Atrial fibrillation resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hilda Mahmoudi M.D., M.P.H.[2]; Vidit Bhargava, M.B.B.S [3]; Priyamvada Singh, M.D. [4]; Rim Halaby, M.D. [5]; Mugilan Poongkunran M.B.B.S [6]

Atrial fibrillation resident survival guide Microchapters
Overview
Classification
Causes
FIRE
Complete Diagnostic Approach
Treatment
New Onset AFib
Recurrent AFib
Permanent AFib
Rate Control Strategy
Maintenance of Sinus Rhythm
Cardioversion Strategy
Anticoagulation Strategy
Do's
Dont's

Overview

Atrial fibrillation (AF) is a supraventricular tachyarrhythmia characterized by uncoordinated atrial activation leading to an irregularly irregular rhythm and absent P waves on ECG. It is characterized by palpitations, dyspnea, chest discomfort, syncope, etc. and can be triggered by a number of conditions. It can be a serious life threatening disorder as the irregular atrial rhythm with rate of 400-700 beats/min may transpire into a rapid ventricular rhythm eventually leading to ventricular failure. It can occur in a heart with underlying structural heart defect or in a structurally normal heart. Treatment of AF depends on hemodynamic status of the patient. If unstable, rapid DC cardioversion is attempted, otherwise rate control and anticoagulation are the treatment of choice, followed by antiarrhythmic therapy.

Classification

Paroxysmal Atrial Fibrillation

Atrial fibrillation is paroxysmal when it terminates within 7 days of onset (most frequently in less than 24 hours) either spontaneously or with intervention.

Persistent Atrial Fibrillation

Atrial fibrillation is persistent when it is continuous for more than 7 days.

Long Standing Persistent Atrial Fibrillation

Atrial fibrillation is long standing persistent when it continuous for more than 12 months.

Permanent Atrial Fibrillation

Atrial fibrillation is permanent when it lasts for a longer period and there has been a joint decision made by clinician and patient to cease all attempts to restore and/or maintain sinus rhythm.

Non-valvular Atrial Fibrillation

Atrial fibrillation in the absence of rheumatic mitral stenosis, a mechanical valve or bioprosthetic heart valve, or mitral valve repair.

Causes

Life Threatening Causes

Atrial fibrillation can be a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in red color signify that an urgent management is needed.

Abbreviations: EKG: Electrocardiogram; SBP: Systolic blood pressure

 
 
 
 
 
 
 
 
Identify cardinal findings that increase the pretest probability of atrial fibrillation:

Palpitations
Irregularly irregular pulse
Heart rate > 100 beats/min
❑ Typical EKG findings:

❑ Lack of discrete P waves
❑ Variability in the intervals between QRS complexes
❑ Narrow QRS complexes
❑ Ventricular rate of 90 to 170 beats/min
Absent P waves and irregularly irregular heart rate, suggestive of atrial fibrillation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following findings that require urgent cardioversion?

❑ Hemodynamic instability

Hypotension
Cold extremities
Peripheral cyanosis
Mottling
Altered mental status

❑ Acute ischemia

Chest discomfort
EKG findings for acute coronary syndrome

Decompensated heart failure

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient has any symptoms and signs of pulmonary edema?

Dyspnea
Crackles

Chest X-ray (pulmonary edema)
 
Proceed with the complete diagnostic approach below
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Manage pulmonary edema:

❑ Initiate oxygen therapy
❑ High dose IV diuretics
❑ BP management

❑ SBP 85 - 100 mm Hg (dobutamine or milrinone)
:❑ SBP < 85 mm Hg (dopamine and norepinephrine)
 
Immediate DC cardioversion
❑ 120-200 Joules biphasic or 200 Joules monophasic [3][4]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
After initial pulmonary edema management proceed with DC cardioversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Successful
 
Unsuccessful
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
After stabilization proceed with the complete diagnostic approach below
 
Repeat cardioversion
❑ Adjust the location of the electrodes
❑ Apply pressure over the electrodes
❑ May proceed after a trial of antiarrhythmic medication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
After stabilization proceed with the complete diagnostic approach below
 
 
 

Complete Diagnostic Approach to Atrial Fibrillation

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.

