Atrial Fibrillation

with controlled rate HR < 100–110
with Rapid Ventricular Response HR > 110–120 bpm

  • Duration: ___ days

  • CC: palpitations

  • Onset: (sudden)

  • Course: (constant / intermittent)

  • Progression: (worsening / improving / unchanged)

  • Associated symptoms: palpitations, dyspnea, fatigue, lightheadedness, dizziness, chest discomfort, exercise intolerance, ± signs of heart failure (orthopnea, PND, edema)

  • Pertinent negatives: no syncope (if absent), no severe chest pain suggestive of ACS, no focal neurologic deficits (stroke/TIA), no fever/chills (if infection not suspected)

  • Pertinent Exam: irregularly irregular rhythm, tachycardia, ± signs of heart failure (crackles, elevated JVP, peripheral edema)

  • Pertinent Data: CBC (anemia/infection), BMP (electrolytes, renal function and LFTs for med), Mg/Phos (worsen AF), Coags (prior to AC), Trop, BNP, consider UDS, EKG, chest CXR (pulmonary causes, CHF, infection)_; consider TTE (structural, valvular disease, EF)

  • Pertinent PMH/SH/FH: Prior cardioversion attempts, ablations

  • Pertinent Home meds: AC, rate control

  • DDx: Atrial flutter, Can’t Miss: Acute coronary syndrome (ACS), pulmonary embolism (PE), thyrotoxicosis, sepsis, pericardial tamponade, and Wolff-Parkinson-White syndrome (WPW).

  • Etiology

    • Cardiac: Hypertension, coronary artery disease, valvular disease, cardiomyopathy

    • Pulmonary: COPD, pulmonary embolism, pneumonia

    • Endocrine: Hyperthyroidism, pheochromocytoma

    • Metabolic: Electrolyte imbalances (especially potassium, magnesium)

    • Toxic: Alcohol, caffeine (exacerbates symptoms), sympathomimetics, certain medications

    • Other: Sepsis, post-operative state, obstructive sleep apnea

    • Can’t Miss: ACS, PE, Thyrotoxicosis, Sepsis, tamponade, WPW

    • Hospital course to date:

  • CHA2DS2-VASc score to assess stroke risk:

Plan

  • To identify and treat the underlying cause

  • unstable: immediate synchronized cardioversion; midazolam 1–2 mg IV q 1–2 min max 5mg + 200 → 300 → 360 J (biphasic), if refractory Amio and cardiology consult

  • If stable and onset < 48 hours safe for cardioversion (low clot risk)**

  • If stable and onset > 48 hours or unknown duration (if on Anticoagulate ≥3 weeks → can cardiovert) or TEE → if no clot → cardiovert

  • Unfractionated heparin IV bolus 60–80 units/kg IV (max 4,000–5,000 units) + infusion 2–18 units/kg/hr IV (max ~1,000–1,500 units/h) before electrical or chemical cardioversion (unless took DOAC as prescribed ~12–24 hours)

  • After cardioversion stop heparin and start DOAC (Apixaban 5 mg BID) at same time or with out cardioversion if CHA₂DS₂-VASc ≥2 (men) or ≥3 (women) for at least 4 weeks then indefinite

  • Continuous telemetry and pulse oximetry

  • Rate contro if stable:

    • diltiazem (0.25 mg/kg) IV can Repeat 0.35 mg/kg IV after 15 min (NO HFrEF and robust BP) if works Then start infusion 5-15 mg/hr once <110 switch PO 120–180 mg daily (ER) OR

    • metoprolol 5mg IV q5 min x3 (if HF, CAD, soft BP) (PO-tartrate 25–50 mg q6–12h after- max 400) if refractory --> amiodarone 150mg IV bolus can x 3 until sinus, Transition to drip 1mg/min for 6 hours then 0.5 mg/min for 18 hours then then 200-400mg PO daily as maintenance

    • if refractory --> Amio 150 mg IV bolus → 1 mg/min ×6 hr → 0.5 mg/min ×18 hr (max ~2.2 g/day), repeat bolus if needed x3

  • Pressor: if needed phenylephrine (↓ or neutral affect on HR)

  • Maintain electrolytes: Keep K >4 and Mg >2.

  • daily CBC and BMP+Mag

  • consider cardiology consult for ablation if Symptomatic AFib despite meds or AFib causing cardiomyopathy

  • appointment with cardiology in 2-3 weeks

  • New amiodarone start requires baseline PFTs and annual CXR while continued

Note:

Paroxysmal AF: stop on their own (or with treatment) within 7 days, often within 48 hours.
Persistent AF: Lasts >7 days and requires cardioversion (electrical or pharmacologic) to terminate.
Long-standing Persistent AF: Continuous AF lasting >12 months despite treatment attempts.
Permanent AF: Ongoing AF where no further rhythm control is pursued by mutual decision.

  • Goal rate <110

  • Symptoms: Palpitations, chest discomfort, fatigue, dyspnea, dizziness or syncope, and hypotension in severe cases.

  • Triggers: CHF, CAD, Sepsis, hypoxia, thyrotoxicosis, alcohol withdrawal, stimulant use (meth), drug toxicity, electrolyte abnormalities (↓K⁺, ↓Mg²⁺), volume depletion.Noncompliance with meds, GI bleed, pulmonary embolism.

  • Clinical Concerns is Rapid, irregular rhythm increases myocardial O₂ demand and can precipitate ischemia or cardiomyopathy hemodynamic instability, hypotension, heart failure, and stroke
    -treat the underlying cause.
    -Treat hypoxia with supplemental O₂