Atrial fibrillation with RVR: Difference between revisions
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*[[Shortness of breath]] | *[[Shortness of breath]] | ||
*Dyspnea on exersion | *Dyspnea on exersion | ||
*Chest pain | *[[Chest pain]] | ||
*Consider [[WPW]] if: | *Consider [[WPW]] if: | ||
**Wide QRS | **Wide QRS | ||
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Tachycardia (narrow) DDX}} | |||
{{Palpitations DDX}} | {{Palpitations DDX}} | ||
==Evaluation== | ==Evaluation== | ||
[[File:Afib ecg.jpg|thumb|ECG of atrial fibrillation (top) and normal sinus rhythm (bottom). The purple arrow indicates a P wave, which is lost in atrial fibrillation.]] | |||
===Workup=== | |||
*[[ECG]] | *[[ECG]] | ||
*CBC | *Labs | ||
*Chem 10 | **CBC | ||
*[[Troponin]] if patient has chest pain | **Chem 10 | ||
*[[Ultrasound:_Cardiac|Cardiac Echo]] - if signs of new/worsening heart failure | **Consider coags, especially if on anticoagulation | ||
**Consider LFTs | |||
**Consider [[BNP]] if heart failure unclear | |||
**Consider thyroid function tests | |||
**[[Troponin]] if patient has chest pain | |||
*[[Chest XR]] | |||
*Consider [[Ultrasound:_Cardiac|Cardiac Echo]] - if signs of new/worsening heart failure | |||
===Diagnosis=== | |||
[[File:RapidAFib150.jpg|thumb|Atrial fibrillation at approximately 150 beats per minute]] | |||
*Based on [[ECG]] | |||
==Management== | ==Management== | ||
===Unstable=== | ===Unstable=== | ||
*Synchronized cardioversion (100-200J) | *[[Synchronized cardioversion]] (100-200J) | ||
**Atrial fibrillation - start at 200 J | **Atrial fibrillation - start at 200 J | ||
**Atrial flutter - start at 50 J | **Atrial flutter - start at 50 J | ||
*Indications: ischemic chest pain, SBP < 90, acute pulmonary edema, altered mental status | *Indications: ischemic chest pain, SBP < 90, acute pulmonary edema, altered mental status | ||
*Consider cardiostable sedation such as 5mg etomidate | *Consider cardiostable sedation such as 5mg [[etomidate]] | ||
**+/- subdissociative pain dosage ketamine at 15mg | **+/- 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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****50-200mcg q2-5min with goal DBP >60 | ****50-200mcg q2-5min with goal DBP >60 | ||
**[[Amiodarone]] 150mg over 10min (preferably through central venous access) OR [[diltiazem]] 2.5mg/min until HR <100 or max 50mg | **[[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<ref>Kwok MH et al. Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta‐analysis. Heart. 2007 Nov; 93(11): 1433–1440.</ref> | **[[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<ref>Kwok MH et al. Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta‐analysis. Heart. 2007 Nov; 93(11): 1433–1440.</ref> | ||
***Significantly less effective than | ***Significantly less effective than [[amiodarone]] or [[calcium-channel blockers]] | ||
***Ensure baseline magnesium level | ***Ensure baseline magnesium level | ||
***Check magnesium q2hrs if infusing | ***Check magnesium q2hrs if infusing | ||
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===Stable and Symptomatic=== | ===Stable and Symptomatic=== | ||
'''Make sure you are not slowing down a normal physiologic response (e.g. fever, hypoxia, shock, etc.)''' | |||
*Goal <110bpm | |||
**RACE-II trial demonstrated that lenient control (goal HR < 110bpm) was noninferior to strict control (HR < 80 bpm) in preventing the primary outcome<ref>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. [http://www.nejm.org/doi/full/10.1056/NEJMoa1001337 full text]</ref> | **RACE-II trial demonstrated that lenient control (goal HR < 110bpm) was noninferior to strict control (HR < 80 bpm) in preventing the primary outcome<ref>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. [http://www.nejm.org/doi/full/10.1056/NEJMoa1001337 full text]</ref> | ||
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*Bolus 0.25mg/kg (average adult dose 20mg) over 2 min | *Bolus 0.25mg/kg (average adult dose 20mg) over 2 min | ||