Abbreviations: AF: Atrial fibrillation; COPD: Chronic obstructive pulmonary disease; EKG: Electrocardiogram; MI: Myocardial infarction; TSH: Thyroid stimulating harmone

 
 
 
 
 
 
 
 
Characterize the symptoms:

❑ Asymptomatic
Palpitations
Fatigue
Lightheadedness
Mild shortness of breath
Increased urination
Severe dyspnea
Chest discomfort (suggestive of angina or MI)
Presyncope/ syncope
Abdominal distension (suggestive of right heart failure)
Leg swelling (suggestive of right heart failure)
Weakness (suggestive of an embolic event)
Hemoptysis (suggestive of an embolic event)

Characterize the timing of the symptoms:
❑ Onset

❑ First episode
❑ Recurrent

❑ Duration
❑ Frequency
❑ Termination of the episode

❑ Spontaneous
❑ Medication use
❑ Not terminated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Vital signs:
Pulse

Tachycardia
❑ Irregularly irregular (typical)

Blood pressure

Hypertension
Hypotension (suggestive of ventricular dysfunction)
❑ Narrow pulse pressure (suggestive of congestive heart failure)

Respiratory rate

Tachypnea

Skin:
Diaphoresis
Peripheral edema (suggestive of right heart failure)

Cardiovascular system:
Tachycardia
❑ Any murmur (suggestive of valvular heart disease)
Jugular vein distention
❑ Flutter waves in jugular vein
Third heart sound (suggestive of heart failure)
Gallop rhythm

Respiratory system:
Crackles (suggestive of pulmonary edema)
❑ Hyperresonance/hyperinflation/wheeze (suggestive of COPD)

Eye:
Exopthalmos (suggestive of hyperthyroidism)
Retinal hemorrhage (suggestive of malignant hypertension)

Neck:
Thyroid enlargement

Neurological system:
Stroke (in case of thromboembolism)

Signs of embolization:
❑ Cold extremities
❑ Loss of distal pulsations
Pallor of the extremity
❑ Muscle pain/spasm in concerned area
❑ Weakness/lack of movement
Tingling and numbness


Order an EKG:
❑ Atrial fibrillation rhythm

❑ Irregularly irregular rhythm
❑ Absent P waves
❑ Atrial rate 400-700 beats/minute
❑ Ventricular rate 75-180 beats/minute

A fib with LVH.jpg

❑ Other signs on EKG

Left ventricular hypertrophy
Preexcitation
Bundle branch block
❑ Previous myocardial infarction
❑ Other types of arrhythmias
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Order blood tests: (if AF has not been investigated before)
Complete blood count
Serum glucose
Serum electrolytes
TSH and free T4
❑ Serum BUN and creatinine
Coagulation studies (INR/aPTT)
Serum cardiac troponin I and T (in case of acute-onset AF associated with chest pain)

Order imaging studies:
❑ Order a chest X-ray

❑ Cardiogenic pulmonary edema
Cardiomegaly
❑ To detect any pulmonary cause (COPD/pneumonia)

❑ Order a TTE or TEE

❑ To evaluate the size of the right and left atria
❑ To detect possible valvular heart disease
❑ To identify thrombi in the left atrium or left atrial appendage

Other tests:
Holter monitor

❑ If arrhythmia is intermittent and not captured on routine EKG

Exercise Stress Testing

❑ To exclude ischemia before treatment of selected patients with a type IC antiarrhythmic drug
❑ To reproduce exercise induced AF
❑ If the adequacy of rate control is in question (permanent AF)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
New onset paroxysmal AF

