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===Cardioversion upto7 Days===
{{familytree/start}}
 
{{familytree | | | | | | | A01 | | | | | | | | | | |A01=[[Atrial flutter]] }}
<table class="wikitable">
{{familytree | | | | | | | | | | | | | | | | | | | | }}
<tr class="v-firstrow"><th>Drug</th><th>Class of Recommendation/<br>Level of Evidence</th><th> Dosage </th></tr>
{{familytree | | | B01 | | | | | | B02 | | | | | | |B01=Unstable |B02=Stable }}
<tr><th>Agents with proven efficacy</th></tr>
{{familytree | | | | | | | | | | | | | | | | | | | | }}
<tr><td>Dofetilide</td><td>I A</td><td><table class="wikitable">
{{familytree | | | C01 | | | | | | C02 | | | | | | |C01=Look for the presence of any of these: <br> Chronic heart failure <br> Hypotension <br> Acute myocardial infarction <br> Attempt to terminate flutter with DC cardioversion|C02= ❑ Administer anticoagulation therapy based on the risk of stroke if total duration of flutter > 48 hours <br> Administer rate control therapy (AV nodal blockers) <br> ''THEN'' <br> Attempt conversion <br> DC cardioversion <br> Atrial pacing <br> Pharmacological cardioversion }}
<tr class="v-firstrow"><th>Creatinine clearance(ml/min)</th><th>Dose (mg)</th></tr>
{{familytree | | | | | | | | | | | | | | | | | | | | }}
<tr><td> >60</td><td>500</td></tr>
{{familytree | | | D01 | | | | | | | | | | | | | | |D01=Assess need for therapy to prevent recurrence }}
<tr><td> 40 to 60 </td><td>250 </td></tr>
{{familytree | | | | | | | | | | | | | | | | | | | | }}
<tr><td>20 to 40 </td><td>125 </td></tr>
{{familytree | | | | | | | E01 | | | | | | | | | | |E01=Antiarrythmic therapy
<tr><td> <20</td><td>Contraindicated</td></tr>
----
</table></td></tr>
Catheter ablation }}
<tr><td>Flecainide</td><td> I A</td><td>'''Oral:''' 200 to 300 mg <br>
{{familytree | | | | | | | | | | | | | | | | | | | | }}
'''Intravenous:''' 1.5 to 3.0 mg/kg over 10 to 20 min</td></tr>
{{familytree | | | | | | | | | | | | | | | | | | | | }}
<tr><td>Ibutilide</td><td>I A </td><td>1 mg over 10 min; repeat 1 mg when necessary</td></tr>
{{familytree | | | | | | | | | | | | | | | | | | | | }}
<tr><td>Propafenone</td><td>I A</td><td>'''Oral:''' 600 mg <br>
{{familytree | | | | | | | | | | | | | | | | | | | | }}
'''Intravenous:''' 1.5 to 2.0 mg/kg over 10 to 20 min</td></tr>
{{familytree | | | | | | | | | | | | | | | | | | | | }}
<tr><td>Amiodarone</td><td>IIa A</td><td>'''Oral:'''
{{familytree | | | | | | | | | | | | | | | | | | | | }}
: Inpatient: 1.2 to 1.8 g per day in divided dose until 10 g total <br> then 200 to 400 mg per day maintenance or 30 mg/kg as single dose <br>
{{familytree | | | | | | | | | | | | | | | | | | | | }}
: Outpatient: 600 to 800 mg per day divided dose until 10 g total <br> then 200 to 400 mg per day maintenance. <br>
{{familytree | | | | | | | | | | | | | | | | | | | | }}
'''Intravenous:'''
{{familytree | | | | | | | | | | | | | | | | | | | | }}
: 5 to 7 mg/kg over 30 to 60 min then 1.2 to 1.8 g per day continuous IV or <br>
{{familytree | | | | | | | | | | | | | | | | | | | | }}
: in divided oral doses until 10 g total then 200 to 400 mg per day maintenance.</td></tr>
{{familytree | | | | | | | | | | | | | | | | | | | | }}
</table>
{{familytree | | | | | | | | | | | | | | | | | | | | }}
 
