Acute Management of
Atrial Fibrillation
Dalia Hawwass PGY2
June 2015
Objectives
• To review the initial management of atrial
fibrillation with RVR in acute setting
• Assessment for hemodynamic instability
• Indications for urgent cardioversion
• Different Rate Control agents
Case Vignette
• A 75 year old woman with PMHx of HTN, HLD and DM, CKD
presents to ED for new onset dizziness, shortness of breath
and palpitations that began 3 hours ago while patient was
gardening in her lawn. She denies any associated chest pain
and no actual loss of consciousness.
• Vital Signs: T: 37.5 C, BP 90s/60s (Baseline BP 115/80s), HR
140s-160s bpm and RR 24. A&O x3 with some facial
grimmace. Cardiac exam is irregulary irregular without
murmurs. Lungs CTAB. Remainder of exam unremarkable.
• She received a 2L bolus in the ED without increase in blood
pressure
EKG
What is the next appropriate management
for this patient?
• A) IV diltiazem
• B) Intubation
• C) Urgent Cardioversion
• D) IV pain control
• E) CT pulmonary angiogram
Indications for Urgent Direct Cardioversion
• Hemodynamic Instability:
• Patient with decompensated heart failure
• Active ischemia: if symptomatic with angina or
evidence of ischemia/infarction on EKG
• Evidence of organ hypoperfusion (altered
mental status, cold clammy skin, acute kidney
injury)
Urgent Cardioversion
• Electrical Cardioversion: sedate patient and place
setting on direct synchronization then shock
• Initial shock setting of 100J 200J 300J 360J until
sinus rhythm returns
• Make sure you perform direct cardioversion with R
wave synchronization to prevent an “R on T”
phenomenon which can lead to V fib
• Restoration of normal sinus rhythm takes precedence
over need for protection from thromboembolic risk
• Would recommend cardiology consult at this time
If Patient is Hemodynamically Stable
• Goal is ventricular rate control (<100 bpm) and anticoagulation
•
Resting HR goal should be 60-85 bpm in symptomatic patient
• Roughly 50% of patients with new onset AF will spontaneously convert to
NSR spontaneously within 48 hours of onset
• Rate control or Rhythm control?
•
AFFIRM trial and RACE trial
•
No survival advantage in terms of stroke prevention rhythm control over rate
control rate control
• Rate control agents
•
•
•
•
Calcium Channel Blockers
Beta blockers (caution in patients with reactive airway disease)
Digoxin
Amiodarone (for patients intolerant or unresponsive to other agents)
Rate Control Agents
Drug Classes
Drug
Loading Dose
Maintenance
Dose
Calcium Channel
Blockers (nondihydropyridine)initial DOC
Diltiazem
10 mg IV over 2
minutes
Can repeat up to
20 mg IV
30 mg PO q6 hrs
(can transition to
long acting)
Can use 10 mg IV
q6 hrs prn
Beta Blockersinitial DOC
Metoprolol
5 mg IVP q5min
x3 doses
25 mg PO BID,
can uptitrate to
100mg PO BID
Digoxin
0.5 mg IV loading
dose0.25mg IV
in 6 hrs0.25mg
IV 6 hrs after
0.125 mg PO QD
Amiodarone
150 mg IV/10
min 1mg/minx
6 hrs 0.5
mg/min x 18hrs
100-200 mg PO
QD
Other
Other
Rate Control Agents
Calcium Channel blockers-non-dihydropyridine
agents
• IV diltiazem-initial dose 10 mg IV over 2 minutes
• Can increase dose to 20mg IV if needed
• Maintenance diltiazem 30mg PO q6hrs (short
acting) or can transition to total long acting
diltiazem
• Can also use 10mg IVP q6 hrs prn
• Start PO dose at same time as IV dosing, so PO
can kick in by time IV dosing wears off
Rate Control Agents
Beta blockers
• Metoprolol- Initial dose: 5mg IVP q5 minutes x3
doses and q6hrs prn
• Maintenance Dose: 25 mg PO BID, can uptitrate to
100mg PO BID max
• Start PO at same time as IV medication
• Esmolol –Initial dose: 500mcg/kg IV over 1 min, can
repeat in 5 minutes
• Maintenance drip: 50-300 mcg/kg per min IV continuous
infusion
• Used only in ICU:
• Advantage: short duration of action, easy to titrate to
heart rate goal
Rate Control Agents
Digoxin can be used in acute setting but rarely as
monotherapy
• Initial loading dose: 0.5mg IVthen 0.25mg IV in 6
hrs0.25 mg IV 6 hours after
• Maintenance dose: 0.125mg daily PO
• Caution in elderly patients and those with renal
failure (need to renally dose)
• TREAT-AF study-increased risk in mortality in elderly
patients by >20% on digoxin
• Indicated in patients with LVEF<30% (inotropic
agent)
Rate Control Agents
Amiodarone- both a rate control and rhythm control
agent
• Initial loading dose: 150 mg IV over 10 minutes, then
1 mg/min x 6 hrs, then 0.5mg/min x18 hrs
• Maintenance dose: can change to oral 100mg200mg daily
• Can promote cardioversion-so need to be on
anticoagulation
• Preferred agent in WPW to prevent AF impulses
down accessory pathway leading to promotion of
VF
Case Revisited
What is the next appropriate management for
this patient?
A)
B)
C)
D)
E)
IV diltiazem
Intubation
Urgent Cardioversion
IV pain control
CT pulmonary angiogram
Summary
• If patient is hemodynamically unstable in
setting of atrial fibrillation (with hypotension,
angina, decompensated heart failure, AMS)
then proceed with direct synchronized
cardioversion
• Rate control is goal for Afib with RVR for
symptomatic management
• Initial rate control agents are diltiazem or
metoprolol
References
• Uptodate.com: Topics: Acute Management of Atrial Fibrillation
• Uptodate.com: Topics: Rhythm Control vs Rate Control in Atrial
Fibrillation
• January, Craig T. et al. “2014 AHA/ACC/HRS Guideline for
Management of Patient with Atrial Fibrillation: Executive
Summary." Journal of American College of Cardiology (2014): n.
pag. American College Cardiology Foundation. Web. 29 Sept. 2014.
http://content.onlinejacc.org/article.aspx?articleid
• wmshp.org/sg_userfiles/Sarigianis_CE_10172013_handout.pptx
• King, D, Dickerson, Sack J. Acute Management of Atrial
Fibrillation: Part I. Rate and Rhythm Control. Am Fam Physician.
2002 Jul; 66(2): 249-257.