❑ First Episode
❑ Lasts less than 7 days

❑ Usually self terminating
 
New onset persistent AF

❑ First Episode
❑ Lasts more than 7 days

❑ Doesn't terminate on its own
 
Recurrent paroxysmal AF

❑ Previous history of AF
❑ Lasts less than 7 days

❑ May or may not be self terminating
 
Recurrent persistent AF

❑ Previous history of AF
❑ Lasts more than 7 days

❑ Needs medical or surgical management
 
Permanent AF

Fibrillation present continuously

❑ Needs constant management
 

Treatment

New Onset Atrial Fibrillation

Shown below is an algorithm depicting the management of patients with newly discovered atrial fibrillation based on the 2014 ACCF/AHA/HRS Guideline for the Management of Patients With Atrial Fibrillation.[5]

Abbreviations: AF: Atrial fibrillation; BP: Blood pressure; bpm: Beats per minute; DC: Direct current; EF: Ejection fraction; HR: Heart rate; SBP: Systolic blood pressure

 
 
 
 
 
 
 
 

New onset atrial fibrillation

(Paroxysmal or persistent or permanent)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Stable:
❑ Asymptomatic
OR

❑ Mild to moderate symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient require heart rate control therapy?
 
 
 
 
 
 
 
Does the patient has any symptoms and signs of pulmonary edema?

Dyspnea
Crackles

Chest X-ray showing pulmonary edema
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No (spontaneous cardioversion)
 
Yes
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Identify the underlying etiology and treat accordingly
❑ Proceed with anticoagulation strategy as shown below
 
❑ Proceed with the heart rate control strategy
 
 
 
Manage pulmonary edema:

❑ Initiate oxygen therapy
❑ High dose IV diuretics
❑ BP management

SBP 85 - 100 mm Hg (dobutamine or milrinone)
❑ SBP < 85 mm Hg (dopamine and norepinephrine)
 
Immediate DC cardioversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Did the patient achieve heart rate control goal:

❑ Resting HR <110 bpm in asymptomatic and EF > 40% patients
❑ Resting HR <80 bpm in symptomatic and EF < 40% patients

 
 
 
After initial pulmonary edema management proceed with DC cardioversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
Successful
 
Unsuccessful
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Identify the underlying etiology and treat accordingly
❑ Proceed with cardioversion strategy for initial symptomatic patients as shown below
❑ Proceed with anticoagulation strategy as shown below
 
❑ Identify the underlying etiology and treat accordingly
❑ Proceed with cardioversion strategy as shown below
❑ Proceed with anticoagulation strategy as shown below
 
Identify the underfying cause and treat accordingly
 
Repeat cardioversion:
❑ After adjusting the location of the electrodes and applying pressure over the electrodes
OR
❑ After administration of an antiarrhythmic medication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with the anticoagulation strategy
 
 
 
 
 

Note: For the treatment of newly persistent AF, choose the therapy depending on the severity of symptoms and the risk of administration of anti-arrhythmic.

Recurrent Atrial Fibrillation

Shown below is an algorithm depicting the management of patients with recurrent atrial fibrillation based on the 2014 ACCF/AHA/HRS Guideline for the Management of Patients With Atrial Fibrillation.[5]

Abbreviations: AF: Atrial fibrillation; bpm: Beats per minute; DC: Direct current; EF: Ejection fraction; HR: Heart rate

 
 
 
 
 
 
 
 

Recurrent atrial fibrillation

(Paroxysmal or persistent)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asymptomatic
 
 
 
 
 
 
 
Symptomatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Identify the underlying etiology and treat accordingly
❑ Proceed with heart rate control strategy as shown below
 
 
 
 
 
 
 
❑ Identify the underlying etiology and treat accordingly
❑ Proceed with heart rate control strategy as shown below
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Did the patient achieve heart rate control goal:

❑ Resting HR <110 bpm in asymptomatic and EF > 40% patients
❑ Resting HR <80 bpm in symptomatic and EF < 40% patients

 
 
 
 
 
 
 
Did the patient achieve heart rate control goal:

❑ Resting HR <110 bpm in asymptomatic and EF > 40% patients
❑ Resting HR <80 bpm in symptomatic and EF < 40% patients

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Initiate long term rate control strategy
❑ Proceed with anticoagulation strategy as shown below
 