{{familytree/end}}
===Cardioversion after 7 Days===
 
<table class="wikitable">
<tr class="v-firstrow"><th>Drug</th><th> Dosage </th></tr><tr><td>Dofetilide (I A)</td><td><table class="wikitable">
<tr class="v-firstrow"><th>Creatinine clearance(ml/min)</th><th>Dose (mg)</th></tr>
<tr><td> >60</td><td>500</td></tr>
<tr><td> 40 to 60 </td><td>250 </td></tr>
<tr><td>20 to 40 </td><td>125 </td></tr>
<tr><td> <20</td><td>Contraindicated</td></tr>
</table></td></tr>
<tr><td>Amiodarone (IIa A)</td><td>'''Oral:'''
: Inpatient: 1.2 to 1.8 g per day in divided dose until 10 g total <br> then 200 to 400 mg per day maintenance or 30 mg/kg as single dose <br>
: Outpatient: 600 to 800 mg per day divided dose until 10 g total <br> then 200 to 400 mg per day maintenance. <br>
'''Intravenous:'''
: 5 to 7 mg/kg over 30 to 60 min then 1.2 to 1.8 g per day continuous IV or <br>
: in divided oral doses until 10 g total then 200 to 400 mg per day maintenance.</td></tr>
<tr><td>Ibutilide (IIa A)</td><td>1 mg over 10 min; repeat 1 mg when necessary</td></tr>
</table>
 
Drugs which enhance the efficacy of cardioversion when given prior to the procedure: (Level of recommendation: IIa B)
* Amiodarone
* Flecainide
* Ibutilide
* Propafenone
* Sotalol
 
===Drug Dosages for Maintenance of Sinus Rhythm===
Following table summarizes the list of most commonly used drugs and their dosages for maintenance of sinus rhythm:
<table class="wikitable">
<tr class="v-firstrow"><th>Drug</th><th>Dose</th></tr>
<tr><td>Amiodarone</td><td>100 to 400 mg</td></tr>
<tr><td>Disopyramide</td><td>400 to 750 mg </td></tr>
<tr><td>Dofetilide</td><td>5000 to 1000 mcg </td></tr>
<tr><td>Flecainide</td><td>200 to 300 mg</td></tr>
<tr><td>Procainamide</td><td>1000 to 4000 mg</td></tr>
<tr><td>Propafenone</td><td>450 to 900 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>
</table>
 
===Pharmacological Agents for Heart Rate Control===
<table class="wikitable">
<tr class="v-firstrow"><th>Drug</th><th>Class/LOE <br> Recommendations</th><th>Loading Dose</th><th>Maintenance Dose</th></tr>
<tr><th>Acute Setting</th></tr>
<tr><th>Heart rate control in patients without accessory pathway</th></tr>
<tr><td>Esmolol</td><td>I C</td><td>500 mcg/kg IV over 1 min</td><td>60 to 200 mcg/kg/min IV</td></tr>
<tr><td>Propanolol</td><td>I C </td><td>0.15 mg/kg IV</td><td>NA</td></tr>
<tr><td>Metoprolol</td><td>I C </td><td>2.5 to 5 mg IV bolus over 2 min; up to 3 doses</td><td>NA</td></tr>
<tr><td>Diltiazem</td><td>I B</td><td>0.25 mg/kg IV over 2 min</td><td>5 to 15 mg/h IV</td></tr>
<tr><td>Verampil</td><td>I B</td><td>0.075 to 0.15 mg/kg IV over 2 min</td><td>NA</td></tr>
<tr><th>Heart Rate Control in patients with accessory pathway</th></tr>
<tr><td>Amiodarone</td><td>IIa C</td><td>150 mg over 10 min</td><td>0.5 to 1 mg/min IV</td></tr>
<tr><th>Heart Rate Control in patients with heart failure and without accessory pathway</th></tr>
<tr><td>Digoxin</td><td>I B</td><td>0.25 mg IV each 2 h, up to 1.5 mg</td><td>0.125 to 0.375 mg daily IV or orally</td></tr>
<tr><td>Amiodarone</td><td>IIa C</td><td>150 mg over 10 min</td><td>0.5 to 1 mg/min IV</td></tr>
<tr><th>Non-Acute Setting and Chronic Maintenance Therapy</th></tr>
<tr><th>Heart rate control</th></tr>
<tr><td>Metoprolol</td><td>I C</td><td>Same as maintenance dose</td><td>25 to 100 mg twice a day, orally</td></tr>
<tr><td>Propanolol</td><td>I C</td><td>Same as maintenance dose</td><td>80 to 240 mg daily in divided doses, orally</td></tr>
<tr><td>Verampil</td><td>I B</td><td>Same as maintenance dose</td><td>120 to 360 mg daily in divided doses; slow release available, orally</td></tr>
<tr><td>Diltiazem</td><td>I B</td><td>Same as maintenance dose</td><td>120 to 360 mg daily in divided doses; slow release available, orally</td></tr>
<tr><th>Heart Rate Control in patients with heart failure and without accessory pathway</th></tr>
<tr><td>Digoxin </td><td>I C</td><td>0.5 mg by mouth daily</td><td>0.125 to 0.375 mg daily, orally</td></tr>
<tr><td>Amiodarone</td><td>IIb C</td><td>800 mg daily for 1 wk, orally <br> 600 mg daily for 1 wk, orally <br> 400 mg daily for 4 to 6 wk, orally</td><td>200 mg daily, orally</td></tr>
</table>
 
