Atrial fibrillation resident survival guide: Difference between revisions
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==Antiarrhythmic Drug Therapy in Atrial Fibrillation== | ==Antiarrhythmic Drug Therapy in Atrial Fibrillation== | ||
Shown below is an algorithm depicting the [[Antiarrhythmic therapy|antiarrhythmic drug therapy]] for maintaining [[sinus rhythm]] in patients with [[Atrial fibrillation resident survival guide#Definitions|recurrent paroxysmal]] or [[Atrial fibrillation resident survival guide#Definitions|persistent atrial fibrillation]]: | Shown below is an algorithm depicting the [[Antiarrhythmic therapy|antiarrhythmic drug therapy]] for maintaining [[sinus rhythm]] in patients with [[Atrial fibrillation resident survival guide#Definitions|recurrent paroxysmal]] or [[Atrial fibrillation resident survival guide#Definitions|persistent atrial fibrillation]]: | ||
''Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.''<ref name="Fuster-2011">{{Cite journal | last1 = Fuster | first1 = V. | last2 = Rydén | first2 = LE. | last3 = Cannom | first3 = DS. | last4 = Crijns | first4 = HJ. | last5 = Curtis | first5 = AB. | last6 = Ellenbogen | first6 = KA. | last7 = Halperin | first7 = JL. | last8 = Kay | first8 = GN. | last9 = Le Huezey | first9 = JY. | title = 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. | journal = Circulation | volume = 123 | issue = 10 | pages = e269-367 | month = Mar | year = 2011 | doi = 10.1161/CIR.0b013e318214876d | PMID = 21382897 }}</ref> | |||
{{familytree/start}} | {{familytree/start}} | ||
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{{familytree| | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | }} | {{familytree| | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | }} | ||
{{familytree| | | | | | | F01 | | F02 | | | | | | | | | F01= [[Amiodarone]]<br> [[Dofetilide]]|F02= [[Catheter ablation]]}} | {{familytree| | | | | | | F01 | | F02 | | | | | | | | | F01= [[Amiodarone]]<br> [[Dofetilide]]|F02= [[Catheter ablation]]}} | ||
{{familytree/end}} | {{familytree/end}} <br> | ||
Drugs are listed alphabetically and not in order of suggested use. <br>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. | Drugs are listed alphabetically and not in order of suggested use. <br>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. | ||
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<tr><td>[[Quinidine]]</td><td>600 to 1500 mg</td></tr> | <tr><td>[[Quinidine]]</td><td>600 to 1500 mg</td></tr> | ||
<tr><td>[[Sotalol]]</td> <td>160 to 320 mg </td></tr> | <tr><td>[[Sotalol]]</td> <td>160 to 320 mg </td></tr> | ||
</table> | </table> <br> | ||
==Pharmacological Cardioversion== | ==Pharmacological Cardioversion== |
Revision as of 21:07, 5 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]
Definitions
Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia, characterized by uncoordinated atrial activation and improper atrio-ventricular mechanical function.
Primary AF is classified as shown below:
Term | Definition |
---|---|
Paroxysmal | AF lasting < 7 days (most last < 24 hours). Usually self terminating. |
Persistent | AF lasting > 7 days. Usually does not terminate on its own. |
Permanent | AF lasting for a longer period, where in 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.
- Congestive heart failure
- Dehydration
- Electrolyte disturbance
- Hypothermia
- Hypoxia
- Myocardial infarction[1]
- Myocarditis
- Pericarditis
- Pheochromocytoma
- Pulmonary embolism[2]
- Uremic pericarditis
Common Causes
Management
Shown below is an algorithm summarizing the initial approach to evaluation of AF.