❑ Proceed with the cardioversion strategy
 
 
 
❑ Proceed with the cardioversion strategy
 
❑ Initiate antiarrhythmic drug therapy for maintenance of sinus rhythm
❑ Proceed with anticoagulation strategy as shown below
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Successful (sinus rhythm)
 
 
 
Unsuccessful (AF)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Initiate antiarrhythmic drug therapy for maintenance of sinus rhythm
❑ Proceed with anticoagulation strategy as shown below
 
 
 
❑ Initiate long term rate control strategy
❑ Proceed with anticoagulation strategy as shown below
❑ Consider catheter ablation
 
 
 

Permanent Atrial Fibrillation

Shown below is an algorithm depicting the management of patients with permanent atrial fibrillation based on the 2011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[6]

Permanent AF
 
 
 
 
 

❑ Initiate long term rate control strategy
❑ Proceed with anticoagulation strategy as shown below


Rate Control Strategy

Shown below is an algorithm depicting the management of ventricular rate in patients with atrial fibrillation based on the 2014 ACCF/AHA/HRS Guideline for the Management of Patients With Atrial Fibrillation.[5]

Abbreviations: AF: Atrial fibrillation; bpm: Beats per minute; COPD: Chronic obstructive pulmonary disease; CVD: Cardiovascular disease; EF: Ejection fraction; HF: Heart failure; HFpEF: Heart failure with preserved ejection fraction; HFrEF: Heart failure with reduced ejection fraction; HR: Heart rate; LV: Left ventricle

 
 
 
 
 
 
 
 
 
 
Stable AF patients requiring heart rate control therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Heart rate control goal:

❑ Resting HR <110 bpm in asymptomatic and EF > 40% patients
❑ Resting HR <80 bpm in symptomatic and EF < 40% patients

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any evidence of an accessory pathway (pre-excitation syndrome)?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NO
 
 
 
 
 
YES
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
COPD
 
HFrEF or LV dysfunction
 
Hypertension or HFpEF or No CVD
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Nondihydropyridine calcium channel blockers: Most preferred
OR
Beta blockers: Cardioselective
❑ Oral vs IV according to the clinical urgency

 

Beta blockers: After stabilization in patients with decompensated HF
OR
Digoxin
❑ Oral vs IV according to the clinical urgency

 

Beta blockers
OR
Nondihydropyridine calcium channel blockers
❑ Oral vs IV according to the clinical urgency

 

Procainamide
OR
Ibutilide
❑ Oral vs IV according to the clinical urgency

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Amiodarone
❑ Oral vs IV according to the clinical urgency

 
 
 
 
 
Consider catheter ablation if the accessory pathway has a short refractory period that allows rapid antegrade conduction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Rate Control Drugs & Dosages

Shown below is a table summarizing the list of recommended agents for control of heart rate and their dosages.[6]

Heart Rate Control in Acute Setting
Drug Loading dose Maintenance dose
Heart rate control in patients without accessory pathway
Esmolol
(class I, level of evidence C)
500 mcg/kg IV over 1 min 60 to 200 mcg/kg/min IV
Propanolol
(class I, level of evidence C)
0.15 mg/kg IV NA
Metoprolol
(class I, level of evidence C)
2.5 to 5 mg IV bolus over 2 min; up to 3 doses NA
Diltiazem
(class I, level of evidence B)
0.25 mg/kg IV over 2 min 5 to 15 mg/h IV
Verapamil
(class I, level of evidence B)
0.075 to 0.15 mg/kg IV over 2 min NA
Heart rate control in patients with accessory pathway
Amiodarone
(class IIa, level of evidence 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
(class I, level of evidence B)
0.25 mg IV each 2 h, up to 1.5 mg 0.125 to 0.375 mg daily IV or orally
Amiodarone
(class IIa, level of evidence C)
150 mg over 10 min 0.5 to 1 mg/min IV
Heart Rate Control in Non Acute Setting and Long Term Maintenance
Heart rate control
Metoprolol
(class I, level of evidence C)
25 to 100 mg twice a day, orally 25 to 100 mg twice a day, orally
Propanolol
(class I, level of evidence C)
80 to 240 mg daily in divided doses, orally 80 to 240 mg daily in divided doses, orally
Verapamil
(class I, level of evidence B)
120 to 360 mg daily in divided doses, orally 120 to 360 mg daily in divided doses, orally
Diltiazem
(class I, level of evidence B)
120 to 360 mg daily in divided doses, orally 120 to 360 mg daily in divided doses, orally
Heart Rate Control in patients with heart failure and without accessory pathway
Digoxin
(class I, level of evidence B)
0.5 mg by mouth daily 0.125 to 0.375 mg daily, orally
Amiodarone
(class IIb, level of evidence C)
800 mg daily for 1 week, orally
600 mg daily for 1 week, orally
400 mg daily for 4 to 6 week, orally
200 mg daily, orally

