Cardiology — Atrial Fibrillation Management Template
The Atrial Fibrillation Management Template is designed for cardiologists and electrophysiologists managing patients with atrial fibrillation or flutter. This template documents rhythm assessment, stroke risk stratification, anticoagulation management, rate/rhythm control strategies, and procedural planning. Supports appropriate billing for E/M services and includes CHA2DS2-VASc and HAS-BLED scoring, medication optimization, and cardioversion or ablation planning. Ideal for cardiology practices, EP clinics, and anticoagulation management services.
Template
Visit Information
Date: [Date]
Visit type: New AFib / Follow-up / Post-procedure / Urgent
Atrial Fibrillation History
Type: Paroxysmal / Persistent / Long-standing persistent / Permanent
Date of diagnosis: [Date]
Duration of current episode: [If applicable]
Known triggers: [Alcohol, caffeine, sleep deprivation, stress, illness]
Prior cardioversions: [Dates, success]
Prior ablations: [Dates, type, success]
Symptom Assessment
EHRA Score: I / IIa / IIb / III / IV
Palpitations: None / [Frequency, duration]
Dyspnea: None / Exertional / Rest
Fatigue: None / Mild / Moderate / Severe
Chest discomfort: None / [Details]
Lightheadedness: None / [Details]
Exercise intolerance: None / [Details]
Syncope: None / [Details]
Symptom burden: Asymptomatic / Mildly symptomatic / Significantly symptomatic
Stroke Risk Assessment
CHA2DS2-VASc Score: [0-9]
- C: CHF/LV dysfunction (1 point): Yes / No
- H: Hypertension (1 point): Yes / No
- A2: Age ≥75 (2 points): Yes / No
- D: Diabetes (1 point): Yes / No
- S2: Stroke/TIA/thromboembolism (2 points): Yes / No
- V: Vascular disease (1 point): Yes / No
- A: Age 65-74 (1 point): Yes / No
- Sc: Sex category female (1 point): Yes / No
Annual stroke risk: [X]% (based on score)
Anticoagulation indicated: Yes / No
Bleeding Risk Assessment
HAS-BLED Score: [0-9]
- H: Hypertension (uncontrolled >160) (1 point): Yes / No
- A: Abnormal renal/liver function (1-2 points): Yes / No
- S: Stroke history (1 point): Yes / No
- B: Bleeding history/predisposition (1 point): Yes / No
- L: Labile INR (if on warfarin) (1 point): Yes / No
- E: Elderly >65 (1 point): Yes / No
- D: Drugs/alcohol (1-2 points): Yes / No
Bleeding risk: Low (<3) / High (≥3)
Current Anticoagulation
Status: On anticoagulation / Not anticoagulated / Contraindicated
Agent: Warfarin / Apixaban / Rivaroxaban / Dabigatran / Edoxaban / None
Dose: [Dose, frequency]
Duration on therapy: [X] months/years
Compliance: Excellent / Good / Fair / Poor
INR (if warfarin): [Value], TTR: [X]%
Renal function (CrCl): [X] mL/min — Dose appropriate: Yes / No
Prior bleeding events: None / [Details]
Prior thromboembolic events: None / [Details]
Rate vs Rhythm Control Strategy
Current strategy: Rate control / Rhythm control
Rationale: [Patient preference, symptom burden, structural heart disease]
Rate control:
- Target HR: <110 bpm (lenient) / <80 bpm (strict)
- Current resting HR: [X] bpm
- Agents: [Beta-blocker, CCB, digoxin, doses]
- Control achieved: Yes / No
Rhythm control:
- Antiarrhythmic: [Flecainide, propafenone, sotalol, dofetilide, amiodarone, dronedarone]
- Dose: [X]
- Duration: [X]
- Side effects: None / [Details]
- Efficacy: Maintaining SR / Breakthrough AFib [frequency]
Physical Examination
Vital signs: BP [X/X], HR [X] ([regular/irregular]), RR [X], SpO2 [X]%
Cardiovascular:
- JVP: Normal / Elevated
- Heart rhythm: Regular / Irregularly irregular
- Heart rate: Controlled / Uncontrolled
- Murmurs: None / [Description]
- S3/S4: Absent / Present
Lungs: Clear / [Findings]
Extremities: No edema / [Findings]
Neurological: [Focal deficits if stroke concern]
Diagnostic Studies
ECG: [Rhythm, rate, intervals, ST-T changes]
- Rhythm: Sinus / AFib / Aflutter / [Other]
- Ventricular rate: [X] bpm
- PR/QRS/QTc: [Values]
Recent Holter/monitor: [Date, AFib burden %, average HR, max HR]
Echocardiogram: [Date, EF, LA size, LVH, valves]
- LA diameter/volume: [X] cm / [X] mL/m²
TEE (if applicable): [Date, LAA thrombus, spontaneous echo contrast]
Sleep study: Done / Pending / Not indicated — OSA: Yes / No / Unknown
Assessment
1) Atrial fibrillation — [Type], CHA2DS2-VASc [X], HAS-BLED [X]
Rate control: Adequate / Inadequate
Rhythm control: Maintaining SR / Recurrent AFib
Anticoagulation: Appropriate / Needs adjustment / Contraindicated
2) [Associated conditions: HTN, HFrEF, valvular disease, OSA, thyroid]
Plan
1) Anticoagulation:
- Continue [agent, dose] / Change to [agent, dose] / Initiate [agent]
- Rationale: [CHA2DS2-VASc justification]
- Monitoring: [INR schedule if warfarin, renal function]
2) Rate control:
- Continue current regimen / Adjust [specific changes]
- Target: HR <[X] bpm at rest
3) Rhythm control:
- Continue [AAD] / Adjust dose / Discontinue / Initiate [AAD]
- Monitoring: [QTc, renal/liver function, thyroid if amiodarone]
4) Procedural considerations:
- Cardioversion: [Planned date / Not indicated]
- Catheter ablation: [Referral / Scheduled / Not candidate]
- LAA occlusion: [If anticoagulation contraindicated]
- AV node ablation + pacemaker: [If rate control failing]
5) Lifestyle modifications:
- Weight loss: [If BMI elevated]
- Alcohol reduction: [If trigger identified]
- OSA treatment: [CPAP compliance]
- Exercise: [Recommendations]
6) Monitoring:
- Labs: [BMP, CBC, LFTs, TSH timing]
- ECG: [Timing for QTc if on AAD]
- Device check: [If pacemaker/ICD]
7) Follow-up:
- Cardiology/EP: [Timeframe]
- Anticoagulation clinic: [If applicable]
Patient Education
AFib overview, stroke risk and anticoagulation importance, symptoms requiring urgent evaluation (stroke signs, severe bleeding, rapid palpitations), medication compliance, lifestyle modifications, when to seek emergency care.
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