Atrial fibrillation resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hilda Mahmoudi M.D., M.P.H.[2]; Priyamvada Singh, M.D. [3]

Definitions

Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia, characterized by uncoordinated atrial activation and improper atrio-ventricular mechanical function. This classification is for pri af

  • Paroxysmal - recurrent, transient, last less than 7 days,
  • Persistent - last more than 7 days
  • Permanent - lasting a long period, where in attempted cardioversion has failed or shows no improvement.
  • Lone Afib - patients > 60 years, without any cardiopulmonary disease

recurrent - after 2 or more episodes af is considered recurrent.

Secondary af are classified differently.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Management

 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms:
❑ Asymptomatic PalpitationsDyspnea
Fatigue Chest discomfort Lightheadedness
Syncope

Characterize the timing of the symptoms:
❑ Onset
❑ Duration
❑ Frequency

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Examine the patient
❑ Order an EKG
 

Newly Discovered Atrial Fibrillation

Shown below is an algorithm depicting the pharmacological management of patients with newly discovered atrial fibrillation:

 
 
 
 
 
 
 
Newly discovered AF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Paroxysmal
 
 
 
 
 
 
 
Persistent
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No therapy needed unless severe symptoms (hypotension, heart failure, angina pectoris
 
 
 
 
 
Accept permanent AF
 
Rate control and anticoagulation as needed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anticoagulation as needed
Recommended in all cases except lone AF (I A)
Reassess need for anticoagulation at periodic intervals
Risk CategoryRecommended Therapy
No risk factorsAspirin, 81-325 mg daily
1 Moderate risk factor Aspirin, 81-325 mg daily or
Warfarin (INR 2.0 to 3.0, target 2.5)
Any high risk factor or
more than 1 moderate risk factor
Warfarin
(INR 2.0 to 3.0, target 2.5)*
 
 
 
 
 
Anticoagulaion and rate control* as needed
 
Consider antiarrhythmic drug therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cardioversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Long term antiarrhythmic drug therapy unnecessary

ADD indicates antiarrhythmic drugs
*See figure 5
Algorithm based on the 2011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]

Recurrent Paroxysmal Atrial Fibrillation

Shown below is an algorithm depicting the pharmacological management of patients with recurrent paroxysmal atrial fibrillation:

 
 
 
 
 
 
 
Recurrent paroxysmal AF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Minimal or no symptoms
 
 
 
 
 
 
Disabling symptoms in AF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anticoagulation and rate control as needed
 
 
 
 
 
 
Anticoagulation and rate control as needed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No drug for prevention of AF
 
 
 
 
 
 
Antiarrhythmic drug therapy*
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
AF ablation if ADD treatment fails

ADD indicates antiarrhythmic drugs
*See figure 5
Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]

Recurrent Persistent Atrial Fibrillation

Shown below is an algorithm depicting the pharmacological management of patients with recurrent persistent atrial fibrillation:

 
 
 
 
 
 
 
Recurrent persistent AF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Minimal or no symptoms
 
 
 
 
 
 
Disabling symptoms in AF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anticoagulation and rate control as needed
 
 
 
 
 
 
Anticoagulation and rate control
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antiarrhythmic drug therapy*
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Electrical cardioversion as needed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continue anticoagulation as needed and therapy to maintain sinus rhythm*
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider ablation for severely symptomatic recurrent AF after failure of greater than or equal to 1 ADD plus rate control

ADD indicates antiarrhythmic drugs
*See figure 5. Initiate drug therapy before cardioversion to reduce the likelihood of early recurrence of AF.
Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]

Permanent Atrial Fibrillation

Shown below is an algorithm depicting the pharmacological management of patients with permanent atrial fibrillation:

 
 
 
 
 
 
 
 
 
 
 
 
Permanent AF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anticoagulation and rate control* as needed

*See figure 5
Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]

Antiarrhythmic Drug Therapy in Atrial Fibrillation

Shown below is an algorithm depicting the antiarrhythmic drug therapy for maintain sinus rhythm in patients with recurrent paroxysmal or persistent atrial fibrillation:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Maintenance of sinus rhythm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No (or minimal) heart disease
 
 
 
 
 
Hypertension
 
 
 
 
 
Coronary artery disease
 
 
 
Heart failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dronedarone
Flecainide
Propafenone
Sotalol
 