Maintenance of Sinus Rhythm

Shown below is an algorithm depicting the antiarrhythmic drug therapy for maintaining sinus rhythm in patients with recurrent paroxysmal or persistent atrial fibrillation based on the 2011 ACCF/AHA/HRS updates for the management of atrial fibrillation. Drugs are listed alphabetically and not in order of suggested use.[6]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Maintenance of sinus rhythm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No or minimal heart disease
 
 
 
 
 
Hypertension
 
 
 
 
 
Coronary artery disease
 
 
 
Heart failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
First line therapy:
Dronedarone
Flecainide
Propafenone
Sotalol
 
 
 
 
 
Substantial LVH
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Second line therapy:
Amiodarone
Dofetilide
 
Catheter ablation
 
No
 
Yes
 
Amiodarone
 
Catheter ablation
 
Catheter ablation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Amiodarone
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Catheter ablation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Catheter ablation
 
 
 
 
 
 
 
 


Drugs & Dosages

Shown below is a table summarizing the list of recommended agents for maintenance of sinus rhythm and their dosages.[6]

Maintenance of sinus rhythm
Drug Dose Avoid or Use with caution
Disopyramide Immediate release: 100-200 mg QID
Extended release: 200-400 mg BID
HF
Prolonged QT interval
Prostatism
Glaucoma
Avoid other QT interval-prolonging drugs
Quinidine 324-648 mg TID Prolonged QT interval
Diarrhea
Flecainide 350-200 mg BID Sinus or AV node dysfunction
HF
CAD
Atrial flutter
Infranodal conduction
Propafenone Immediate release: 150-300 mg TID
Extended release: 225-425 mg BID
Sinus or AV node dysfunction
HF
CAD
Atrial flutter
Infranodal conduction
Brugada syndrome
Liver disease
Asthma
Amiodarone Oral: 400-600 mg daily in divided doses for 2-4 wk; maintenance typically 100-200 mg QD
IV: 150 mg over 10 min; then 1 mg/min for 6 h; then 0.5 mg/min for 18 h or change to oral dosing; after 24 h, consider decreasing dose to 0.25 mg/min
Sinus or AV node dysfunction
Infranodal conduction
Prolonged QT interval
Dofetilide 125-500 mcg BID Prolonged QT interval
Renal disease
Hypokalemia
Diuretic therpay
Avoid other QT interval-prolonging drugs
Dronedarone 400 mg BID Bradycardia
HF
Long-standing or persistent AF/flutter
Liver disease
Prolonged QT interval
Sotalol 40-160 mg BID Prolonged QT interval
Renal disease
Hypokalemia
Diuretic therapy
Avoid other QT interval prolonging drugs
Sinus or AV nodal dysfunction
HF
Asthma

Cardioversion Strategy

Shown below is an algorithm depicting the cardioversion treatment in patients with atrial fibrillation.[5]

Abbreviations: AF: Atrial fibrillation; LA: Left atrium; TEE: Transesophageal echocardiogram

Choice of Cardioversion

 
 
 
 
 
 
 
 
 
Does the patient have any signs of hemodynamic instability
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recurrent paroxysmal or persistent AF
 
