New Onset Atrial Fibrillation
Check:
Consider:
•ECG , Echo (? Structurally normal)
•Troponin, D-Dimers (?PE)
•Perfusion Indices esp Lactate
•CXR - ? LVF, ? CVC tip in RA
•Drug chart – drugs affecting Q-T
eg Antibiotics, antifungals,
antipsychotics, antiretrovirals
Rx:
• Restart previous antiarrhythmics
(particularly Beta Blockers)
• Give K, Mg, FiO2, PO4, Ca if ↓
• Give fluid challenge
• Ensure adequate analgesia /
sedation
• Treat LVF
Invasive
Haemodynamic
Monitoring
(increase sampling
time for greater
accuracy)
Unstable
Stable
(SBP > 90, no Ischaemia)
1° line - Amiodarone
(2° line – Vernakalant – v expensive)
INITIAL
MANAGEMENT
(SBP < 90, Ischaemia)
1st line - Amiodarone  DC Shock
2nd line - Low dose Norad  IV short
acting Beta Blocker
Still in AF after 60 mins
•Rpt Mg (>1.5), K (>4.5)
•Trial Rate Control : IV Metoprolol or Diltiazem if CVS stable
•If still on vasopressors, change Norad to Vasopressin ( less arythmogenic )
Still in AF after 24 hrs
•Add Digoxin
•If contra-indication to Anticoagulation, consider :
o Vernakalant
o Propafenone (if no structural abnormality on echo) =>DC Shock
Still in AF after 48 hrs
•Consider Anticoagulation if High Risk of Stroke (check CHADS2VASC +
HASBLED scores)
oHigh Risk (MS, Dilated LA, Poor LV, LVH) = Full
oLow Risk + High bleeding risk = Aspirin or Clopdogrel
•Stop Amiodarone (unless previous Broad complex tachy)
•TTE (TOE if DC cardioversion planned) once rate controlled
Predisposing factors:
•Dilated RA – COAD, OSA, Pulm. / Systemic Hypertension, Pneumonia, LVF, Alcohol, IHD
•Primary Cardiac Abnormality – Mitral stenosis, accessory bundle (WPW), Atrial myxoma
•Infection – Endocarditis (partic. Ao root), Pericarditis, Myocarditis
•Others – Pulmonary Embolism, Dig. Toxicity ,Beta agonists, Thyrotoxicosis, Cardiac trauma
Exacerbating factors  Irritable Myocardium:
 Adrenaline – pain, anxiety, LVF, Hypovolaemia
 Electrolytes – K (aim > 4.5 – 5.0), Mg (aim > 1.5)
CVP line tip irritation, Thyrotoxicosis
Severe Acidosis / Alkalosis
Hypoxaemia / Ischaemia and Sepsis
Doses
DC Cardioversion – 3 shocks @ 200, 360 and 360J, max likelihood of success with Propafenone / Amiodarone
MgSO4 – 20mmol over 30mins
Digoxin – Load with 0.5 – 1.0mg in divided doses over 24hrs, maintenance 0.0625 – 0.25mg/24hrs
Metoprolol – 0.5-1mg IV if on Norad, 2.5mg – 5mg IV bolus if stable  TDS
Diltiazem - 30mg po qds, max 360mg / day in divided doses. IV 0.25mg/kg bolus over 2mins
Verapamil – 5-10mg IV bolus after cardiology review only
Propafenone – 150mg po tds prior to DC cardioversion after cardiology review only
Vernakalant – 3mg/kg IV over 10mins after cardiology review only
Amiodarone – Loading 300mg over 10 mins  900mg over first 24hrs  600mg over next 24hrs  STOP
Ibutilide – 0.01mg/kg iv (1mg if > 60kg), rpt after 10min if required, for conversion of Atrial Flutter after cardiology review only
Ivabridine – 5mg po bd, useful for catecholamine induced sinus tachycardia in patients with reduced ejection fraction
Use CHA2DS2-VASC score to estimate risk if stroke :
**Chronic heart failure - 1pt
**Hypertension - 1pt
**Age > 75 - 2pts
**Diabetes - 1pt
**Stroke in past - 2pts
**Vascular disease - 1pt
**Age 65-74 - 1pt
**Sex Category - 1pt if female
Score > 1 - anticoagulation advised
Use HASBLED score to estimate risk of bleeding :
**Hypertension
**Abnormal liver / renal function
**Stroke history
**Bleeding pre-disposition
**Labile INR's
**Elderly (age > 65)
**Drugs / alcohol use
**Use of Antiplatelet therapy / NSAIDs
Score 1 point for each, score > 2 - High risk