Familial Atrial Fibrillation

22-year-old male woke up with palpitations to his local ID in atrial fibrillation with RVR.  He noticed that when he woke up his heart was racing.  Patient drank a couple of beers the night before.  He was placed on a Cardizem drip and start on oral beta-blocker and admitted to the ICU

Family history: Father had atrial fibrillation when he was 21.

Vital signs blood pressure 117/72 heart rate 62 respirations 20 temperature 98 on room air
Notable labs White count 10.8, hemoglobin 17.2, platelet count 244, d-dimer less than 0.19 mg/L, potassium 3.4, total protein 8.7, TSH 2.55 drug screen negative hepatitis C antibody negative, troponin less than 0.017

Patient likely has familial atrial fibrillation:

This is an autosomal dominant disorder .The first single gene found to be associated with familial atrial fibrillation was KCNQ1, which provides instructions for making a channel that is embedded in the outermembrane of cardiac muscle cells.

How would you treat such a young patient ?

Get stat echocardiogram to rule out structural heart disease, obstructive coronary artery disease would be extremely unlikely, check TSH and if patient  he has no structural heart disease would give 300 mg of flecainide  PO x1, type Ic antiarrhythmic on Cardizem, after correction of all electrolytes and likely patient will cardiovert back to normal sinus rhythm as new onset.

Would watch patient for 4 hours for pro-arrhythmias.  Patient can then be discharged same day and given instructions on how to use pill in the pocket approach [i.e take 300 mg of by mouth flecainide ×1 or 600 mg propafenone, but the latter has also beta blockade effect, while on either a beta-blocker or calcium channel blocker].  I would not put the chronically on an antiarrhythmic drug, especially note amiodarone, but continue Cardizem after his converted.

Never give a type Ic antiarrhythmic without use of either calcium channel blocker or beta-blocker prior to given flecainide or propafenone.  This can lead to one-to-one conduction and ventricular rate of 300 bpm and cardiac arrest secondary to V. fib

 Beta-blockers are usually not well tolerated in young men This approach would also avoid any need for anticoagulation at any point.  It is a real case with the patient came in on Saturday morning, but then approach was chosen to keep him until Monday morning for possible electrical cardioversion if he did not spontaneously convert with Cardizem IV/by mouth beta-blocker .  The downside of this approach is that the patient is for at least 2 days in the hospital if not 3.
If an episode happens again he will have to come back to the emergency room, while with the above approach he can treat himself.

Obtain a single lead tracing at the time of atrial fibrillation and another one after he has converted and forward tracings to his physician.  If he does not convert then he can go to the emergency room.

Therefore I always recommend for the patient to obtain an AliveCor monitor so he can tell when is in atrial fibrillation and can forward this in a HIPAA compliant way to his cardiologist.
There is no reason reason to follow this with an apple watch and more expensive devices.

Presenting this case not so much from the perspective of familial atrial fibrillation, although this is also an interesting observation.  In this vignette , like to point out why we have such an expensive health care system.  I am not sure how a case like this would be handled in Europe now, but doubt the patient would have to stay overnight.  Now you are talking about 2-3 days in the hospital, possible electrical cardioversion and no future on hand treatment for the patient if this should recur in a couple of weeks requiring trip back to the ER.