 
 
New onset AF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No structural heart disease
 
Structural heart disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pharmacological cardioversion
 
DC cardioversion
 
Pharmacological cardioversion
 
DC cardioversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

DC Cardioversion Strategy

 
 
 
 
 
 
 
 
 
 
 

Does the patient with AF has any contraindication for cardioversion :
Asymptomatic elderly patients (>80 years) with multiple comorbidities
❑ Patients with high risk of bleeding

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anticoagulation strategy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ <48 hours
 
 
 
 
 
 
 
❑ >48 hours
❑ Unknown duration
❑ Prior history of a thromboembolism
❑ Prior history of TEE evidence of left atrial thrombus
❑ Mitral valve disease or significant cardiomyopathy or heart failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ IV heparin
 
 
 
 
 
❑ 3 week oral anticoagulation
 
 
 
TEE
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cardioversion
 
 
 
 
 
 
 
 
 
 
No LA thrombus
 
 
LA thrombus
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sinus rhythm
 
Atrial fibrillation
 
 
 
 
 
 
 
 
❑ IV heparin
 
 
❑ 3 week oral anticoagulation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Initiate 4 week anticoagulation therapy after cardioversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat TEE showing no LA thrombus
 
Repeat TEE showing LA thrombus
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cardioversion
 
 
 
 
❑ Initiate rate control & proceed with other management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Atrial fibrillation
 
Sinus rhythm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Repeat cardioversion or use AV nodal blocking agents
 
 
 
 
 
❑ 4 week anticoagulation after cardioversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sinus rhythm
 
Atrial fibrillation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Initiate 4 week anticoagulation therapy
 
❑ Initiate 4 week anticoagulation therapy
❑ Proceed with other management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Pharmacological Cardioversion Drugs & Dosages

Shown below is a table summarizing the pharmacological cardioversion for atrial fibrillation of a duration less or more than 7 days.[6]

Pharmacological Cardioversion for Atrial Fibrillation of a Duration Up to 7 Days
Drug Dosage
Dofetilide
(class I, level of evidence A)
Oral dose depends on creatinine clearance (ml/min):
> 60: 500 mg, BID
40 to 60: 250 mg, BID
20 to 40: 125 mg, BID
< 20: contraindicated
Flecainide
(class I, level of evidence A)
Oral: 200 to 300 mg
▸ Intravenous: 1.5 to 3.0 mg/kg, over 10 to 20 min
Ibutilide
(class I, level of evidence A)
Intravenous: 1 mg over 10 min, repeat 1 mg if necessary
Propafenone
(class I, level of evidence A)
Oral: 600 mg
▸ Intravenous: 1.5 to 2.0 mg/kg, over 10 to 20 min
Amiodarone
(class IIa, level of evidence A)
Oral:
Inpatient
1.2 to 1.8 g per day in divided dose until a maximum of 10 g
Followed by a maintenance dose of 200 to 400 mg per day or 30 mg/kg
Outpatient
600 to 800 mg per day divided dose until a maximum of 10 g
Followed by a maintenance dose of 200 to 400 mg per day

Intravenous:

5 to 7 mg/kg, over 30 to 60 min
Followed by 1.2 to 1.8 g per day continuous IV
OR
5 to 7 mg/kg, in divided oral doses until a maximum of 10 g
Followe by a maintenance dose of 200 to 400 mg per day
Pharmacological Cardioversion for Atrial Fibrillation of a Duration More Than 7 Days
Drug Dosage
Dofetilide
(class I, level of evidence A)
Oral dose depends on creatinine clearance (ml/min):
> 60: 500 mg, BID
40 to 60: 250 mg, BID
20 to 40: 125 mg, BID
< 20: contraindicated
Ibutilide
(class IIa, level of evidence A)
Intravenous: 1 mg over 10 min; repeat 1 mg when necessary
Amiodarone
(class IIa, level of evidence A)
Oral:
Inpatient
1.2 to 1.8 g per day in divided dose until a maximum of 10 g
Followed by a maintenance dose of 200 to 400 mg per day or 30 mg/kg
Outpatient
600 to 800 mg per day divided dose until a maximum of 10 g
Followed by a maintenance dose of 200 to 400 mg per day