===CHADS<sub>2</sub>Scoring for Predicting Risk of Stroke===
{| class="wikitable" style = "text-align:center"
!
!Condition
!Points
|-
| &nbsp;'''C'''&nbsp;
| &nbsp;[[Congestive heart failure]]
| <center>1</center>
|-
| &nbsp;'''H'''
| &nbsp;[[Hypertension]]: blood pressure consistently above 140/90 mmHg <br> (or treated hypertension on medication)
| <center>1</center>
|-
| &nbsp;'''A'''
| &nbsp;Age >/=75 years
| <center>1</center>
|-
| &nbsp;'''D'''
| &nbsp;[[Diabetes Mellitus]]
| <center>1</center>
|-
| &nbsp;'''S<sub>2</sub>''' 
| &nbsp;Prior [[Stroke]] or [[Transient ischemic attack | TIA]] 
| <center>2</center>
|}
{{Clr}}
 
{| class="wikitable" style = "text-align:center"
|-
! Score
! Risk
! Anticoagulation Therapy
! Considerations
|-
| '''0'''
| Low
| [[Aspirin]]
| Aspirin daily
|-
| '''1'''
| Moderate
| Aspirin or Warfarin
| Aspirin daily or [[International normalized ratio|INR]] to 2.0-3.0, depending on factors such as patient preference
|-
| '''2 or greater'''
| Moderate or High
| [[Warfarin]]
| [[International normalized ratio|INR]] to 2.0-3.0, unless contraindicated (e.g. clinically significant GI bleeding, inability to obtain regular INR screening)
|}
 
Anticoagulation is recommended for 3 wk prior to and 4 wk after cardioversion for patients with AF of unknown duration or with AF for
longer than 48 h.
When acute AF produces hemodynamic instability in the form of angina pectoris, MI, shock, or pulmonary edema, immediate cardioversion should not be delayed to deliver therapeutic anticoagulation, but intravenous unfractionated heparin or subcutaneous injection of a low-molecular-weight heparin should be initiated before cardioversion by direct-current countershock or intravenous antiarrhythmic medication.
 
===Risk Factors for Stroke and Recommended Antithrombotic Therapy===
<table class="wikitable">
<tr class="v-firstrow"><th>Low Risk Factors</th><th>Moderate Risk Factors</th><th>High Risk Factors</th></tr>
<tr><td>Female gender</td><td>Age ≥ 75 years</td><td>Previous stroke, TIA or embolism </td></tr>
<tr><td>Age 65-74 years</td><td>Hypertension</td><td>Mitral stenosis</td></tr>
<tr><td>Coronary artery disease</td><td>Heart failure</td><td>Prosthetic heart valve</td></tr>
<tr><td>Thyrotoxicosis</td><td>LV ejection fraction ≤ 35%</td><td> - </td></tr>
<tr><td> - </td><td>Diabetes mellitus</td><td> - </td></tr>
</table>
 
<table class="wikitable">
<tr class="v-firstrow"><th>Risk Category</th><th>Recommended Therapy</th></tr>
<tr><td>No risk factors</td><td>Aspirin, 81-325 mg daily</td></tr>
<tr><td>1 Moderate risk factor </td><td>Aspirin, 81-325 mg daily or <br> Warfarin (INR 2.0 to 3.0, target 2.5)</td></tr>
<tr><td>Any high risk factor or <br> more than 1 moderate risk factor</td><td>Warfarin<br> (INR 2.0 to 3.0, target 2.5)*</td></tr>
</table>

Revision as of 16:49, 10 March 2014

 
 
 
 
 
 
Atrial flutter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable
 
 
 
 
 
Stable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Look for the presence of any of these:
Chronic heart failure
Hypotension
Acute myocardial infarction
Attempt to terminate flutter with DC cardioversion
 
 
 
 
 
❑ Administer anticoagulation therapy based on the risk of stroke if total duration of flutter > 48 hours
Administer rate control therapy (AV nodal blockers)
THEN
Attempt conversion
DC cardioversion
Atrial pacing
Pharmacological cardioversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess need for therapy to prevent recurrence
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antiarrythmic therapy
Catheter ablation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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