Atrial fibrillation resident survival guide: Difference between revisions
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:❑ [[Angina pectoris]] | :❑ [[Angina pectoris]] | ||
❑ Administer long term anticoagulation therapy based on the risk of stroke | ❑ Administer long term anticoagulation therapy based on the risk of stroke | ||
:❑ Measure INR weekly initially, then monthly when stable ([[ACC AHA guidelines classification scheme| | :❑ Measure INR weekly initially, then monthly when stable ([[ACC AHA guidelines classification scheme|class I, level of evidence A]]) | ||
:❑ Reassess need for anticoagulation at periodic intervals ([[ACC AHA guidelines classification scheme| | :❑ Reassess need for anticoagulation at periodic intervals ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]]) </div> | ||
| D02= <div style="float: left; text-align: left; width: 25em; padding:1em;"> | | D02= <div style="float: left; text-align: left; width: 25em; padding:1em;"> | ||
❑ Administer long term anticoagulation therapy based on the risk of stroke<br> | ❑ Administer long term anticoagulation therapy based on the risk of stroke<br> | ||
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| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center; colspan="3" | '''''Heart rate control in patients without [[accessory pathway]]''''' | | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center; colspan="3" | '''''Heart rate control in patients without [[accessory pathway]]''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Esmolol]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Esmolol]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence C]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''500 mcg/kg IV over 1 min''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''60 to 200 mcg/kg/min IV''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Propanolol]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Propanolol]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence C]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''0.15 mg/kg IV''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''NA''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Metoprolol]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Metoprolol]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence C]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''2.5 to 5 mg IV bolus over 2 min; up to 3 doses''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''NA''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Diltiazem]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Diltiazem]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence B]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''0.25 mg/kg IV over 2 min''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''5 to 15 mg/h IV''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Verapamil]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Verapamil]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence B]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''0.075 to 0.15 mg/kg IV over 2 min''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''NA''''' | ||
|- | |- | ||
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center; colspan="3" | '''''Heart rate control in patients with [[accessory pathway]]''''' | | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center; colspan="3" | '''''Heart rate control in patients with [[accessory pathway]]''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amiodarone]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amiodarone]] <br>([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''150 mg over 10 min''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''0.5 to 1 mg/min IV''''' | ||
|- | |- | ||
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center; colspan="3" | '''''Heart Rate Control in patients with [[heart failure]] and without [[accessory pathway]]''''' | | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center; colspan="3" | '''''Heart Rate Control in patients with [[heart failure]] and without [[accessory pathway]]''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Digoxin]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Digoxin]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence B]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''0.25 mg IV each 2 h, up to 1.5 mg''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''0.125 to 0.375 mg daily IV or orally''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amiodarone]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amiodarone]] <br>([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''150 mg over 10 min''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''0.5 to 1 mg/min IV''''' | ||
|- | |- | ||
| style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center colspan="3"| {{fontcolor|#FFF|'''Heart Rate Control in Non Acute Setting and Long Term Maintenance'''}} | | style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center colspan="3"| {{fontcolor|#FFF|'''Heart Rate Control in Non Acute Setting and Long Term Maintenance'''}} | ||
