For elderly patients (i.e. older than 80) with only one documented episode of paroxysmal atrial fibrillation following a stress event (such as acute illness/steroid administration) and a CHADsVASc score greater than 1, how would you counsel them on the risks/benefits of anticoagulation and subsequent monitoring for afib recurrence?

If it were an isolated event, I would advocate continued monitoring for recurrence before starting an anticoagulant with the understanding that the risk of AF recurrence is relatively high.

This is a relatively common scenario for which there are no randomized trials to guide management. There is strong observational evidence that an isolated episode of atrial fibrillation (AF) in the setting of an acute trigger is a marker for increased risk of subsequent recurrence and for stroke. Bu...

Increased risk of recurrence. One-time provoked event. Monitor with loop record. Discuss the risks and benefits of AC with the patient, allowing for an informed decision.

Prevent the worst complication, CVA, therefore anticoagulation even if guidelines don’t support this patient’s personal situation.

Study has shown recurrence of afib in 1 year follow up after a provoked event even the patient has already returned sinus rhythm. Will do DOAC unless contraindicated.

I will initially a/c for 3 months (similar to after valve or CABG) and reassess at that time.

Less likely to do long-term A/C if the patient presents with severe pulmonary deterioration, which transiently increases R-sided pressure - especially PE, which resolves.