benzodiazepine
    1-4 mg PO/IV q1h symptom-triggered per CIWA protocol • PO/IV • q1h CIWA-triggered
    triggers: ciwa_>=10, severe_withdrawal_risk
    CIWA-Ar protocol for alcohol withdrawal management; severe withdrawal (CIWA >15) requires aggressive benzodiazepine treatment + ICU consideration; withdrawal can perpetuate flutter via sympathetic surge
    rxcui 6470
  • naltrexone
    comorbidity specific
    opioid_antagonist_aud_treatment
    50 mg PO daily OR 380 mg IM monthly • PO/IM • daily/monthly
    triggers: aud_long_term_treatment, audit_c_>=4_male_or_>=3_female, no_active_opioid_use
    FDA-approved AUD pharmacotherapy; reduces alcohol craving + heavy drinking days; SBIRT-driven referral pathway; AUDIT-C ≥4/3 is positive screen
    rxcui 105069
  • thiamine
    first line
    vitamin_supplementation
    100 mg IV/IM × 3 doses then 100 mg PO daily • IV/IM/PO • TID acute → daily long-term
    triggers: alcohol_use_disorder, all_alcohol_admissions
    Wernicke prophylaxis — give BEFORE glucose to avoid precipitating WE; standard alcohol-admission protocol
    rxcui 10454

outpatient playbook — drug actions (4)

  1. 1. long-term AC per CHA2DS2-VASc
    rxcui 1364430
    apixaban 5 mg BID per CHA2DS2-VASc + dose-reduction criteria; STOP if score 0-1 + sustained NSR + abstinence + no recurrence • PO • BID
    trigger: Long-term per stroke risk
    ACC/AHA 2024 — AC indication is per stroke risk, NOT per alcohol status; isolated Holiday Heart in young patient with CHA2DS2-VASc 0-1 may not need lifelong AC
  2. 2. continue rate control if needed
    rxcui 866427
    metoprolol succinate 25-50 mg PO daily; taper if successful CTI ablation + sustained NSR • PO • daily
    trigger: Persistent flutter pre-ablation
    ACC/AHA 2024
  3. 3. continue naltrexone or alternative AUD pharmacotherapy
    rxcui 105069
    50 mg PO daily OR 380 mg IM monthly OR acamprosate 666 mg PO TID OR disulfiram 250 mg PO daily • PO/IM • daily/monthly/TID
    trigger: Long-term AUD treatment
    Sustained reduction in heavy drinking; switch if first-line ineffective
  4. 4. thiamine PO long-term
    rxcui 10454
    100 mg PO daily • PO • daily
    trigger: AUD ongoing
    Continue prophylaxis

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: New-onset palpitations, dyspnea, or fatigue within 12-48 h of acute alcohol binge (>5 drinks/day in 1 day) in patient without known structural heart disease — Holiday Heart Syndrome screen; Atrial flutter (or AF) on 12-lead ECG with documented recent alcohol binge — confirm and trigger acute management; Recurrent flutter episodes in patient with chronic heavy drinking (per AUDIT-C ≥4 male / ≥3 female, or self-reported >14 drinks/week male / >7 drinks/week female) — chronic alcohol-related flutter pattern.

Objective

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

Assessment

**Alcohol-related atrial flutter ("Holiday Heart Syndrome")** (cardio.atrial_flutter.alcohol-related.v1).
Scope: Alcohol-related atrial flutter = trigger-identifiable + modifiable arrhythmia in (typically) structurally normal heart. Acute focus: rate control + cardioversion + alcohol cessation; Long-term focus: AUD treatment + lifestyle modification per LEGACY (PMID 25788534) + abstinence per ALCOHOL-AF (PMID 31893513). Route to cardio.atrial_flutter.v1 for acute rate/rhythm + AC decisions

No severity triggers fired against current inputs.