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| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center; colspan="3" | '''''Heart rate control''''' | | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center; colspan="3" | '''''Heart rate control''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Metoprolol]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Metoprolol]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence C]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''25 to 100 mg twice a day, orally''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''25 to 100 mg twice a day, orally''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Propanolol]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Propanolol]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence C]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''80 to 240 mg daily in divided doses, orally''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''80 to 240 mg daily in divided doses, orally''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Verapamil]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Verapamil]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence B]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''120 to 360 mg daily in divided doses, orally''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''120 to 360 mg daily in divided doses, orally''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Diltiazem]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Diltiazem]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence B]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''120 to 360 mg daily in divided doses, orally''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''120 to 360 mg daily in divided doses, orally''''' | ||
|- | |- | ||
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center; colspan="3" | '''''Heart Rate Control in patients with heart failure and without accessory pathway''''' | | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center; colspan="3" | '''''Heart Rate Control in patients with heart failure and without accessory pathway''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Digoxin]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Digoxin]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence B]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''0.5 mg by mouth daily''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''0.125 to 0.375 mg daily, orally''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amiodarone]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amiodarone]] <br>([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]])''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''800 mg daily for 1 week, orally <br> 600 mg daily for 1 week, orally <br> 400 mg daily for 4 to 6 week, orally''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''200 mg daily, orally''''' | ||
|- | |- | ||
|} | |} | ||
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| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Drug''' || style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Dosage''' | | style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Drug''' || style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Dosage''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Dofetilide]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Dofetilide]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence A]]) ''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''Oral dose depends on creatinine clearance (ml/min): '''''<br> | ||
:▸ '''''> 60: 500 mg, BID '''''<br> | :▸ '''''> 60: 500 mg, BID '''''<br> | ||
:▸ '''''40 to 60: 250 mg, BID '''''<br> | :▸ '''''40 to 60: 250 mg, BID '''''<br> | ||
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:▸ '''''< 20: contraindicated''''' | :▸ '''''< 20: contraindicated''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Flecainide]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Flecainide]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence A]]) ''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ ''''' Oral: 200 to 300 mg <br> ▸ Intravenous: 1.5 to 3.0 mg/kg, over 10 to 20 min''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ibutilide]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ibutilide]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence A]]) ''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''Intravenous: 1 mg over 10 min, repeat 1 mg if necessary''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Propafenone]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Propafenone]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence A]]) ''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ ''''' Oral: 600 mg <br> ▸ Intravenous: 1.5 to 2.0 mg/kg, over 10 to 20 min''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amiodarone]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amiodarone]] <br>([[ACC AHA guidelines classification scheme|class IIa, level of evidence A]]) ''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ ''''' Oral:''''' | ||
: '''''Inpatient'''''<br> | : '''''Inpatient'''''<br> | ||
:▸ '''''1.2 to 1.8 g per day in divided dose until a maximum of 10 g '''''<br> | :▸ '''''1.2 to 1.8 g per day in divided dose until a maximum of 10 g '''''<br> | ||
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| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Drug''' || style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Dosage''' | | style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Drug''' || style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Dosage''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Dofetilide]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Dofetilide]] <br>([[ACC AHA guidelines classification scheme|class I, level of evidence A]]) ''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''Oral dose depends on creatinine clearance (ml/min): '''''<br> | ||
