Primary Care Lens: Atrial Fibrillation From Detection to Referral in Primary Care

Welcome back to Primary Care Lens!

Atrial fibrillation (AF) is among the most common arrhythmias in clinical care, and for many patients the first sign appears in a primary care office: an irregular pulse, an abnormal electrocardiogram (ECG), a report of palpitations, or, increasingly, a smartwatch notification. What follows is a series of decisions about anticoagulation, rate and rhythm strategy, lifestyle change, and referral, each with consequences for long-term stroke risk.

In this episode, host Jubril Oyeyemi, MD, chief medical officer of the Camden Coalition of Health Care Providers and founder of the Cherry Hill Free Clinic, speaks with Troy L. Randle, DO, a board-certified cardiologist at Virtua Health. The 2 physicians, who both see patients at the free clinic, translate current AF management into practical steps for primary care.

Evaluating New Atrial Fibrillation and Knowing When to Send Patients to the ED

Randle notes most patients with new AF do not need emergency care. He reserves ED referral for patients who are grossly symptomatic, with chest discomfort, near-syncope, or lightheadedness, and for those with uncontrolled ventricular rates in the 140s to 150s beats per minute. Rates in the 110s can usually be managed in the outpatient setting, as can moderately elevated blood pressure, but a pressure in the 180s to 190s mm Hg alongside symptomatic, uncontrolled AF warrants an emergency visit. He also sends patients with a reliable onset within the past 24 hours, since they may be candidates for prompt cardioversion without 4 to 6 weeks of preceding anticoagulation.

Many patients with AF report no symptoms, and Randle increasingly sees patients referred after a smartwatch flagged an irregular rhythm. A careful history often reveals subtle changes in energy or functional status patients have not connected to the arrhythmia, so he recommends asking how daily life compares with a month or 2 earlier.

For workup, Randle obtains an echocardiogram on every patient with new AF, along with a baseline ECG, electrolytes, thyroid function, blood pressure assessment, and evaluation of pulmonary status. He also screens for alcohol use and obstructive sleep apnea, particularly given the prevalence of obesity. Identifying these triggers early, he explains, improves the odds of success for later rhythm-control procedures.

Anticoagulation, Left Atrial Appendage Occlusion, and Choosing a DOAC

Randle's default is to anticoagulate every patient at diagnosis and de-escalate later, once the treatment pathway is clear. Even a younger patient with a CHA2DS2-VASc score of 0 should be protected if cardioversion is on the table, he says. He also walks through the score's evolution from CHADS2 to CHA2DS2-VASc, which added vascular disease and female sex and assigned 2 points to age 75 years or older.

For borderline patients, Randle weighs lifestyle, adherence, and the planned strategy, leaning toward anticoagulation whenever restoring sinus rhythm is the goal. He reminds patients who defer anticoagulation their stroke risk rises with age, so the conversation will return.

Randle recommends against warfarin (Coumadin) for AF in the current era. Its low cost keeps it in use among underserved populations, but frequent laboratory monitoring and inconsistent time in therapeutic range leave many patients inadequately protected. Among direct oral anticoagulants (DOACs), which also include dabigatran (Pradaxa) and edoxaban (Savaysa), cardiology has gravitated toward apixaban (Eliquis) because of its bleeding profile. Randle still prescribes rivaroxaban (Xarelto) for patients unable to manage twice-daily dosing, with a reminder to take it with a meal. A Medicare cohort study of 581,451 patients found rivaroxaban associated with roughly double the rate of nonfatal extracranial bleeding compared with apixaban (HR, 2.07; 95% CI, 1.99-2.15).¹

For patients with a CHA2DS2-VASc score of 3 or higher who face high bleeding risk, falls, or long-term cost barriers, Randle believes left atrial appendage occlusion (LAAO) with a device such as Watchman is underused. Patients remain on anticoagulation for a period after implantation, transition to aspirin and clopidogrel, and eventually continue low-dose aspirin 81 mg alone. LAAO can now be performed alongside catheter ablation, and in the OPTION trial, appendage closure after ablation reduced nonprocedural major or clinically relevant nonmajor bleeding versus oral anticoagulation (8.5% vs 18.1%; P<0.001) while remaining noninferior for death, stroke, or systemic embolism.² The key, Randle says, is identifying candidates before the bleed, the fall, or the financial strain occurs.

