ATRIAL FIBRILLATION

MANAGEMENT
MINI-LECTURE
OBJECTIVES

 REVIEW INITIAL MANAGEMENT OF AFIB;

MEDICAL VS CARDIOVERTING
 MEDICAL MANAGEMENT: RATE VS
RHYTHM CONTROL
 ROLE OF ANTICOAGULATION
 CASE VIGNETTE
 This is a 65 y/o M who presents to the ED with dizziness,
shortness of breath, and palpitations which began
approximately two hours ago when he was playing catch
with his grandson. No syncope or chest pain.

 On exam: He is afebrile with a BP=110/55, HR=110-162

bpm, and respiratory rate of 25. A&Ox4 w/ NAD.
Cardiac exam reveals tachycardia with an irregularly
irregular rhythm.

 How would you approach the initial management of this

patient?
EKG
Demographics
 Common; 2.2 million people in U.S.

 Male>Female

 Prevalence increases with age

 Leading cause of embolic strokes

 Associated with increased risk for heart failure and all

cause mortality
WORK-UP
 H and P

 CXR

 EKG

 Echo

 TFTs

 CMP

 Trop and EKG

MANAGEMENT
The first step in management is to determine whether the
patient is stable or not…

-Look for any hemodynamic instability such as hypotension

-Is the patient responsive?

-Are there any mental status changes?

-are symptoms persistent and unbearable?

INITIAL MANAGEMENT DECISION
Urgent
afib Unstable
Cardiovert

Stable

S
s

Rate vs
Anticoagulate**
rhythm
Control
RATE VS RHYTHM CONTROL
 Rate Control vs Rhythm Control

 **no clear survival benefit in rate vs rhythm control**

RATE CONTROL
 Agents:

 Beta Blocker: Metoprolol and Propranolol (ICU=esmolol gtt)

 Non-dihydropyridine CA blockers: verapamil & Diltiazem

(ICU=diltiazem gtt)

 Digoxin

Goal: Rest 60-80 bpm and Activity 80-110

 RATE CONTROL; Which Agent to choose?
AFIB

SBP
SBP
>120
SBP 100
90-110 to
120

DIGOXIN B-Blocker Ca2+ Blockers

Load: 0.5mg Initial: Metoprolol 5mg Initial and prn:
IV6 hrs later; IVP q5min x3doses Diltiazem 10mg
Prn: metoprolol 5mg IV
0.25mg IV6 hrs IVP q6hrs
q6hr prn
later; 0.25 mg IV Maintenance: Maintenance:
Maintenance: Metoprolol 25 mg po Diltiazem 30mg
0.125 mg daily BID (max 100mg BID)
PO q6hs
Rhythm Control
 AGENT:

 III: Amiodarone, Ibutilide, Dofetilide, Sotalol

 IC: Flecainide, Propafenone

 IA: Procainamide
ANTICOAGULATION
 Risk of stroke increases with valvular afib

 Risk of CVA=4.5% per year in nonvalvular afib

 Risk of CVA in recurrent paroxysmal afib=persistent

afib=permanent afib

 Agents: ASA vs Coumadin vs Dabigatran vs Rivaroxaban

ANTICOAGULATION; Which Agent to
Choose?

 CHADS2 SCORE

 CHF: 1 point

 HTN: 1 point

 AGE >75: 1 point

 DM: 1 point

 Stroke or prior TIA: 2 points

Score:

0=ASA alone

1= either warfarin or ASA

2 or more= warfarin
ASPRIRIN
 CHADS2=0 or 1

 81 mg to 325mg PO daily

 Lower risk for bleeding than warfarin

 No need to check INRs etc

 Lower risk of major bleeds in patients who are a fall risk

Coumadin
 For CHADS2 score 2 or greater and also 1 depending on
patient and physician preference

 Goal INR= 2 to 3

 Must monitor INRs regularly

 Can be dangerous if fall risk or bleeding risk high

ASA + Clopidogrel
 If not a candidate for warfarin; this can reduce stroke
risk greater than ASA alone

 Risk for major bleeding increased

Dabigatran
 Direct Thrombin Inhibitor

 Alternative to warfarin for CHADS2=1 or greater in those

without valvular afib

 RE-LY Trial showed superior to warfarin in preventing

ischemic and hemorrhagic CVAs with reduced risk of life
threatening bleeding but higher risk of GI bleeds

 No lab monitoring*

 No reversal agent available for major bleeding events

Rivaroxaban
 Oral factor Xa inhibitor

 Seems to be equivalent in efficacy to warfarin for CVA

prevention and no difference in major bleeding events

 Demonstrates a reduction in intracranial hemorrhage

 Note: risk of thrombotic events increased for 28 days

after stopping drug so may need to bridge with another
anticoagulant during this time.
SUMMARY
 AFIB: very common arrhythmia and leading cause of
embolic CVAs
 Initial Workup: H and P, trop, EKG, TSH, Echo, CXR, CMP
 Management: First must determine if stable vs unstable
(medically manage vs cardiovert immediately)
 For stable Afib: rate vs rhythm control (equal in
efficacy). Start with rate control and if that fails try
rhythm.
 Always remember to calculate CHADS2 score and
anticoagulate for CVA ppx.
References
 Uptodate.com; Topics: SVT, atrial fibrillation management,
afib overview
 Sabatine, Marc S. Ed.; Pocket Medicine The Mass General
Hospital Handbook of Internal Medicine 4th edition Lippincott
Williams and Wilkins Philadelphia, PA 2008.
 MKSAP 16; Cardiology ACP 2012
 Maxine A. Papadakis, Stephen J. McPhee, Eds; CURRENT
Diagnosis and Treatment; McGraw Hill Education 2012.
 Dan L. Longo, Anthony S. Fauci, Dennis L. Kasper, Stephen L.
Hauser, J. Larry Jameson, Joseph Loscalzo, Eds. Harrison's
Principles of Internal Medicine, Online. 18th ed. McGraw Hill
2012