:▸ '''''> 60: 500 mg, BID '''''<br> | :▸ '''''> 60: 500 mg, BID '''''<br> | ||
:▸ '''''40 to 60: 250 mg, BID '''''<br> | :▸ '''''40 to 60: 250 mg, BID '''''<br> | ||
Line 345: | Line 345: | ||
:▸ '''''< 20: contraindicated''''' | :▸ '''''< 20: contraindicated''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ibutilide]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ibutilide]] <br>([[ACC AHA guidelines classification scheme|class IIa, level of evidence A]]) ''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''Intravenous: 1 mg over 10 min; repeat 1 mg when necessary''''' | ||
|- | |- | ||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amiodarone]] <br>([[ACC AHA guidelines classification scheme| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amiodarone]] <br>([[ACC AHA guidelines classification scheme|class IIa, level of evidence A]]) ''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ ''''' Oral:''''' | ||
: '''''Inpatient'''''<br> | : '''''Inpatient'''''<br> | ||
:▸ '''''1.2 to 1.8 g per day in divided dose until a maximum of 10 g '''''<br> | :▸ '''''1.2 to 1.8 g per day in divided dose until a maximum of 10 g '''''<br> | ||
Line 364: | Line 364: | ||
====Rate Control==== | ====Rate Control==== | ||
* Begin therapy with either a [[beta blocker]], [[diltiazem]], or [[verapamil]] ([[ACC AHA guidelines classification scheme| | * Begin therapy with either a [[beta blocker]], [[diltiazem]], or [[verapamil]] ([[ACC AHA guidelines classification scheme|class I, level of evidence B]]). Use a combination of [[digoxin]] and either a [[beta blocker]], [[diltiazem]], or [[verapamil]] if AF is not controlled by monotherapy ([[ACC AHA guidelines classification scheme|class IIa, level of evidence B]]). | ||
* Administer [[Catheter ablation|ablation]] of the [[AV node|arterioventricular (AV) node]] or [[accessory pathway]] if pharmacological therapy is insufficient ([[ACC AHA guidelines classification scheme| | * Administer [[Catheter ablation|ablation]] of the [[AV node|arterioventricular (AV) node]] or [[accessory pathway]] if pharmacological therapy is insufficient ([[ACC AHA guidelines classification scheme|class IIa, level of evidence B]]). | ||
* If rate is not controlled by the above measures administer oral or IV [[amiodarone]] either alone or in combination with other agents ([[ACC AHA guidelines classification scheme| | * If rate is not controlled by the above measures administer oral or IV [[amiodarone]] either alone or in combination with other agents ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]]). | ||
====Antithrombotic Therapy==== | ====Antithrombotic Therapy==== | ||
* [[Dabigatran]] may be administered as an alternative to [[warfarin]] in patients who do not have any of the following ([[ACC AHA guidelines classification scheme| | * [[Dabigatran]] may be administered as an alternative to [[warfarin]] in patients who do not have any of the following ([[ACC AHA guidelines classification scheme|class I, level of evidence B]]): | ||
:* [[Prosthetic heart valve]] | :* [[Prosthetic heart valve]] | ||
:* Hemodynamically significant valve disease | :* Hemodynamically significant valve disease | ||
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:* Advanced liver disease (impaired baseline clotting function) | :* Advanced liver disease (impaired baseline clotting function) | ||
* Administer [[anticoagulants]] 3 weeks prior to and 4 weeks after [[cardioversion]] for patients with unknown duration of AF or AF for > 48 hours ([[ACC AHA guidelines classification scheme| | * Administer [[anticoagulants]] 3 weeks prior to and 4 weeks after [[cardioversion]] for patients with unknown duration of AF or AF for > 48 hours ([[ACC AHA guidelines classification scheme|class I, level of evidence B]]). Patients who require immediate cardioversion should be administered IV [[heparin]] followed by 4 weeks of oral anticoagulant therapy. | ||
* If a patient is on anticoagulants for AF develops [[stroke]] or systemic [[embolism]], target [[INR]] may be raised to 3.0 - 3.5 ([[ACC AHA guidelines classification scheme| | * If a patient is on anticoagulants for AF develops [[stroke]] or systemic [[embolism]], target [[INR]] may be raised to 3.0 - 3.5 ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]]). | ||
* Anticoagulation therapy can be interrupted for up to 1 week if patients require a procedure that carries an elevated risk of bleeding ([[ACC AHA guidelines classification scheme| | * Anticoagulation therapy can be interrupted for up to 1 week if patients require a procedure that carries an elevated risk of bleeding ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]]). If anticoagulation therapy has to be interrupted for more than 1 week, [[heparin|unfractionated]] or [[LMWH|low molecular weight heparin]] may be given intravenously ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]]). | ||
====Cardioversion==== | ====Cardioversion==== | ||
* Use a rate control agent such as [[beta blocker]], [[diltiazem]] or [[verapamil]] before initiating [[antiarrhythmic]] medication to prevent rapid AV conduction ([[ACC AHA guidelines classification scheme| | * Use a rate control agent such as [[beta blocker]], [[diltiazem]] or [[verapamil]] before initiating [[antiarrhythmic]] medication to prevent rapid AV conduction ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]]). | ||