Characterize the symptoms:
Characterize the timing of the symptoms: | ||||||||||||||||||
Identify possible triggers: | ||||||||||||||||||
❑ 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: Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]
Newly discovered AF | |||||||||||||||||||||||||||||||||||||||||||
❑ Look for the presence of one of these severe symptoms:
Severe symptoms absent: Severe symptoms present: ❑ Attempt direct-current cardioversion | Anticoagulation: ❑ Consider anticoagulation as needed based on the risk of stroke ❑ Click here for the risk of stroke and anticoagulation therapy Heart rate control: ❑ Control heart rate as an initial method to manage AF, and regulate ventricular output Click here for pharmacological agents and doses used to control heart rate | ||||||||||||||||||||||||||||||||||||||||||
Anticoagulation: ❑ Consider 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) | Antiarrhythmic therapy: ❑ Consider antiarrhythmic therapy for maintenance of sinus rhythm Click here for recommended pharmacological agents used for maintenance of sinus rhythm | ||||||||||||||||||||||||||||||||||||||||||
Cardioversion: ❑ Attempt cardioversion ❑ Click here for drugs and doses used for pharmacologic cardioversion ❑ If patient hemodynamically unstable or tachycardic, attempt electric cardioversion ❑ If pharmacological cardioversion fails, attempt electric cardioversion | |||||||||||||||||||||||||||||||||||||||||||
❑ Do not treat with long term antiarrhythmic therapy, unless indicated. | |||||||||||||||||||||||||||||||||||||||||||
Recurrent Paroxysmal Atrial Fibrillation
Shown below is an algorithm depicting the pharmacological management of patients with recurrent paroxysmal atrial fibrillation: Algorithm 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 | ||||||||||||||||||||||||||||||||
Anticoagulation: ❑ Consider anticoagulation as needed based on the risk of stroke ❑ Click here for the risk of stroke and anticoagulation therapy Heart rate control: ❑ Control heart rate as an initial method to manage AF, and regulate ventricular output Click here for pharmacological agents and doses used to control heart rate | Anticoagulation: ❑ Consider anticoagulation as needed based on the risk of stroke ❑ Click here for the risk of stroke and anticoagulation therapy Heart rate control: ❑ Control heart rate as an initial method to manage AF, and regulate ventricular output Click here for pharmacological agents and doses used to control heart rate | ||||||||||||||||||||||||||||||||
❑ Long term therapy for prevention of AF not needed | Antiarrhythmic therapy: ❑ Consider antiarrhythmic therapy for maintenance of sinus rhythm Click here for recommended pharmacological agents used for maintenance of sinus rhythm | ||||||||||||||||||||||||||||||||
❑ Consider AF ablation if antiarrhythmic drug treatment fails | |||||||||||||||||||||||||||||||||
Recurrent Persistent Atrial Fibrillation
Shown below is an algorithm depicting the pharmacological management of patients with recurrent persistent atrial fibrillation: Algorithm 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 | ||||||||||||||||||||||||||||||||
Anticoagulation: ❑ Consider anticoagulation as needed based on the risk of stroke ❑ Click here for the risk of stroke and anticoagulation therapy Heart rate control: ❑ Control heart rate as an initial method to manage AF, and regulate ventricular output Click here for pharmacological agents and doses used to control heart rate | Anticoagulation: ❑ Consider anticoagulation as needed based on the risk of stroke ❑ Click here for the risk of stroke and anticoagulation therapy Heart rate control: ❑ Control heart rate as an initial method to manage AF, and regulate ventricular output Click here for pharmacological agents and doses used to control heart rate | ||||||||||||||||||||||||||||||||
Antiarrhythmic therapy: ❑ Consider antiarrhythmic therapy for maintenance of sinus rhythm Click here for recommended pharmacological agents used for maintenance of sinus rhythm | |||||||||||||||||||||||||||||||||
❑ Perform electrical cardioversion as needed ❑ Pretreat with one of the following agents to reduce the risk of early recurrence of AF after cardioversion:
| |||||||||||||||||||||||||||||||||
❑ Continue anticoagulation therapy based on risk factor profile as above ❑ Continue antiarrhythmic therapy to maintain sinus rhythm as above | |||||||||||||||||||||||||||||||||
Permanent Atrial Fibrillation
Shown below is an algorithm depicting the pharmacological management of patients with permanent atrial fibrillation:Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]
Permanent AF | |||||||||||||||||||||||||||||||
Anticoagulation: ❑ Consider anticoagulation as needed based on the risk of stroke ❑ Click here for the risk of stroke and anticoagulation therapy Heart rate control: ❑ Control heart rate as an initial method to manage AF, and regulate ventricular output Click here for pharmacological agents and doses used to control heart rate | |||||||||||||||||||||||||||||||
Antiarrhythmic Drug Therapy in Atrial Fibrillation
Shown below is an algorithm depicting the antiarrhythmic drug therapy for maintaining sinus rhythm in patients with recurrent paroxysmal or persistent atrial fibrillation: Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[3]
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.
