Acute Management of Atrial Fibrillation

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Acute Management of Atrial Fibrillation
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Case

• A 66 year-old man comes to the emergency
  department complaining of a several-day history
  of an intermittent sensation of fluttering in the
  chest. He feels weak when the episodes occur but
  denies chest pain or shortness of breath. He has
  had hypertension for 20 years, controlled well
  with enalapril, and he takes albuterol for
  asthma. He denies any alcohol use.

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Case- cont

• VS Temperature 36.8C (98.3F), Blood pressure
  140/80, pulse 140/min, respirations 12/min
• PE supple neck, no jugular vein distension or
  thyromegaly.
• CV irregularly irregular rhythm with no rubs or
  gallops.
• Chest clear sounds
• Abd Benign
• Extremities no edema

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Differential Diagnosis

• Atrial Fibrillation
• Multifocal atrial tachycardia
• Supraventricular tachycardia
• Pulmonary Embolism
• Thyrotoxicosis

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Diagnostic plan

• EKG
• Thyroid Function tests
• Cardiac enzymes
• Echocardiogram
• ABGA

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• Elderly patient
• Palpitation
• Fatigue/weakness
• Long term hypertension
• Tachycardia
• Irregularly irregular rhythm
• EKG atrial fibrillation waves, inconsistent R-R
  intervals, absence P waves.

ATRIAL FIBRILLATION
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Management

• GOALS
• Hemodynamic stabilization
• Ventricular rate control
• Prevention of embolic complication

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Patient with diagnosis of atrial fibrillation
Hemodynamically stable
Yes
No

• Unstable
• Hypotension
• Confusion
• Angina
• .

Control ventricular rate Diltiazem
Cardioversion

• Beta Blockers
• Calcium Channel blockers
• Digoxin
• Amiodarone

Long standing HTN Ischemic heart
dz CHF Hyperthyroidism PE Lung ca Alcohol Hypother
mia Electrolytes imbalance Etc. .
Spontaneous conversion to sinus rhythm
Yes
No
Assess cause of atrial fibrillation
Contraindication to cardioversion?
Cont
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Cont
Yes
No
Cardiversion
Start Heparin IV
Warfarin
Aspirin
Consider long-term anticoagulation
gt48hs
lt48hs

• Immediate medical or electrical cardioversion

• Later elective cardioversion after 3weeks of
  warfarin
• Early TEE-guided cardioversion

Long standing HTN Ischemic heart
dz CHF Hyperthyroidism PE Lung ca Alcohol Hypother
mia Electrolytes imbalance Etc. .
Yes
Atrial fibrillation persist?
No
Assess cause of atrial fibrillation
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References

• http//www.chestjournal.org/content/135/3/849.full
  .html
• http//www.aafp.org/afp/20020715/249.html
• http//www.aafp.org/afp/20020715/261.html
• http//www.americanheart.org/downloadable/heart/22
  2_ja20017993p_1.pdf