Sandbox vidit2
| Newly discovered AF | |||||||||||||||||||||||||||||||||||||
| Paroxysmal | Persistent | ||||||||||||||||||||||||||||||||||||
| Look for the presence of one of these severe symptoms Hypotension Heart failure Angina pectoris Severe symptoms absent: Severe symptoms present: Attempt direct-current cardioversion | Permanent AF | Anticoagulation as needed based on the risk of stroke Click here for the risk of stroke and anticoagulation therapy Control heart rate as an intial method to terminate AF Click here for recommended pharmacological agents used for rate control | |||||||||||||||||||||||||||||||||||
| Anticoagulation as needed based on the risk of stroke Click here for the risk of stroke and anticoagulation therapy Recommended in all cases except lone AF (I A) Measure INR weekly initially, then monthly when stable (I A) Reassess need for anticoagulation at periodic intervals (IIa C) | Anticoagulation as needed based on the risk of stroke Click here for the risk of stroke and anticoagulation therapy Control heart rate as an intial method to terminate AF Click here for recommended pharmacological agents used for rate control | ||||||||||||||||||||||||||||||||||||
Risk Factors for Stroke and Recommended Antithrombotic Therapy
| Low Risk Factors | Moderate Risk Factors | High Risk Factors |
|---|---|---|
| Female gender | Age ≥ 75 years | Previous stroke, TIA or embolism |
| Age 65-74 years | Hypertension | Mitral stenosis |
| Coronary artery disease | Heart failure | Prosthetic heart valve |
| Thyrotoxicosis | LV ejection fraction ≤ 35% | - |
| - | Diabetes mellitus | - |
| Risk Category | Recommended Therapy |
|---|---|
| No risk factors | Aspirin, 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)* |
Pharmacological Agents for Heart Rate Control
| Drug | Class/LOE Recommendations | Loading Dose | Maintenance Dose |
|---|---|---|---|
| Acute Setting | |||
| Heart rate control in patients without accessory pathway | |||
| Esmolol | I C | 500 mcg/kg IV over 1 min | 60 to 200 mcg/kg/min IV |
| Propanolol | I C | 0.15 mg/kg IV | NA |
| Metoprolol | I C | 2.5 to 5 mg IV bolus over 2 min; up to 3 doses | NA |
| Diltiazem | I B | 0.25 mg/kg IV over 2 min | 5 to 15 mg/h IV |
| Verampil | I B | 0.075 to 0.15 mg/kg IV over 2 min | NA |
| Heart Rate Control in patients with accessory pathway | |||
| Amiodarone | IIa C | 150 mg over 10 min | 0.5 to 1 mg/min IV |
| Heart Rate Control in patients with heart failure and without accessory pathway | |||
| Digoxin | I B | 0.25 mg IV each 2 h, up to 1.5 mg | 0.125 to 0.375 mg daily IV or orally |
| Amiodarone | IIa C | 150 mg over 10 min | 0.5 to 1 mg/min IV |
| Non-Acute Setting and Chronic Maintenance Therapy | |||
| Heart rate control | |||
| Metoprolol | I C | Same as maintenance dose | 25 to 100 mg twice a day, orally |
| Propanolol | I C | Same as maintenance dose | 80 to 240 mg daily in divided doses, orally |
| Verampil | I B | Same as maintenance dose | 120 to 360 mg daily in divided doses; slow release available, orally |
| Diltiazem | I B | Same as maintenance dose | 120 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 C | 0.5 mg by mouth daily | 0.125 to 0.375 mg daily, orally |
| Amiodarone | IIb C | 800 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 |
- Dabigatran may be used as an alternative to warfarin in those wdo don't have: (I B)
- Prosthetic heart valve
- Hemodynamically significant valve disease
- Severe renal failure (creatinine clearance <15 mL/min) or
- Advanced liver disease (impaired baseline clotting function).
- If patient on anticoagulants with AF sustains stroke or systemic embolism, target INR may be raised to 3.0 - 3.5 (IIb C).
- Anticoagulation therapy can be interrupted for upto 1 week, if patients needs a procedure that carries a risk of bleeding (IIa C). For periods > 1 week unfractionated or low molecular weight heparin may be given IV (IIb C).