Atrial fibrillation resident survival guide: Difference between revisions

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** [[Hypotension]] could be rate related so treatment should not be avoided.
** [[Hypotension]] could be rate related so treatment should not be avoided.
** Cardioversion should be done in hemodynamically unstable patients.
** Cardioversion should be done in hemodynamically unstable patients.
** Important points to remember for anti-arrhythmic drugs:
*** 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.
* Anticoagulation for atrial fibrillation
* Anticoagulation for atrial fibrillation
** CHADS2 score
** CHADS2 score

Revision as of 14:28, 26 November 2013

File:Critical Pathways.gif

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

Definition

Atrial fibrillation (AF or Afib) is a cardiac arrhythmia that originates in the atria of the heart.

Causes

Life Threatening Causes

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

Common Causes

Management

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 (e.g., hypotension, HF, angina pectoris
 
 
 
 
 
Accept permanent AF
 
Rate control and anticoagulation as needed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anticoagulation as needed
 
 
 
 
 
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 Drugs Used 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
 
 
 
 
 
Dofetilide
Dronedarone
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]

Do's

  • Atrial fibrillation nomenclature:
    • Paroxysmal - recurrent, transient, last less than 7 days, terminate without therapeutic intervention.
    • Persistent - last more than 7 days, terminate with therapeutic intervention.
    • Permanent - last > 1 year, can't be converted or conversion not attempted.
    • Lone Afib - without any structural heart disease
  • Chronic atrial fibrillation
    • Drug choices for rate control in atrial fibrillation:
      • Beta blocker metoprolol/lopressor, atenolol/tenormin.
      • Non-dihydropyridine calcium channel blockers diltiazem/cardizem, verapamil.
      • Digoxin can be used as a second line drug.
      • If drug therapy fails cardioversion with 100 joules of electricity can be tried. Prior to an elective cardioversion either a negative TEE or 3-4 weeks of anticoagulation is required. Post cardioversion 4 weeks of anticoagulation is recommended.
  • Acute atrial fibrillation
    • Hemodynamic stability is first priority, rate control 2nd.
    • Hypotension could be rate related so treatment should not be avoided.
    • Cardioversion should be done in hemodynamically unstable patients.
    • Important points to remember for anti-arrhythmic drugs:
      • 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.
  • 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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