Atrial fibrillation with RVR: Difference between revisions
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**Atrial flutter - start at 50 J | **Atrial flutter - start at 50 J | ||
*Indications: ischemic chest pain, SBP < 90, acute pulmonary edema, AMS | *Indications: ischemic chest pain, SBP < 90, acute pulmonary edema, AMS | ||
*Consider cardiostable sedation such as | *Consider cardiostable sedation such as 5mg etomidate | ||
**+/- subdissociative pain dosage ketamine at | **+/- subdissociative pain dosage ketamine at 15mg | ||
*If shock does not work: | *If shock does not work: | ||
**Verify not preexcitation | **Verify not preexcitation | ||
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| [[Diltiazem]]|| | | [[Diltiazem]]|| | ||
*Bolus 0. | *Bolus 0.25mg/kg (average adult dose 20mg) over 2 min | ||
*If, after 15min 1st dose is tolerated but inadequate re-bolus 0. | *If, after 15min 1st dose is tolerated but inadequate re-bolus 0.35mg/kg | ||
*If patient responds start infusion at 5-15mg/hr or give PO dilt 30mg QID | *If patient responds start infusion at 5-15mg/hr or give PO dilt 30mg QID | ||
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| [[Esmolol]]|| | | [[Esmolol]]|| | ||
*Bolus 0. | *Bolus 0.5mg/kg over one minute, followed by 50 µg/kg/min | ||
*If, after 4min response is inadequate, re-bolus followed by infusion of 100 µg/kg/min | *If, after 4min response is inadequate, re-bolus followed by infusion of 100 µg/kg/min | ||
*If, after 4min response is still inadequate, try final bolus followed by infusion of 150 µg/kg/min | *If, after 4min response is still inadequate, try final bolus followed by infusion of 150 µg/kg/min | ||
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| [[Digoxin]]|| | | [[Digoxin]]|| | ||
*0. | *0.25mg IV q2hr up to 1.5mg, then 0.125-0.25mg PO or IV QD | ||
*Adjust dose in presence of renal failure, amiodarone, etc | *Adjust dose in presence of renal failure, amiodarone, etc | ||
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Revision as of 03:19, 19 July 2016
Background
Atrial fibrillation categories[1]
Atrial Fibrillation Category | Definition |
Paroxysmal |
|
Persistent |
|
Long-standing persistent |
|
Permanent |
|
Nonvalvular |
|
With Rapid Ventricular Response (RVR) |
|
Causes of atrial fibrillation
- Cardiac (atrial enlargement)
- Hypertension
- Ischemic heart disease
- Rheumatic heart disease
- Valvular heart disease (any lesion that leads to significant stenosis or regurgitation)
- Noncardiac (increased automaticity)
- Thyrotoxicosis
- Chronic lung disease
- Pericarditis
- Ethanol ("holiday heart")
- Pulmonary embolism
- Pneumonia
- Drugs (cocaine, TCA, Milk of the Poppy)
Clinical Features
- Palpitations
- Shortness of breath
- Dyspnea on exersion
- Chest pain
- Consider WPW if:
- Wide QRS
- Rate approaching 300 bpm
Differential Diagnosis
Palpitations
- Arrhythmias:
- Non-arrhythmic cardiac causes:
- Psychiatric causes:
- Drugs and Medications:
- Alcohol
- Caffeine
- Drugs of abuse (e.g. cocaine)
- Medications (e.g. digoxin, theophylline)
- Tobacco
- Misc
Diagnosis
- ECG
- CBC
- Chem 10
- Troponin if patient has chest pain
- Cardiac Echo - if signs of new/worsening heart failure
Management
Unstable
- Synchronized cardioversion (100-200J)
- Atrial fibrillation - start at 200 J
- Atrial flutter - start at 50 J
- Indications: ischemic chest pain, SBP < 90, acute pulmonary edema, AMS
- Consider cardiostable sedation such as 5mg etomidate
- +/- subdissociative pain dosage ketamine at 15mg
- If shock does not work:
- Verify not preexcitation
- Increase diastolic BP to perfuse the heart
- Push-dose phenylephrine
- Will maintain BP when give rate-control meds
- 50-200mcg q2-5min with goal DBP >60
- Push-dose phenylephrine
- Amiodarone 150mg over 10min (preferably through central venous access) OR diltiazem 2.5mg/min until HR <100 or max 50mg
- Magnesium 2 g over 1-5 min, repeat if no response after 15 min, then consider 1-2 g/h for 4 hrs if response[2]
- Significantly less effective than amio or CCBs
- Ensure baseline magnesium level
- Check magnesium q2hrs if infusing
Stable and Asymptomatic
If mild or no symptoms and pulse only mildly elevated (<110bpm) ok to manage with PO meds