Plan

Regimen axis: **Alcohol-related atrial flutter ("Holiday Heart") — acute rate/rhythm + electrolyte repletion + alcohol cessation/SBIRT + lifestyle modification per LEGACY pathway — ACC/AHA 2024 (PMID 38753446) + ALCOHOL-AF (PMID 31893513)**.
1. metoprolol_tartrate 5 mg IV q5min × 3 then 25-50 mg PO BID IV/PO IV q5min × 3 → PO BID (beta_blocker, first line) — AVN slowing for flutter; preferred over non-DHP CCB if alcoholic cardiomyopathy suspected (any LV dysfunction); ACC/AHA 2024 (PMID 38753446) Class I rate control
2. metoprolol_succinate 25-50 mg PO daily PO daily (beta_blocker, first line) — Once-daily formulation for outpatient transition; ACC/AHA 2024
3. diltiazem 0.25 mg/kg IV bolus then 5-15 mg/h infusion OR 30-60 mg PO QID IV/PO continuous IV / QID PO (non_dhp_ccb, first line) — Alternative AVN blocker; AVOID if EF <40 or alcoholic CMP — can worsen HF; ACC/AHA 2024 Class I
4. apixaban 5 mg BID (2.5 mg BID if 2 of: ≥80 yr, ≤60 kg, Cr ≥1.5) PO BID (DOAC_factor_Xa, first line) — 4-wk post-CV AC mandatory per ACC/AHA 2024 (PMID 38753446); long-term AC if CHA2DS2-VASc ≥2; ARISTOTLE foundational (PMID 21870978); DOAC preferred over warfarin in non-valvular flutter
5. rivaroxaban 20 mg with food (15 mg if CrCl 15-50) PO once daily (DOAC_factor_Xa, first line) — ROCKET-AF reference; alternative DOAC
6. dabigatran 150 mg BID (110 mg BID if ≥80 yr or higher bleed risk; avoid CrCl <30) PO BID (DOAC_direct_thrombin, first line) — RE-LY reference; idarucizumab available for emergent reversal — useful in alcohol-related patients with elevated falls/GIB risk
7. warfarin 5 mg daily; INR target 2-3 PO daily (vitamin_K_antagonist, comorbidity specific) — Cirrhosis Child-Pugh C contraindicates DOACs (apixaban can be used in Child-Pugh B with caution); warfarin alternative if DOAC contraindicated; INR monitoring challenging in heavy drinkers
8. magnesium_sulfate 2-4 g IV over 15-30 min then 1-2 g IV q4-6h to Mg ≥2.0 IV q4-6h until repleted (electrolyte_replacement, first line) — Hypomagnesemia common in binge drinkers; Mg repletion supports rhythm stability + cardioversion success; ACC/AHA 2024 supportive measure
9. potassium_chloride 40-80 mEq PO/IV over 4 h to K ≥4.0; max 10 mEq/h IV peripheral PO/IV until repleted (electrolyte_replacement, first line) — Hypokalemia common from binge + emesis; K repletion reduces ectopy + supports rhythm stability
10. lorazepam 1-4 mg PO/IV q1h symptom-triggered per CIWA protocol PO/IV q1h CIWA-triggered (benzodiazepine, comorbidity specific) — CIWA-Ar protocol for alcohol withdrawal management; severe withdrawal (CIWA >15) requires aggressive benzodiazepine treatment + ICU consideration; withdrawal can perpetuate flutter via sympathetic surge
11. naltrexone 50 mg PO daily OR 380 mg IM monthly PO/IM daily/monthly (opioid_antagonist_aud_treatment, comorbidity specific) — FDA-approved AUD pharmacotherapy; reduces alcohol craving + heavy drinking days; SBIRT-driven referral pathway; AUDIT-C ≥4/3 is positive screen
12. thiamine 100 mg IV/IM × 3 doses then 100 mg PO daily IV/IM/PO TID acute → daily long-term (vitamin_supplementation, first line) — Wernicke prophylaxis — give BEFORE glucose to avoid precipitating WE; standard alcohol-admission protocol

