Atrial Fibrillation

1
Atrial Fibrillation

• Syed Bokhari
• PGY2 Internal Medicine

2
Introduction

• Irregularly Irregular rhythm
• Supraventricular tachycardia
• HR ranges between 80-180 bpm.
• Important differentials
• Atrial Flutter
• Other SVTs

3
EKG

• Narrow complex tachycardia
• No P waves
• Rate 80-180 bpm
• Irregular heart rate (variable RR interval)

4
Management

• Management of A fib is divided into two aspects
• Acute (short term) for new onset A fib seen on
  floor/ER
• Chronic (Long term)

5
Acute Management Ask your self?

• First question Is this A fib?
• Get EKG
• Second Question Is the patient unstable? Does
  the patient have
• Hypotension
• Chest pain
• Signs of CHF

6
Acute Management

• If the pt has any signs of instability, the only
  option is DC Cardioversion.
• Call your resident
• Transfer pt to CCU or at least Tele bed.
• Call Cardiology to get there blessings

7
Chronic Management

• Chronic management has two aspects
• Rate Control vs Rhythm control
• Anti-coagulation.
• A fib is associated with 5-7 risk of stroke per
  annum.
• Immediate anti-coagulation with Low intensity
  heparin
• Long term anti-coagulation with Warfarin
• Look for contraindications to anti-coagulation
  (falls risk, GI bleed, recent stroke)

8
Rate Control vs Rhythm control

• Rate Control
• Is equal to rhythm control in terms of mortality
  and quality of life
• Target HR is
• 60-80 bpm at rest
• 80-100 bpm with walking/mild exertion
• Start IV meds immediately and once stable, switch
  to PO

9
Options for Rate Control

• Diltiazem
• 0.25mg/kg IV bolus followed by 5-15 mg/hr drip.
  Uptitrate drip by 5mg/hr to max of 25mg/hr.
• Esmolol
• Preferred in pt with Angina (beta blocker effect)
• 500 mcg/kg IV bolus over 1 min followed by 50
  mcg/kg/min uptitrate by 50mcg/kg/min upto
  200mcg/kg/min.
• Amiodarone
• Preferred in pt with CHF (minimal negative
  inotropy)
• 150 mg IV bolus over 10 min followed by 1mg/min
  for 6 hours, then 0.5mg/min for 18 hours then
  start oral.

10
Rhythm Control

• Long term management of rhythm control is limited
  to patients who are symptomatic with A fib
  (palpitations, mild SOB)
• Options include Amiodarone, Propafenone and other
  anti-arrythmics
• Refer to Cardiology.