 
 
 
 
Substantial LVH
 
 
 
 
 
Dronedarone
Dofetilide
Sotalol
 
 
 
Amiodarone
Dofetilide
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Amiodarone
Dofetilide
 
Catheter ablation
 
No
 
Yes
 
Amiodarone
 
Catheter ablation
 
Catheter ablation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dronedarone
Flecainide
Propafenone
Sotalol
 
Amiodarone
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Catheter ablation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Amiodarone
Dofetilide
 
Catheter ablation
 
 
 
 
 
 
 
 

Drugs are listed alphabetically and not in order of suggested use.
The seriousness of heart disease progresses from left to right, and selection of therapy in patients with multiple conditions depends on the most serious condition present.
LVH indicates left ventricular hypertrophy.
Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]

Pharmacological Agents for Heart Rate Control

DrugClass/LOE
Recommendations
Loading DoseMaintenance Dose
Acute Setting
Heart rate control in patients without accessory pathway
EsmololI C500 mcg/kg IV over 1 min60 to 200 mcg/kg/min IV
PropanololI C 0.15 mg/kg IVNA
MetoprololI C 2.5 to 5 mg IV bolus over 2 min; up to 3 dosesNA
DiltiazemI B0.25 mg/kg IV over 2 min5 to 15 mg/h IV
VerampilI B0.075 to 0.15 mg/kg IV over 2 minNA
Heart Rate Control in patients with accessory pathway
AmiodaroneIIa C150 mg over 10 min0.5 to 1 mg/min IV
Heart Rate Control in patients with heart failure and without accessory pathway
DigoxinI B0.25 mg IV each 2 h, up to 1.5 mg0.125 to 0.375 mg daily IV or orally
AmiodaroneIIa C150 mg over 10 min0.5 to 1 mg/min IV
Non-Acute Setting and Chronic Maintenance Therapy
Heart rate control
MetoprololI CSame as maintenance dose25 to 100 mg twice a day, orally
PropanololI CSame as maintenance dose80 to 240 mg daily in divided doses, orally
VerampilI BSame as maintenance dose120 to 360 mg daily in divided doses; slow release available, orally
DiltiazemI BSame as maintenance dose120 to 360 mg daily in divided doses; slow release available, orally
Heart Rate Control in patients with heart failure and without accessory pathway
Digoxin I C0.5 mg by mouth daily0.125 to 0.375 mg daily, orally
AmiodaroneIIb C800 mg daily for 1 wk, orally
600 mg daily for 1 wk, orally
400 mg daily for 4 to 6 wk, orally
200 mg daily, orally


Do's

Therapeutic agents for Atrial fibrillation

  • No mortality benefit is evident from rhythm control over rate control.
  • Rate control with beta blockers (metoprolol/lopressor, atenolol/tenormin) or non-dihydropyridine calcium channel blockers (diltiazem/cardizem, verapamil)is recommended in older patients with chronic AF or unknown duration. Digoxin can be used as a second line drug.
  • For young symptomatic AF patients rhythm control is preferred over rate control. Rhythm control can be achieved by medications, synchronized cardioversion or both. If both these options fail, catheter based ablation is an option.
  • Sotalol and Dofetelide - monitor QTc interval for prolongation for 48 hrs post initiation. QTc >= 500 or 15% above baseline may increase the risk of Torsades. Check daily EKG or EKG 2 hours post the drug dose.
  • Amiodarone can cause bradycardia, hepatotoxicity, throtoxicity, pulmonary fibrosis, and retinopathy.
  • Flecanide should be used with beta blockers as it may increases the risk of rapid AV nodal conduction. It also increases digoxin levels
  • Hemodynamic stability is first priority, rate or rhythm control 2nd.
  • Hypotension could be rate related so treatment should not be avoided.

Cardioversion

  • Emergent cardioversion for hemodynamically unstable AF.
  • If drug therapy fails, cardioversion with 100 joules of electricity is recomended.
  • Prior to an elective cardioversion in patients who have been in AF > 48hrs or unknown duration, either a negative TEE or 3-4 weeks of anticoagulation is recommended.
  • Post cardioversion 4 weeks of anticoagulation is recommended.

Anticoagulation for atrial fibrillation

Don't

References

  1. 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)
  2. 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. 3.0 3.1 3.2 3.3 3.4 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)


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