A first-time detection or occurrence of atrial fibrillation (AF) can challenge the treating physician with the following question: What was its cause?

The arrhythmia might not be the primary result of an irregular heart rate or rhythm but rather the product of an underlying acute or chronic issue such as sleep apnea, dehydration, obesity, diabetes, sepsis, and inflammatory bowel disease. Discerning the root cause of a trigger-induced type of arrhythmia is vital to the patient’s treatment and in the prevention of future AF events.

Barat S. Venkataramany, MD, PGY-3, University of Cincinnati Medical Center (UCMC), Cincinnati, and colleagues discuss the treatment and management of trigger-induced AF in a new, hospitalist-focused review. Medscape Medical News asked Venkataramany to share more information with readers.

What was the impetus that led you and your coauthors to write this review?

My fascination with trigger-induced AF stems from a rapid response situation that occurred during my intern year. A patient admitted for sepsis — secondary to a urinary tract infection — had new AF with rapid ventricular response.

Up until this point, I did not know that sepsis could trigger it. I’d never learned that in medical school. I was enthralled that such a thing could happen; my prior experience with AF was only in isolated contexts, such as cardiology rotations.

When I worked with Sarah Horn, MD, a mentor and co-author of this review, we found ourselves interested in patients who were admitted for primarily cardiac pathologies, especially AF. We started looking into trigger-induced AF and how its management might differ from other cases of AF.

What did the literature tell you?

Our initial idea was to review the most recent American and European guidelines on AF and distill them into practical recommendations for the hospitalist. But we found few recommendations or evidence on acute and trigger-induced AF.

We decided to write a review that addressed reshaping how we think of and manage trigger-induced AF. With our other coauthors Aparna Kambhampati, MD, and Alex Arora, MD, we expanded the review to include pathophysiology, models to inform care, anticoagulation, rate/rhythm control strategies, and the “then what?” of understanding risk and recurrence after resolution of the episode and hospital discharge. We have presented this work at residency conferences, discussed it on rounds, and applied it to specific clinical scenarios — all of which have sparked further conversations on how we think of AF in the hospital.

Considering that obesity and obstructive sleep apnea are common diagnoses in the US, and high blood pressure — an important cause of an enlarged left atrium — is very common as well, is it reasonable to propose that trigger-induced AF — when history of AF is lacking — should be the primary reason for the event?

It is certainly a consideration, though I would stop short of automatically presuming it to be the event’s primary reason. Numerous possible triggers exist for AF, and importantly, these triggers can be acute and chronic in nature. Eliciting a focused but comprehensive clinical history and performing a detailed physical exam are crucial in such situations to assess for triggers. But no doubt, the prevalence of trigger-induced AF (though not quantified) and its risk for recurrence should not be dismissed.

Do sex differences exist with regard to trigger-induced AF?

I cannot say for certain; one would have to examine every risk factor and trigger for trigger-induced AF and assess for sex differences in each and then make extrapolations based on that. What we do know is that women have lower incidence of AF but are at higher risk when height and/or body size are controlled. A large-scale study would be needed to accurately answer the question. Without better characterization, we won’t be able to find sex differences.

I am going to presume that you instruct fellow resident hospitalists at UCMC. What types of questions are you hearing the most?

The most common questions that I receive on trigger-induced AF center on anticoagulation and rate/rhythm control strategies. These are questions I want to keep hearing because of how individualized the management strategies have to be for each patient and because the answers challenge our conventional approaches to AF. We know we must hone illness scripts and we do so with each patient encounter.

Is there a reason that type 2 diabetes is not listed among the offending triggers in your review, considering the damage it can do to the heart muscle?

Diabetes is certainly a risk factor for AF. I would certainly be interested in exploring the mechanisms underlying its role in AF, especially to consider it as a trigger. It is possible that oxidative stress and inflammatory-mediated remodeling would induce myocardial changes that could trigger AF.

At what point should the hospitalist caring for a person with trigger-induced AF consult with a cardiologist?

I will defer to each hospitalist’s comfort level and clinical judgment regarding when to make the call, but I would advocate for cardiology to be involved in a patient’s care (if they are not already) given the risk for recurrence. But ultimately, each patient needs a multidisciplinary team with a structured approach to care. The 2024 European Society of Cardiology guidelines posit a model called AF-CARE that outlines specific groups to be involved at each of the four tenets, so perhaps the hospitalist could refer to this model when considering cardiology service involvement.

No reported disclosures.