*If, after 15min 1st dose is tolerated but inadequate re-bolus 0.35mg/kg | *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 | *If patient responds start infusion at 5-15mg/hr or give PO [[diltiazem]] 60mg QID | ||
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*Preferred in patients with chronic lung such as [[Asthma]] and [[COPD]]<ref>Short PM, Lipworth SI, Elder DH, Schembri S, Lipworth BJ. Effect of | *Preferred in patients with chronic lung such as [[Asthma]] and [[COPD]]<ref>Short PM, Lipworth SI, Elder DH, Schembri S, Lipworth BJ. Effect of β-blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study. BMJ. 2011 May 10;342:d2549</ref> | ||
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*Decompensated heart failure | *Decompensated heart failure | ||
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*Particularly useful when A-fib associated with exercise, after acute [[MI]], or with [[thyrotoxicosis]] | *Particularly useful when A-fib associated with exercise, after acute [[MI]], or with [[thyrotoxicosis]] | ||
*Long-term | *Long-term β-blocker improves patient survival (CCB may worsen outcomes), thus starting a β-blocker upon discharge, strongly consider using the agent for rate control also.<ref>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</ref> | ||
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*[[COPD]] | *[[COPD]] | ||
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*If necessary, infusion can be increased to maximum of 200 µg/kg/min after another four minutes | *If necessary, infusion can be increased to maximum of 200 µg/kg/min after another four minutes | ||
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*Use if unsure whether patient will tolerate a | *Use if unsure whether patient will tolerate a β-blocker since the duration of action is only 10 minutes | ||
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|- | |- | ||
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*Consider as initial therapy for patients with LV dysfunction who: | *Consider as initial therapy for patients with LV dysfunction who: | ||
**Do not achieve rate control targets on | **Do not achieve rate control targets on β-blockers alone | ||
**Cannot tolerate addition of or increased doses of | **Cannot tolerate addition of or increased doses of β-blocker due to decompensated [[CHF]] | ||
**Would have [[digoxin]] added anyway to improve [[CHF]] symptoms independent of A-fib | **Would have [[digoxin]] added anyway to improve [[CHF]] symptoms independent of A-fib | ||
*Consider as initial therapy in patients with severe hypotension | *Consider as initial therapy in patients with severe hypotension | ||
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*Consider for patients with decompensated heart failure or those with accessory pathways | *Consider for patients with decompensated heart failure or those with accessory pathways | ||
*2nd-line agent for chronic rate control when [[ | *2nd-line agent for chronic rate control when [[beta-blockers]] and [[calcium-channel blockers]], alone, combined, or when used with [[digoxin]], are ineffective | ||
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|- | |||
| [[Magnesium sulfate]]|| | |||
*4.5 IV over 30 min<ref>Bouida W et al. Low-dose Magnesium Sulfate Versus High Dose in the Early Management of Rapid Atrial Fibrillation: Randomized Controlled Double-blind Study (LOMAGHI Study). Acad Emerg Med 2018 Feb;26(2):183-191.</ref> | |||
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*IV MgSO4 appears to have a synergistic effect when combined with other AV nodal blockers resulting in improved rate control. | |||
*Given in conjunction with [[beta-blockers]] and [[calcium-channel blockers]]. | |||
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|} | |} | ||
===Evidence of preexcitation=== | ===Evidence of preexcitation (slurred upstroke of QRS complex, wide QRS complex >120 msec, short PR interval <120msec)=== | ||
