ATRIAL FIBRILLATION

Past medical history

hypertension, hyperlipidemia, diabetes, chronic obstructive lung disease (COPD with cor pulmonale),
ischemic heart disease, rheumatic heart disease, thyroid dysfunction, or malignancy

use of alcohol, tobacco, and drugs

Risk factors for pulmonary embolism (travelling, immobilisation), symptoms of palpitation, congestive
heart failure, infectious state, as well as thyroid dysfunction (diarrhea, weight lost)

FOCUS ON PX EXAM

irregularly irregular fast heart rate. Close attention should be given to the present of an elevated jugular
venous pressure with loss of the a wave, a displaced point of maximal impulse, cardiac murmurs,
pulmonary crackles or wheezing, and finally focal neurological deficits.

ECG

irregularly irregular narrow complex with the absence of p wave

PX PENUNJANG

CBC (looking for sign of infection), electrolytes, liver/renal function, thyroid function, echocardiogram
(looking for structural heart disease and intracardiac thrombus), a chest x-ray (looking for any sign of
dilated heart, and/or increase pulmonary vasculature), and finally a spiral ct chest to rule out pulmonary
embolism in the appropriate clinical setting.

MANAGEMENT

The management of atrial fibrillation consists of heart rate control

act on the atrioventricular (AV) node to prolong its refractory period and to slow its conduction  avoid
the hemodynamic instability associated with tachycardia such as heart failure, angina, and prevent long
term tachycardia-mediated cardiomyopathy, unwanted side effects, such as hypotension and
bradycardia. Beta-blockers, and calcium channel blockers are both effective at rest and during exercise,
while digoxin is only effective at rest.

A special consideration should be given to patient with Wolff-Parkinson-White syndrome as

administration of a beta-blocker, calcium channel blocker, adenosine, or digoxin would facilate
antegrade conduction through the accessory conduction pathway and cause ventricular
preexcitation. In this particular case, class I and III antiarrhythmic agents (amiodarone) become the best
treatment option.

Table 2. Rate Control Pharmacological Options

Loading dose by
Onset of
Drug route of Maintenance dose Major side effect
action
administration
Hypotension*, heart
2.5 to 5 mg IV bolus
block,
Metoprolol over 2 min, up to 3 5 mins IV infusion n/a
asthma/COPD**, heart
doses
failure
Hypotension*, heart
25-100 mg block,
4 to 6 hrs 25 - 100 mg PO bid
PO bid asthma/COPD**, heart
failure
Hypotension*, heart
0.15 mg/kg IV over block,
Propanolol 5 mins IV infusion n/a
1 min asthma/COPD**, heart
failure
Hypotension*, heart
80 - 240 mg/day in 80 - 240 mg/day in block,
1 to 1.5 hrs
divided doses divided doses asthma/COPD**, heart
failure
Hypotension*, heart
0.25 mg/kg IV over 5 - 15 mg/hr
Diltiazem 2 to 7 mins block,
2 mins infusion
heart failure
120 - 360 mg/day in 120 - 360 mg/day Hypotension*, heart
2 to 4 hrs
divided doses in block,
 divided doses heart failure
Hypotension*, heart
0.075 - 0.15 mg/kg
Verapamil 3 to 5 mins IV infusion n/a block,
IV over 2 mins
heart failure
120 - 360 mg/day Hypotension*, heart
120 - 360 mg/day in
1 to 2 hrs in block,
divided doses
divided doses heart failure
0.25 mg IV every 0.125 - 0.25 Digoxin toxicity***,
Digoxin 2 hrs
2 hrs up to 1.5 mg mg/day heart block (bradycardia)
0.25 mg PO every 2 hrs 0.125 - 0.375 Digoxin toxicity***,
2 hrs
up to 1.5 mg mg/day heart block (bradycardia)
Hypotension*, heart
block,
Amiodaron 150 mg IV over
days 0.5 - 1 mg/min IV pulm toxicity, thyroid
e 10 mins
dysfct,
warfarin interaction
800 mg/day for 1 wk Hypotension*, heart
600 mg/day for 1 wk block,
400 mg/day for 4-6 1 to 3 wks 200 mg/day pulm toxicity, thyroid
wks dysfct,
all PO warfarin interaction

* Do not use if systolic blood pressure less than 90 mmHg

** Severe contraindication
*** Do not use or need careful monitoring in renal failure patient

correction of rhythm disturbances

Rhythm control was only recommended as the best options in patients with persistent symptoms
such as angina, and heart failure with adequate rate control. achieved through pharmacologic or
direct-current cardioversion. Each cardioversion must be carefully planned, using
anticoagulation for at least three weeks in those with atrial fibrillation for more than 48
hours. This waiting period can be avoided, if a transesophageal echocardiogram ruled out the
possibility of an atrial thrombus.

The thromboembolic risk remains elevated up to 10 days post cardioversion because of the early
atrial mechanical dysfunction promoting thrombus formation in the left atrium (atrial
stunning). It is recommended that patient should also be anticoagulated for up to 4 weeks post
sinus rhythm restoration
 Table 3. Rhythm Control Pharmacological Options
Loading dose by
Onset of
Drug route of Maintenance dose Major side effect
action
administration
0.5 - 1 mg/min IV for a Hypotension*, heart
5 - 7 mg/Kg IV total of block,
Amiodarone over Days 1.2 - 1.8 g/day until 10 g pulm toxicity, thyroid
30 to 60 min total then 200 to 400 dysfct,
mg/day warfarin interaction,
1.2 to 1.8 g/day Hypotension*, heart
1.2 to 1.8 g/day PO in
PO in divided block,
divided doses until 10 g
doses until 10 g 1 to 3 wks pulm toxicity, thyroid
total then 200 to 400
total then 200 to dysfct,
mg/day
400 mg/day warfarin interaction,
Creatinine clearance /
dose
(ml/min) / (ug bid)
PO
QT prolongation,
Dofetilide None 2 to 3 hrs > 60 500
torsades de pointes
40 - 60 250
20 - 40 125
<
20 Contraindicated
1.5 to 3.0 mg/kg IV over Hypotension,
Flecainide None 1.5 to 3 hrs
10 to 20 min rapid atrial flutter
200 to 300 mg PO Hypotension,
divided bid rapid atrial flutter
1.5 to 2.0 mg/kg IV over Hypotension,
Propafenone None 2 to 3 hrs
10 to 20 min rapid atrial flutter
Hypotension,
400 to 600 mg PO
rapid atrial flutter
QT prolongation,
0.75 to 1.5 g PO divided
Quinidine None torsades de pointes, GI
qid or bid
upset, Hypotension
160 to 320 mg PO QT prolongation,
Sotalol None 1 to 2 hrs
divided bid torsades de pointes, HF
Procainamid 10 to 30 GI complaint,
None 1 to 4 g PO divided
e mins Hypotension
* Do not use if systolic blood pressure less than 90 mmHg

** Severe contraindication
*** Do not use or need careful monitoring in renal failure patient
 Table 4. Vaughan Williams Classification of
Antiarrhythmic Drugs
Type IA Disopyramide
Procainamide
Quinidine
Type IB Lidocaine
Mexiletine
Type IC Flecainide
Propafenone
Type II Beta Blockerss (Proponolol)
Type III Amiodarone
Dofetilide
Sotalol
Ibutilide
Type IV Nondihydropyridine calcium channel
Antagonists (Verapamil and Diltiazem)

prevention of thromboembolic complications.