Rhythm Control, Wearables, Lifestyle, and Referral to Electrophysiology

Oyeyemi, who trained when rate control dominated, asks whether the pendulum has swung. Randle says it has: rate control and anticoagulation remain the first steps in the office, but "everyone should be entitled to at least one attempt at rhythm control." Earlier intervention, before left atrial enlargement develops, improves the likelihood of success. The EAST-AFNET 4 trial supports this approach, with early rhythm control reducing the composite of cardiovascular death, stroke, or hospitalization for worsening heart failure or acute coronary syndrome versus usual care (HR, 0.79; 96% CI, 0.66-0.94; P=0.005).³

When cardiology is not accessible, Randle suggests anticoagulating for 4 to 6 weeks, maintaining rate control, and considering short-term amiodarone as a first-line rhythm agent, since it can be used before cardiac function is fully characterized. Long-term amiodarone carries toxicity concerns, and he advises deferring flecainide and propafenone until more cardiac data are available.

For smartwatch alerts, Randle asks to see the tracing, since premature atrial contractions or poor-quality recordings can trigger false alarms. If questions remain, he orders ambulatory monitoring for at least 1 week and preferably 2, as longer wear time increases arrhythmia capture; 24- to 48-hour monitors are better suited to assessing rate trends in known AF. Patients with persistent symptoms and unrevealing monitoring may be candidates for an implantable loop recorder, with a battery life of about 3 to 4 years.

Because a first episode raises the risk of recurrence, Randle emphasizes trigger reduction: limiting alcohol and caffeine, controlling blood pressure and glucose, and addressing sleep apnea, which he considers underdiagnosed even within cardiology. Sleep apnea belongs on the radar for nearly every patient with AF, including those with a smaller frame, and a bed partner's description of sleep patterns can guide testing. Weight loss carries the greatest impact; in the LEGACY cohort, losing 10% or more of body weight produced a 6-fold greater probability of arrhythmia-free survival (95% CI, 3.4-10.3; P<0.001).⁴

On referral, Randle leans toward electrophysiology (EP) when rhythm control is the plan. In regions with strong cardiology access, general cardiology often serves as the bridge to EP; where access is limited, direct EP referral may be reasonable. For patients paying out of pocket, general cardiology may offer more affordable medication management, since EP care tends to be procedural.

Randle closes with 3 rules for primary care clinicians: identify and address triggers, control the rate, and anticoagulate. He adds a fourth: decide early between rhythm and rate control, and consider which patients may benefit from LAAO rather than long-term anticoagulation.

References:

1. Ray WA, Chung CP, Stein CM, et al. Association of rivaroxaban vs apixaban with major ischemic or hemorrhagic events in patients with atrial fibrillation. JAMA. 2021;326(23):2395-2404. doi:10.1001/jama.2021.21222 2. Wazni OM, Saliba WI, Nair DG, et al. Left atrial appendage closure after ablation for atrial fibrillation. N Engl J Med. 2025;392(13):1277-1287. doi:10.1056/NEJMoa2408308
3. Kirchhof P, Camm AJ, Goette A, et al. Early rhythm-control therapy in patients with atrial fibrillation. N Engl J Med. 2020;383(14):1305-1316. doi:10.1056/NEJMoa2019422
4. Pathak RK, Middeldorp ME, Meredith M, et al. Long-term effect of goal-directed weight management in an atrial fibrillation cohort: a long-term follow-up study (LEGACY). J Am Coll Cardiol. 2015;65(20):2159-2169. doi:10.1016/j.jacc.2015.03.002