Intravenous:

5 to 7 mg/kg, over 30 to 60 min
Followed by 1.2 to 1.8 g per day continuous IV
OR
5 to 7 mg/kg, in divided oral doses until a maximum of 10 g
Followe by a maintenance dose of 200 to 400 mg per day

Anticoagulation Strategy

Shown below is an algorithm depicting the assessment of risk of stroke and the appropriate anticoagulation therapy among patients with AF.[5]

Abbreviations: AF: Atrial fibrillation; BID: Twice daily; CrCL: Creatinine clearance; INR: International normalized ratio; QD: Once daily

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess the absolute and relative risk of bleeding before initiating long term anticoagulation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-valvular AF
 
 
 
 
 
AF with valvular heart disease
 
 
 
 
 
AF with mechanical heart valves
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess CHA2DS2-VASc scoring risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Score 0
 
Score 1
 
Score ≥ 2
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No antithrombotic therapy
 
No antithrombotic therapy or may consider an oral anticoagulant or aspirin
 
Oral antithrombotic therapy:

Warfarin:

❑ Target INR 2-3
INR determined weekly before stabilization

Dabigatran, or rivaroxaban, or apixaban:

❑ Evaluate renal function before initiation
❑ Dont use apixaban in patients with severe hepatic impairment
 
Oral antithrombotic therapy:

Warfarin:

❑ Target INR 2-3
INR determined weekly before stabilization
 
 
 
 
 
Oral antithrombotic therapy:

Warfarin:

❑ Target INR 2-3 or 2.5-3.5 based on type and location of valve

Caution:

❑ Dont use direct thrombin inhibitor and dabigatran
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the INR of patients on warfarin stabilize to the recommended value
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine INR every month
 
Direct thrombin or factor Xa inhibitor:

Dabigatran, rivaroxaban, or apixaban:

❑ Evaluate renal function before initiation

Caution:

❑ Dont use in patients with end-stage CKD or on hemodialysis
 
 
 
 
 
Determine INR weekly before stabilization and then every month
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Note: For patients with AF undergoing procedures that require interruption of warfarin bridging therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is needed.

Oral Anticoagulant Drugs and Dosages

Shown below is a table summarizing the list of recommended oral anticoagulant drugs and their dosages.[6]

Renal function Dabigatran Rivaroxaban Apixaban
Normal or mild impairment 150 mg BID 20 mg QD with the evening meal 5.0 or 2.5 mg BID
Moderate impairment (CrCl >30 mL/min) 150 or 75 mg BID 15 mg QD with the evening meal 5.0 or 2.5 mg BID
Severe impairment (CrCl 15-30 mL/min) 75 mg BID 15 mg QD with the evening meal No recommendation
End-Stage CKD on/not dialysis (CrCl <15 mL/min) Not recommended Not recommended Not recommended

Note: Warfarin dose is adjusted for an of INR 2.0-3.0 in patients with any severity of the renal impairment.

CHA2DS2-VASc Scoring System

CHA2DS2-VASc
Variable Score
Age ≥75 years 2
Age 65-74 years 1
Female sex 1
Diabetes mellitus 1
Hypertension 1
Congestive heart failure 1
Stroke/TIA/Thromboembolism 2
Vascular disease (prior MI, PAD, or aortic plaque) 1

Do's

Rate Control

Antithrombotic Therapy

Cardioversion

Dont's

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. "Part 8: Adult Advanced Cardiovascular Life Support". Retrieved 3 April 2014.
  4. "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.
  5. 5.0 5.1 5.2 5.3 5.4 January CT, Wann LS, Alpert JS, Calkins H, Cleveland JC, Cigarroa JE; et al. (2014). "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society". J Am Coll Cardiol. doi:10.1016/j.jacc.2014.03.021. PMID 24685668.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 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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