* Perform cardioversion immediately in patients with AF pf less than 48 hours duration without a need for anticoagulation ([[ACC AHA guidelines classification scheme| | * Perform cardioversion immediately in patients with AF pf less than 48 hours duration without a need for anticoagulation ([[ACC AHA guidelines classification scheme|class I, level of evidence C]]). | ||
* [[Transesophageal echocardiography]] may be used to search for [[thrombus]] prior to [[cardioversion]]. If no thrombus is detected, the patient may be treated with 4 weeks of anticoagulants after the procedure ([[ACC AHA guidelines classification scheme| | * [[Transesophageal echocardiography]] may be used to search for [[thrombus]] prior to [[cardioversion]]. If no thrombus is detected, the patient may be treated with 4 weeks of anticoagulants after the procedure ([[ACC AHA guidelines classification scheme|class IIa, level of evidence B]]). If a thrombus is detected, anticoagulant therapy 3 weeks prior and 4 weeks after cardioversion is required ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]]). | ||
==Don't== | ==Don't== | ||
* Do not wait to give [[anticoagulants]] in a patient with [[hemodynamic instability]], perform [[cardioversion]] immediately. Administer IV [[unfractionated heparin]] or SC injection of a [[LMWH|low-molecular-weight heparin]]. | * Do not wait to give [[anticoagulants]] in a patient with [[hemodynamic instability]], perform [[cardioversion]] immediately. Administer IV [[unfractionated heparin]] or SC injection of a [[LMWH|low-molecular-weight heparin]]. | ||
* Don't use [[digoxin]] as a single agent for rate control in patients with paroxysmal AF ([[ACC AHA guidelines classification scheme| | * Don't use [[digoxin]] as a single agent for rate control in patients with paroxysmal AF ([[ACC AHA guidelines classification scheme|class III, level of evidence B]]). | ||
* Do not attempt [[catheter ablation]] unless a trial of medication to control ventricular rate has been made ([[ACC AHA guidelines classification scheme| | * Do not attempt [[catheter ablation]] unless a trial of medication to control ventricular rate has been made ([[ACC AHA guidelines classification scheme|class III, level of evidence C]]). | ||
* Do not give IV [[Calcium channel blocker|nondihydropyridine calcium channel antagonist]] in a patient with decompensated [[heart failure]] and AF. | * Do not give IV [[Calcium channel blocker|nondihydropyridine calcium channel antagonist]] in a patient with decompensated [[heart failure]] and AF. | ||
* Do not use [[digoxin]] and [[sotalol]] for [[Cardioversion|pharmacological cardioversion]] of AF ([[ACC AHA guidelines classification scheme| | * Do not use [[digoxin]] and [[sotalol]] for [[Cardioversion|pharmacological cardioversion]] of AF ([[ACC AHA guidelines classification scheme|class III, level of evidence A]]). | ||
* Do not start [[quinidine]], [[procainamide]], [[disopyramide]], and [[dofetilide]] in out of hospital setting ([[ACC AHA guidelines classification scheme| | * Do not start [[quinidine]], [[procainamide]], [[disopyramide]], and [[dofetilide]] in out of hospital setting ([[ACC AHA guidelines classification scheme|class III, level of evidence B]]). | ||
* Do not perform repeated electric cardioversion in those with short periods of normal sinus rhythm in between ([[ACC AHA guidelines classification scheme| | * Do not perform repeated electric cardioversion in those with short periods of normal sinus rhythm in between ([[ACC AHA guidelines classification scheme|class III, level of evidence C]]). | ||
* Do not perform electric cardioversion in those with [[digitalis toxicity]] and/or [[hypokalemia]] ([[ACC AHA guidelines classification scheme| | * Do not perform electric cardioversion in those with [[digitalis toxicity]] and/or [[hypokalemia]] ([[ACC AHA guidelines classification scheme|class III, level of evidence C]]). | ||
* Don't use [[calcium channel blocker]], [[beta blocker]], and [[digoxin]] in atrial fibrillation patients with [[WPW]]. | * Don't use [[calcium channel blocker]], [[beta blocker]], and [[digoxin]] in atrial fibrillation patients with [[WPW]]. | ||
Revision as of 21:21, 9 March 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]; Hilda Mahmoudi M.D., M.P.H.[3]; Priyamvada Singh, M.D. [4]; Rim Halaby, M.D. [5]
Synonyms and keywords: AF, Afib
Definitions
Atrial fibrillation is a supraventricular tachyarrhythmia characterized by uncoordinated atrial activation leading to an irregularly irregular rhythm and absent P waves on ECG.
▸ Paroxysmal | AF lasting < 7 days (mostly < 24 hours), usually self terminating |
▸ Persistent | AF lasting > 7 days, usually does not terminate on its own |
▸ Permanent | AF lasting for a longer period, an attempted cardioversion has failed or promises no improvement |
▸ Lone AF | AF in patients > 60 years without any pre-existing cardiopulomunary diseases |
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Atrial fibrillation can be a life-threatening condition and must be treated as such irrespective of the causes.
Common Causes
- Alcohol abuse
- Congestive heart failure
- Coronary artery disease
- Dehydration
- Electrolyte disturbance
- Hypertensive heart disease
- Hyperthyroidism
- Hypothermia
- Hypoxia
- Myocardial infarction[1]
- Myocarditis
- Pericarditis
- Pulmonary embolism[2]
- Rheumatic heart disease
- Uremic pericarditis
Management
Shown below is an algorithm summarizing the initial approach to atrial fibrillation.