Following table summarizes the list of most commonly used drugs and their dosages for maintenance of sinus rhythm:
Drug | Dose |
---|---|
Amiodarone | 100 to 400 mg |
Disopyramide | 400 to 750 mg |
Dofetilide | 5000 to 1000 mcg |
Flecainide | 200 to 300 mg |
Procainamide | 1000 to 4000 mg |
Propafenone | 450 to 900 mg |
Quinidine | 600 to 1500 mg |
Sotalol | 160 to 320 mg |
Pharmacological Cardioversion
Cardioversion upto 7 Days
Drug | Dosage | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Agents with proven efficacy | |||||||||||
Dofetilide (I A) |
| ||||||||||
Flecainide (I A) | Oral: 200 to 300 mg Intravenous: 1.5 to 3.0 mg/kg over 10 to 20 min | ||||||||||
Ibutilide (I A) | 1 mg over 10 min; repeat 1 mg when necessary | ||||||||||
Propafenone (I A) | Oral: 600 mg Intravenous: 1.5 to 2.0 mg/kg over 10 to 20 min | ||||||||||
Amiodarone (IIa A) | Oral:
Intravenous:
|
Cardioversion after 7 Days
Drug | Dosage | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Agents with proven efficacy | |||||||||||
Dofetilide (I A) |
| ||||||||||
Amiodarone (IIa A) | Oral:
Intravenous:
| ||||||||||
Ibutilide (IIa A) | 1 mg over 10 min; repeat 1 mg when necessary |
Drugs which enhance the efficacy of electric cardioversion when given prior to the procedure: (Level of recommendation: IIa B)
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 | 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 |
Verapamil (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 |
Verapamil (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 |
Do's
Rate control during AF:
- Begin therapy with either a beta blocker, diltiazem, or verapamil. (I B) Use a combination of digoxin and either a beta blocker, diltiazem, or verapamil if AF not controlled by monotherapy. (IIa B)
- Use ablation of the arterioventricular (AV) node or accessory pathway, if pharmacological therapy is insufficient. (IIa B)
- If rate is not controlled by above measures use oral or IV amiodarone, either alone or in combination with other agents. (IIb C)
Antithrombotic therapy:
- 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).
- Give anticoagulants 3 weeks prior to & 4 weeks after cardioversion for patients with unknown duration of AF or AF > 48 hours. (I B) Those requiring immediate cardioversion should be given IV heparin, followed by 4 weeks of oral anticoagulant therapy.
- 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).
Cardioversion:
- Use a rate control agent such as beta blocker, diltiazem or verapamil before initiating antiarrhythmic medication to prevent rapid AV conduction. (IIa C)
- Perform cardioversion immediately in AF < 48 hours without a need for anticoagulation. (I C)
- Transesophageal echocardiography may be used to search for thrombus prior to cardioversion, if none are found patient may be treated with 4 weeks of anticoagulants after the procedure. (IIa B) If thrombus is found, 3 weeks of anticoagulant therapy prior and 4 weeks afterwards is a must. (IIa 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. (III B)
- Do not attempt catheter ablation unless a trial of medication to control ventricular rate has been made. (III 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. (III A)
- Do not start quinidine, procainamide, disopyramide, and dofetilide in out of hospital setting. (III B)
- Do not perform repeated electric cardioversion in those with short periods of normal sinus rhythm in between. (III C)
- Do not perform electric cardioversion in those with digitalis toxicity and/or hypokalemia. (III 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 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)