Stable and Symptomatic
- Goal <110bpm
- Make sure you are not slowing down a normal physiologic response (e.g. fever, hypoxia, etc)
- RACE-II trial demonstrated that lenient control (goal HR < 110bpm) was noninferior to strict control (HR < 80 bpm) in preventing the primary outcome[3]
Cardioversion
- Consider for:[4]
- Symptoms <48hr
- New diagnosis
- No history of similar episodes
- No LV dysfunction
- No mitral valve disease
- No prior thromboembolic event
- Already Anticoagulated
- If cardioversion is considered, pretreatment with rate or rhythm control medications can reduce effectiveness[5]
- 90% effective, 60% effective with pretreatment
Anticoagulation Prior to Cardioversion
- Anticoagulation with Heparin or LMWH should be considered before cardioversion if time permits, otherwise immediately after cardioversion. (unless you are sure it has been <48 hours since onset of afib) [6][7] [8]
- Generally cardioversion while anti-coagulated is believed to be safe with a 1.3% risk of thromboembolism if on aspirin or other anticoagulant[9] However the risk may be as great as 2% risk after 48 hours and preference should be given to anticoagulation prior to cardioversion in longer cases[10]
Medication Choices
Medication | Dose | Comments | Contraindications | ||
Calcium-Channel Blockers | |||||
---|---|---|---|---|---|
Diltiazem |
|
| |||
Beta-Blockers | |||||
Metoprolol |
|
|
|||
Esmolol |
|
|
|||
Other | |||||
Digoxin |
|
|
|||
Amiodarone |
|
Evidence of preexcitation
- Avoid AV nodal agents
- Unstable:
- Unsynchronized cardioversion (200J)
- Procainamide (if cardioversion unsuccessful)
- 20-50mg/min until arrhythmia is controlled, hypotension occurs, QRS complex widens by 50% of original width, or total of 17mg/kg is given; followed by continuous infusion of 1-4 mg/min
- Stable:
- Try to avoid cardioversion without adequate anticoagulation
See Also
External Links
- ALiEM - BB vs CCB
- Crashing Afib - EMCrit
- Diltiazem load: File:dilt-load.pdf[14]
References
- ↑ 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary. J Am Coll Cardiol. 2014;64(21):2246-2280. doi:10.1016/j.jacc.2014.03.021
- ↑ Kwok MH et al. Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta‐analysis. Heart. 2007 Nov; 93(11): 1433–1440.
- ↑ Van Gelder IC et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010 Apr 15;362(15):1363-73. full text
- ↑ Ottowa Aggressive Protocol
- ↑ Blecher GE, et al. Use of rate control medication before cardioversion of recent-onset atrial fibrillation or flutter in the emergency department is associated with reduced success rates. CJEM. 2012;14(3):169-177.
- ↑ You JJ, Singer DE, Howard PA, Lane DA, Eckman MH, Fang MC, Hylek EM, Schulman S, Go AS, Hughes M, Spencer FA, Manning WJ, Halperin JL, Lip GY. Antithrombotic therapy for atrial fibrillation: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e531S-75S
- ↑ FusterV et al;American Collegeof Cardiology/ American Heart Association Task Force on Practice Guidelines; European Society of Cardiology Committee for Practice Guidelines; European Heart Rhythm Association; Heart Rhythm Society. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006;114(7):e257-e354.
- ↑ Camm AJ, Kirchhof P, Lip GY, et al; European Heart Rhythm Association; European Association for Cardio-Thoracic Surgery. Guidelines for the management of atrial fibrillation: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010;31(19):2369-2429.
- ↑ 48hr Cardioversion for A.fib.
- ↑ Nuotio I. et al. Time to cardioversion for acute atrial fibrillation and thromboembolic complications. JAMA. 2014 Aug 13;312(6):647-9
- ↑ Short PM, Lipworth SI, Elder DH, Schembri S, Lipworth BJ. Effect of beta blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study. BMJ. 2011 May 10;342:d2549
- ↑ Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet. 1999 Jun 12;353(9169):2001-7Effect of verapamil on mortality and major events after acute myocardial infarction (the Danish Verapamil Infarction Trial II–DAVIT II). Am J Cardiol. 1990 Oct 1;66(10):779-85
- ↑ Khan IA et al. Amiodarone for pharmacological cardioversion of recent-onset atrial fibrillation. Int J Cardiol. 2003 Jun;89(2-3):239-48.
- ↑ http://ehced.org/wp-content/site/Drips/dilt-load.pdf