Characterize the symptoms:
Characterize the timing of the symptoms:
❑ Duration
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Identify possible triggers: | ||||||||||||||||||
❑ Examine the patient ❑ Order an EKG ♦ Atrial fibrillation rhythm
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❑ Order a transthoracic echocardiogram
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Newly Discovered Atrial Fibrillation
Shown below is an algorithm depicting the pharmacological management of patients with newly discovered atrial fibrillation based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]
Newly discovered AF | |||||||||||||||||||||||
Paroxysmal AF | Persistent AF | ||||||||||||||||||||||
Accept progression to permanent AF | Restore sinus rhythm | ||||||||||||||||||||||
❑ Do not administer therapy unless the patient has ant of the following symptoms requiring DC cardioversion ❑ Administer long term anticoagulation therapy based on the risk of stroke
| ❑ Administer long term anticoagulation therapy based on the risk of stroke | ❑ Administer anticoagulation therapy based on the risk of stroke | |||||||||||||||||||||
Note: For the treatment of newly persistent AF, choose the therapy depending on the severity of symptoms and the risk of administration of anti-arrhythmic.
Recurrent Paroxysmal Atrial Fibrillation
Shown below is an algorithm depicting the pharmacological management of patients with recurrent paroxysmal atrial fibrillation based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]
Recurrent paroxysmal AF | |||||||||||||||
Minimal or no symptoms | Disabling symptoms in AF | ||||||||||||||
❑ Administer rate control ❑ Administer anticoagulation based on the risk of stroke | ❑ Administer rate control
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❑ Consider AF ablation if antiarrhythmic treatment fails | |||||||||||||||
Recurrent Persistent Atrial Fibrillation
Shown below is an algorithm depicting the pharmacological management of patients with recurrent persistent atrial fibrillation based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]
Recurrent persistent AF | |||||||||||||||
Minimal or no symptoms | Disabling symptoms in AF | ||||||||||||||
❑ Administer rate control ❑ Administer anticoagulation based on the risk of stroke | ❑ Administer rate control | ||||||||||||||
❑ Continue anticoagulation therapy ❑ Continue antiarrhythmic | |||||||||||||||
In case of recurrence of AF, proceed with: ❑ Left atrial ablation | |||||||||||||||
Permanent Atrial Fibrillation
Shown below is an algorithm depicting the pharmacological management of patients with permanent atrial fibrillation based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]
Permanent AF | |||||||
❑ Administer anticoagulation based on the risk of stroke | |||||||
Maintenance of Sinus Rhythm
Shown below is an algorithm depicting the antiarrhythmic drug therapy for maintaining sinus rhythm in patients with recurrent paroxysmal or persistent atrial fibrillation based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation. Drugs are listed alphabetically and not in order of suggested use.[3]
Maintenance of sinus rhythm | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No or minimal heart disease | Hypertension | Coronary artery disease | Heart failure | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Substantial LVH | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Catheter ablation | No | Yes | ❑ Amiodarone | ❑ Catheter ablation | ❑ Catheter ablation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Amiodarone | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Catheter ablation | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Catheter ablation | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Note:
- In vagally mediated AF, disopyramide and flecainide are recommended.
- In adrenergically mediated AF, beta blocker and sotalol are recommended.
Heart Rate Control
Shown below is a table summarizing the list of recommended agents for control of heart rate and their dosages.[3]
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Anticoagulation Therapy
Shown below are tables depicting the assessment of risk of stroke and the appropriate anticoagulation therapy among patients with AF.[3]
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Low Risk Factors | Moderate Risk Factors | High Risk Factors |
▸ Female gender ▸ Age 65-74 years ▸ Coronary artery disease ▸ Thyrotoxicosis |
▸ Age ≥ 75 years ▸ Hypertension ▸ Heart failure ▸ LV ejection fraction ≤ 35% ▸ Diabetes mellitus |
▸ Previous stroke, TIA or embolism ▸ Mitral stenosis ▸ Prosthetic heart valve |
Pharmacological Cardioversion
Shown below is a table summarizing the pharmacological cardioversion for atrial fibrillation of a duration less or more than 7 days.[3]
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Do's
Rate Control
- Begin therapy with either a beta blocker, diltiazem, or verapamil (class I, level of evidence B). Use a combination of digoxin and either a beta blocker, diltiazem, or verapamil if AF is not controlled by monotherapy (class IIa, level of evidence B).
