Atrial Fibrillation

LITERATURE

General Treatment Considerations

  • Multifaceted Treatment plan
    • FOR THE PULMONOLOGIST
      • Sleep Disordered Breathing occurs in upwards of 50% of patients, successfully treating SDB improves AF burden
      • Annual PFTs no longer recommended for patients on Amiodarone
  • Anticoagulation to Prevent Stroke
    • Definitely in patients with risk of thromboembolic event >2%/year
    • Consider in patients with risk of thromboembolic event >1%/year
    • DOACs are drugs of choce, VKA can be considered (particularly if there are drug interactions with DOACs or pt has a mechanical valve)
      • Do not utilize Aspirin and/or Clopidogrel
    • Event monitors detecting episodes >24 hours are significant, short episodes (<5minutes) are not associated with clinical events 
    • Percutaneous or Surgical Left Atrial Appendage Occlusion/Exclusion for those who cannot be anticoagulated
  • AV Node Ablation
    • For patients that cannot be effectively rate controlled
    • Pacemaker placement in conjunction (RVP, right ventricular pacing)
    • BiVP (Biventricular pacing) in patients with concomitant heart failure

Rapid Ventricular Response

  • UNSTABLE PATIENT? DC CARDIOVERSION
    • At least 200J, go up if not successful
    • Consider adjunctive antiarrhythmic drug
  • Rate Control
    • Nondihydropyridine CCB (Diltiazem and Verapamil)
      • Dilt 0.25mg/kg IV over 2 min, may repeat 0.35mg/kg over 2 min then 5-15mg/h as infusion
      • Ver 5-10mg over 2 min, may repeat twice then 5-20mg/h as infusion
        • Negative inotropic and chronotropic effects
        • Do not use in preexcitation
        • Do not use in EF <40%
    • Beta Blockers
      • Metoprolol 2.5-5mg IV bolus over 2 min (up to 3 doses)
      • Careful as it can cause hypotension, be mindful in acute heart failure
    • Digoxin
      • 0.25-0.5 mg over several min; repeat doses of 0.25 mg every 6 h (maximum 1.5 mg/24 h)
      • Positive inotropic and vagotonic effects
  • Rhythm Control
    • Cardioversion
      • If elective and AF >48 hours, 3wks of anticoagulation or imaging evaluation to exclude thrombus is recommended
    • Ibutilide
      • ≥60 kg: 1 mg over 10 min
        <60 kg: 0.01 mg/kg over 10 min
        If arrhythmia does not terminate within 10 min after the end of the first infusion, may administer a second dose, equal to the first dose.
        • Do not use in EF <40% – will induce Torsades
    • Amiodarone
      • 150-300 mg IV over 1 h, then protocolized
        • May not see effects for 8-12 hours
        • Utilize in patients with decompensated heart failure
        • Be mindful of risk of stroke, again, in the acute setting exclude thrombus
    • Procainamide as a secret backpocket option
      • 1 Gm over 30 min
    • Oral Flecanide (200 mg if <70 kg, 300 mg if >70 kg, single dose) and Propafenone (450 mg if <70 kg, 600 mg if >70 kg, single dose) as secret backpocket options
  • Adjunctive Therapies
    • IV Magnesium

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