Setting playbook (outpatient) — Long-term cardiology + addiction medicine + primary care coordination; abstinence preferred per ALCOHOL-AF; lifestyle bundle per LEGACY; recurrence surveillance; long-term AC reassessment per evolving CHA2DS2-VASc; CTI ablation pathway if recurrent typical flutter despite abstinence
13. long-term AC per CHA2DS2-VASc apixaban 5 mg BID per CHA2DS2-VASc + dose-reduction criteria; STOP if score 0-1 + sustained NSR + abstinence + no recurrence PO BID — Long-term per stroke risk (ACC/AHA 2024 — AC indication is per stroke risk, NOT per alcohol status; isolated Holiday Heart in young patient with CHA2DS2-VASc 0-1 may not need lifelong AC)
14. continue rate control if needed metoprolol succinate 25-50 mg PO daily; taper if successful CTI ablation + sustained NSR PO daily — Persistent flutter pre-ablation (ACC/AHA 2024)
15. continue naltrexone or alternative AUD pharmacotherapy 50 mg PO daily OR 380 mg IM monthly OR acamprosate 666 mg PO TID OR disulfiram 250 mg PO daily PO/IM daily/monthly/TID — Long-term AUD treatment (Sustained reduction in heavy drinking; switch if first-line ineffective)
16. thiamine PO long-term 100 mg PO daily PO daily — AUD ongoing (Continue prophylaxis)

Non-pharmacologic actions:
- Sustained AUD treatment program engagement (IOP / AA / SMART Recovery / individual therapy)
- CPAP if OSA diagnosed (per LEGACY / ACC/AHA 2024)
- Weight loss maintenance (10% weight loss target per LEGACY)
- Cardiac rehab maintenance phase if appropriate
- Family + peer support engagement
- Lifestyle bundle: BP, weight, alcohol, OSA, exercise (ACC/AHA 2024)
- EP referral for CTI ablation candidacy if recurrent typical flutter despite abstinence (Calkins 2007 PMID 17572388 — CTI ablation curative >95% for typical)

AVOID / contraindication checks:
- Diltiazem_avoid_significant_LV_dysfunction_alcoholic_CMP — ACC/AHA 2024
- DOAC_renal_dose_adjustment — ESC 2024 (PMID 39050851)
- Apixaban_with_caution_child_pugh_B_avoid_C — drug label
- Rivaroxaban_avoid_child_pugh_B_or_C — drug label
- Warfarin_INR_unstable_in_heavy_drinkers — clinical reality
- Decision:4wk_post_CV_AC_mandatory_per_ACC_AHA_2024 (PMID 38753446)
- Decision:TEE_pre_CV_if_>48h_episode_or_unknown_duration_OR_therapeutic_AC_4wk
- Decision:long_term_AC_per_CHA2DS2VASc_NOT_per_alcohol_status (alcohol modifiable but AC indication is per stroke risk)
- Decision:AUD_treatment_first_line_naltrexone_acamprosate_disulfiram
- Decision:abstinence_preferred_over_moderation_per_ALCOHOL_AF (PMID 31893513)

Monitoring

Regimen monitoring:
- continuous telemetry during acute phase
- daily Mg K Ca until repleted and stable
- CIWA q4-6h if withdrawal protocol active
- AUDIT C at 4wk 3mo 6mo 12mo for AUD treatment response
- 4wk post CV AC adherence + bleed surveillance
- recurrence monitoring via smartwatch or holter 30d at 3-6 mo
- long term AC reassessment per CHA2DS2VASc trajectory
- sleep study for OSA per ACC AHA 2024 lifestyle bundle

Setting (outpatient) monitoring:
- Quarterly clinic + annual EF + lipid (ACC/AHA 2024)
- CBC + eGFR q6m on DOAC (ESC 2024 PMID 39050851)
- Holter at 6 + 12 mo for recurrence (Calkins 2007)
- AUDIT-C at every visit
- LFTs annually (naltrexone monitoring)

