ATRIAL FIBRILLATION Flashcards
MANAGEMENT
DETERMINE STABILITY
Altered Mentation
Hypotension – sBP <90 OR a drop of 30% from their baseline
Cardiac Ischemia / Angina
Decompensated Heart Failure
UNSTABLE
Synchronized cardioversion (150 to 200 J) if onset < 48 hrs or WPW
Consider trial of rate control
PRE-EXCITATION / WPW
Urgent Synchronized cardioversion (150 to 200 J)
Procainamide IV if stable
AV nodal blocking agents contraindicated: digoxin, calcium channel blockers, beta-blockers, adenosine, amiodarone
STABLE HIGH RISK (CAEP):
RATE CONTROL
Clinical Criteria:
No therapeutic OAC > 3 weeks AND
Onset > 48 hrs OR unknown
OR
Stroke/TIA <6 months
OR
Mechanical or Rheumatic Valve
Highly symptomatic
Multiple recurrences
Extreme impairment of quality of life
arrhythmia induced cardiomyopathy
Target <100 bpm at rest, <110 walking
DILTIAZEM
0.25 mg/kg IV over 2 minutes; repeat q15-20 min at 0.35 mg/kg up to 3 doses
Start 30 mg PO within 30 mins of effective IV rate control
Discharge on 30 QID or Extended Release 120-240 mg once daily
C/i: Acute heart failure or LV dysfunction
METOPROLOL
2.5-5 mg IV over 2 minutes, repeat q15-20 min up to 3 doses
Start 25-50 mg PO within 30 mins of effective IV rate control
Discharge on 25-50 mg BID
Preferred in HFrEF
Discharge on OAC x 3 weeks
Early follow up to review long-term OAC
TEE to exclude thrombus then Cardioversion
STABLE LOW RISK (CAEP)
Rhythm Control Preferable: either pharm or electricalcardioversion at 200 J
Clinical Criteria:
Clear onset <48 hrs with no high-risk factors
OR
Therapeutic OAC > 3 weeks
If 24-48 hrs and two or more CHADS-65 criteria, may not be low risk
Shock and then start on anticoagulation and refer
Higher rate of success if within 48 hours
PROCAINAMIDE
15 mg/kg in 500 ml NS over 30-60 minutes
c/i:
avoid if SBP <100 mm Hg or QTc >500 msec
interrupt infusion if BP drops or QRS lengthens visibly (i.e. >30%)
check QTc after conversion
s/e: Hypotension
Bradycardia
Ventricular proarrhythmia
Time to conversion: 1 hr
AMIODARONE
150 mg over 10 minutes → repeat as needed if VT recurs → maintenance infusion of 1mg/min for 8 hours
THEN
0.5 mg/min for 16 hrs
(i.e. 960 mg over 24 hrs)
Indications:
Abnormal VF or CHF
s/e:
Hypotension
Bradycardia
Atrioventricular block
Torsades de pointes
Phlebitis
Time to conversion: 8-12 hrs
INVESTIGATIONS
CBC
Lytes
Extended Lytes (Ca, Mg)
Cr
INR
LFTs
TSH
A1c
Lipids
POST CARDIOVERSION MANAGMENT
CHADS-65:
If >/65 or CHADS2 +ve, start NOAC
APIXABAN
5 mg PO bid
Dose reduction; 2.5 mg po BID if 2 of the 3 following criteria are present: 1) age ≥80 years, 2) body weight ≤60 kg, or 3) serum creatinine ≥133 𝜇mol/L if elderly, frail, renal impairment
c/i CrCl < 30
RIVAROXABAN
CrCl > 50: 20 mg daily
CrCl 30 - 49: 15 mg daily
WARFARIN
5 mg PO daily for 3 days then check INR
Valvular Afib (mechanical prosthetic valve, rheumatic mitral stenosis and moderate - severe non-rheumatic mitral stenosis)
eFGR < 30
DOCUMENTATION
CLINICAL FEATURES
Palpitations
Chest Pain
Dyspnea on exertion
Reduced Exercise Capacity
Syncope / Dizziness
Heart Failure
TRIGGERS
Stimulants
Alcohol
Sleep deprivation
Emotional Stress
Physical Exertion
Sleep/Nocturnal
Digestive
REVERSIBLE CAUSES
Cardiac or non-cardiac surgery
Acute cardiac pathology
Acute pulmonary pathology
Acute infection
Thyrotoxicosis
Alcohol
Pharmacologic agents (e.g. Ibrutinib)
Supraventricular tachycardia
Ventricular pacing
RISK FACTORS
Advancing age
Male sex
Hypertension
HF with reduced ejection fraction
Valvular heart disease
Overt thyroid disease
Obstructive sleep apnea
Obesity
Excessive alcohol intake
Congenital heart disease (e.g. early
repair of atrial septal defect)
ECG CRITERIA
a. Fibrillatory waves of atrial activity best seen in leads V1, V2, V3, and aVf
b. Irregular ventricular response, usually 170 to 180 beats / min
c. Can be paroxysmal, persistent or chronic
CHADS-65
If > 65 -> NOAC
If >/1 point for CHADS2 -> NOAC
If CHADS 65 -ve and CAD or PAD -> Antiplatelet
if CHADS negative with no CAD -> No antithrombotic
ECG DDX
Atrial Flutter with variable AV conduction
Multifocal Atrial Tachycardia
