Triggered Atrial Fibrillation

Triggered atrial fibrillation (AF) means that the AF episode has a clear trigger.

It is most often diagnosed based on symptoms that the patient experiences immediately after the trigger,

The most common AF triggers include an acute critical or high-risk condition.

Sepsis causes AF in up to 20–46% of patients who have not had AF before.

Acute critical condition

This is an acute, life-threatening condition that usually develops within < 24 h.
Patients must be hospitalized in an intensive care unit

Acute critical condition and incidence of atrial fibrillation (AF)
Acute critical condition	Incidence of AF (%)
Cardiac surgery	30 – 60 %
Acute heart failure	25 – 50 %
Sepsis	20 – 46 %
Acute respiratory distress syndrome (ARDS)	20 – 40 %
Stroke	10 – 30 %
Myocardial infarction (STEMI / NSTEMI)	10 – 22 %
Patients in ICU	5 – 25 %
Pulmonary embolism	5 – 15 %
Major bleeding	3 – 5 %

Acute high-risk condition

This is a sudden, significant change in the patient’s condition that developed within < 24 h.
Patients usually provoke the high-risk condition themselves.

Acute high-risk condition and incidence of atrial fibrillation (AF)
Acute high-risk condition	Incidence of AF (%)
Alcohol excess	20 – 30 %
Drug use (cocaine, methamphetamine, ecstasy)	5 – 15 %
Extreme physical exertion	2 – 4 %
Extreme stress	2 – 4 %
Excessive sun exposure	1 – 3 %
Coffee excess	1 – 2 %
Energy drink excess	1 – 2 %
Drug use (marijuana)	1 – 2 %

In clinical practice, however, it usually does not apply that removing the trigger will eliminate AF.

Triggered AF with episodes occurring only after a known trigger is very rare.

If we unequivocally confirm triggered AF in a patient based on a loop recorder,

and after elimination of the trigger (e.g. alcohol, energy drinks, extreme physical exertion) there are no AF episodes,
then discontinuation of anticoagulation therapy may be considered (if it was indicated in the patient).

Treatment of triggered AF is elimination of the trigger (if possible) and management according to the SKC algorithm.

In clinical practice, however, it usually does not apply that removing the trigger will eliminate AF.
Only AF episodes that occur after the trigger are eliminated.

Triggered and “standard” AF have the same risk of thromboembolism.

Because triggered AF often also includes AF episodes that are not linked to a trigger and are asymptomatic.

Anticoagulation therapy in triggered AF is indicated according to the CHA₂DS₂-VA score.

Triggered atrial fibrillation	Class
In triggered AF, anticoagulation therapy is indicated according to the CHA₂DS₂-VA score.	I
If triggered AF is suspected, an ECG should be recorded during symptoms using an ECG smart device (ECG watch, blood pressure monitor with ECG, ECG card).	IIa
Discontinuation of anticoagulation therapy may be considered if a clear trigger has been eliminated (alcohol excess, sepsis, stress, energy drinks).	IIb
Implantation of a loop recorder may be considered to definitively confirm triggered AF.	IIb