- Administer ablation of the arterioventricular (AV) node or accessory pathway if pharmacological therapy is insufficient (class IIa, level of evidence B).
- If rate is not controlled by the above measures administer oral or IV amiodarone either alone or in combination with other agents (class IIb, level of evidence C).
Antithrombotic Therapy
- Dabigatran may be administered as an alternative to warfarin in patients who do not have any of the following (class I, level of evidence B):
- Prosthetic heart valve
- Hemodynamically significant valve disease
- Severe renal failure (creatinine clearance < 15 mL/min)
- Advanced liver disease (impaired baseline clotting function)
- Administer anticoagulants 3 weeks prior to and 4 weeks after cardioversion for patients with unknown duration of AF or AF for > 48 hours (class I, level of evidence B). Patients who require immediate cardioversion should be administered IV heparin followed by 4 weeks of oral anticoagulant therapy.
- If a patient is on anticoagulants for AF develops stroke or systemic embolism, target INR may be raised to 3.0 - 3.5 (class IIb, level of evidence C).
- Anticoagulation therapy can be interrupted for up to 1 week if patients require a procedure that carries an elevated risk of bleeding (class IIa, level of evidence C). If anticoagulation therapy has to be interrupted for more than 1 week, unfractionated or low molecular weight heparin may be given intravenously (class IIb, level of evidence C).
Cardioversion
- Use a rate control agent such as beta blocker, diltiazem or verapamil before initiating antiarrhythmic medication to prevent rapid AV conduction (class IIa, level of evidence C).
- Perform cardioversion immediately in patients with AF pf less than 48 hours duration without a need for anticoagulation (class I, level of evidence C).
- Transesophageal echocardiography may be used to search for thrombus prior to cardioversion. If no thrombus is detected, the patient may be treated with 4 weeks of anticoagulants after the procedure (class IIa, level of evidence B). If a thrombus is detected, anticoagulant therapy 3 weeks prior and 4 weeks after cardioversion is required (class IIa, level of evidence C).
Don't
- Do not wait to give anticoagulants in a patient with hemodynamic instability, perform cardioversion immediately. Administer IV unfractionated heparin or SC injection of a low-molecular-weight heparin.
- Don't use digoxin as a single agent for rate control in patients with paroxysmal AF (class III, level of evidence B).
- Do not attempt catheter ablation unless a trial of medication to control ventricular rate has been made (class III, level of evidence C).
- Do not give IV nondihydropyridine calcium channel antagonist in a patient with decompensated heart failure and AF.
- Do not use digoxin and sotalol for pharmacological cardioversion of AF (class III, level of evidence A).
- Do not start quinidine, procainamide, disopyramide, and dofetilide in out of hospital setting (class III, level of evidence B).
- Do not perform repeated electric cardioversion in those with short periods of normal sinus rhythm in between (class III, level of evidence C).
- Do not perform electric cardioversion in those with digitalis toxicity and/or hypokalemia (class III, level of evidence C).
- Don't use calcium channel blocker, beta blocker, and digoxin in atrial fibrillation patients with WPW.
References
- ↑ Zimetbaum, PJ.; Josephson, ME.; McDonald, MJ.; McClennen, S.; Korley, V.; Ho, KK.; Papageorgiou, P.; Cohen, DJ. (2000). "Incidence and predictors of myocardial infarction among patients with atrial fibrillation". J Am Coll Cardiol. 36 (4): 1223–7. PMID 11028474. Unknown parameter
|month=
ignored (help) - ↑ Goldhaber, SZ.; Visani, L.; De Rosa, M. (1999). "Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER)". Lancet. 353 (9162): 1386–9. PMID 10227218. Unknown parameter
|month=
ignored (help) - ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Fuster, V.; Rydén, LE.; Cannom, DS.; Crijns, HJ.; Curtis, AB.; Ellenbogen, KA.; Halperin, JL.; Kay, GN.; Le Huezey, JY. (2011). "2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines". Circulation. 123 (10): e269–367. doi:10.1161/CIR.0b013e318214876d. PMID 21382897. Unknown parameter
|month=
ignored (help)