*Avoid AV nodal agents | *Avoid AV nodal agents | ||
*Unstable: | *Unstable: | ||
** | **[[Synchronized cardioversion]] (120-200 joules for biphasic waveforms, 200 joules for monophasic waveforms) | ||
* | *Stable <ref> Page RL et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2016;133(14) </ref>: | ||
** | **[[Procainamide]] (17 mg/kg loading dose at 20 to 50 mg/minutes or 100mg every 5 minutes, maintenance infusion 1 to 4 mg/minute) <ref> Neumar RW, Otto CW, Link MS, et al, "Part 8: Adult Advanced Cardiovascular Life Support:2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care," Circulation, 2010, 122:729-67. </ref> | ||
* | **[[Ibutilide]] (1mg over 10 minutes, repeat 10 minute infusion can be given) | ||
**Avoid [[amiodarone]], does not slow accessory pathway and has beta blocking properties, may increase conduction via accessory pathway | |||
**[[Cardioversion]], consider sedation prior | |||
**Avoid AV nodal blocking agents ([[diltiazem]], [[metoprolol]]) as can lead to [[ventricular fibrillation]]/tachycardia | |||
**Try to avoid [[cardioversion]] without adequate anticoagulation | **Try to avoid [[cardioversion]] without adequate anticoagulation | ||
==Disposition== | |||
==See Also== | ==See Also== |
Revision as of 02:11, 16 August 2019
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
Narrow-complex tachycardia
- Regular
- AV Node Independent
- Sinus tachycardia
- Atrial tachycardia (uni-focal or multi-focal)
- Atrial fibrillation
- Atrial flutter
- Idiopathic fascicular left ventricular tachycardia
- AV Node Dependent
- AV Node Independent
- Irregular
- Multifocal atrial tachycardia (MAT)
- Sinus tachycardia with frequent PACs, PJCs, PVCs
- Atrial fibrillation
- Atrial flutter with variable conduction
- Digoxin Toxicity
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
Evaluation
Workup
- ECG
- Labs
- Chest XR
- Consider Cardiac Echo - if signs of new/worsening heart failure
Diagnosis
- Based on ECG
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, altered mental status
- 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 amiodarone or calcium-channel blockers
- 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
Make sure you are not slowing down a normal physiologic response (e.g. fever, hypoxia, shock, etc.)
- Goal <110bpm
- 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 |
|
|
|||
Magnesium sulfate |
|
|
Evidence of preexcitation (slurred upstroke of QRS complex, wide QRS complex >120 msec, short PR interval <120msec)
- Avoid AV nodal agents
- Unstable:
- Synchronized cardioversion (120-200 joules for biphasic waveforms, 200 joules for monophasic waveforms)
- Stable [15]:
- Procainamide (17 mg/kg loading dose at 20 to 50 mg/minutes or 100mg every 5 minutes, maintenance infusion 1 to 4 mg/minute) [16]
- Ibutilide (1mg over 10 minutes, repeat 10 minute infusion can be given)
- Avoid amiodarone, does not slow accessory pathway and has beta blocking properties, may increase conduction via accessory pathway
- Cardioversion, consider sedation prior
- Avoid AV nodal blocking agents (diltiazem, metoprolol) as can lead to ventricular fibrillation/tachycardia
- Try to avoid cardioversion without adequate anticoagulation
Disposition
See Also
External Links
- ALiEM - BB vs CCB
- Crashing Afib - EMCrit
- Diltiazem load: File:dilt-load.pdf[17]
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 β-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.
- ↑ Bouida W et al. Low-dose Magnesium Sulfate Versus High Dose in the Early Management of Rapid Atrial Fibrillation: Randomized Controlled Double-blind Study (LOMAGHI Study). Acad Emerg Med 2018 Feb;26(2):183-191.
- ↑ Page RL et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2016;133(14)
- ↑ Neumar RW, Otto CW, Link MS, et al, "Part 8: Adult Advanced Cardiovascular Life Support:2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care," Circulation, 2010, 122:729-67.
- ↑ http://ehced.org/wp-content/site/Drips/dilt-load.pdf