Follow-up plan: AUDIT-C reassessment at 4 wk + 3 mo; alcohol abstinence (preferred per ALCOHOL-AF) or significant reduction goal; lifestyle bundle per LEGACY (sleep, weight, exercise); recurrence monitoring (Holter or smartwatch); EP referral if recurrent despite abstinence (consider CTI ablation if typical morphology); cardiology + addiction medicine + primary care coordination; long-term AC reassessment per CHA2DS2-VASc trajectory
- Close-out criterion: AUD treatment engagement + lifestyle bundle + recurrence-monitoring + long-term AC plan documented

Monitoring phase: 24-48 h telemetry for recurrence + AC initiation; CIWA q4-6h if withdrawal protocol active; daily Mg/K/Ca; LFT trend; daily AUDIT-C reinforcement + brief intervention; 4-wk post-CV AC adherence + bleed surveillance

Disposition

Current setting: outpatient — Long-term cardiology + addiction medicine + primary care coordination; abstinence preferred per ALCOHOL-AF; lifestyle bundle per LEGACY; recurrence surveillance; long-term AC reassessment per evolving CHA2DS2-VASc; CTI ablation pathway if recurrent typical flutter despite abstinence

Disposition criteria:
- Continue chronic surveillance; cross-link to cardio.atrial_flutter.typical-cavotricuspid.v1 if typical morphology + ablation pathway; cross-link to cardio.acute-hf.core.v1 if alcoholic cardiomyopathy develops

Escalation triggers (move to higher acuity):
- Recurrent flutter despite abstinence + lifestyle bundle → EP for CTI ablation
- AUD relapse with worsening severity → intensify treatment, consider residential, reassess medication
- New LV dysfunction (alcoholic cardiomyopathy) → cardio.acute-hf.core.v1 routing
- Major bleed on AC → reverse + reassess long-term AC strategy
- AUDIT-C high score with outpatient referral failure → escalate to higher level of care (residential, dual-diagnosis program)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Patient with severe alcohol withdrawal (CIWA-Ar >15) + persistent atrial flutter despite rate control attempts — sympathetic surge from withdrawal perpetuates arrhythmia
- [LIFE_THREATENING] Atrial flutter with SBP <90 + lactate elevation OR syncope OR chest pain in post-binge patient — emergent rate/rhythm control required
- [SEVERE] Patient develops recurrent atrial flutter after initial Holiday Heart episode despite (or due to) continued drinking — failure of abstinence intervention

Citations

- 2024 ACC/AHA/ACCP/HRS AF + AFL Joint Guideline (Joglar PMID 38753446) + ESC 2024 AF (Van Gelder PMID 39050851) + ALCOHOL-AF (Voskoboinik NEJM 2020 PMID 31893513) + LEGACY (Pathak JACC 2014 PMID 25788534) [PMID:38753446](https://pubmed.ncbi.nlm.nih.gov/38753446/)
- Cited evidence (PMID 39050851) [PMID:39050851](https://pubmed.ncbi.nlm.nih.gov/39050851/)
- Cited evidence (PMID 31893513) [PMID:31893513](https://pubmed.ncbi.nlm.nih.gov/31893513/)
- Cited evidence (PMID 25788534) [PMID:25788534](https://pubmed.ncbi.nlm.nih.gov/25788534/)
- Cited evidence (PMID 14029) [PMID:14029](https://pubmed.ncbi.nlm.nih.gov/14029/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 2024 ACC/AHA/ACCP/HRS AF + AFL Joint Guideline (Joglar PMID 38753446) + ESC 2024 AF (Van Gelder PMID 39050851) + ALCOHOL-AF (Voskoboinik NEJM 2020 PMID 31893513) + LEGACY (Pathak JACC 2014 PMID 25788534) — PMID:38753446
  • Cited evidence (PMID 39050851) — PMID:39050851
  • Cited evidence (PMID 31893513) — PMID:31893513
  • Cited evidence (PMID 25788534) — PMID:25788534
  • Cited evidence (PMID 14029) — PMID:14029