SIMPLE APPROACH TO ATRIAL

FIBRILLATION IN EMERGENCY
DEPARTMENT

Epidemiologi

 Ketika berusia >55thn, risiko terjadi AF adalah 1 dari 3

 Semakin tua, risiko semakin meningkat
 Laki-laki lebih berisiko daripada Wanita
 Ketika banyak fator risiko dan bertambahnya usia, semakin berisiko
 Tingkat kematian pada AF 3x lipat

1. Laki-laki usia 70thn, post PCI 3 tahun yang lalu. Merasa berdebar sejak 3 jam yang lalu. Tidak
ada data lain. Ronkhi (-), murmur (-), edema tungkai (-). Obat2: Furosemide, spironolakton,
ramipril, carvedilol, ISDN, aspirin, atorvastatin.
A. Amiodarone iv
B. Cardioversi 150 joule
C. Digoxin inj
 D. Metoprolol inj
E. BSSD

2. Wanita usia 25thn. Hamil 6bln. Sejak 1 hari yll berdebar-debar. Tensi 120/60. Hasil EKG:
atrial flutter dengan variable block.
A. Amiodarone iv
B. Cardioversi 150 joule
C. Digoxin tablet
D. Bisoprolol tablet
E. BSSD

3. Wanita usia 48thn. NSTEMI. AHF. Cardiomegali. Keluhan utama sesak nafas, edema tungkai.
TD 82/36. HR 80x/mnt. Atrial fibrilasi.
A. Amiodarone iv
B. Cardioversi 150 joule  gangguan hemodinamik
C. Digoxin inj
D. Metoprolol inj
E. BSSD

4. Pasien usia 45thn. Sesak nafas. Ronkhi +/+. Edema paru. Tensi 80/60. Akral dingin. Riwayat
penyakit jantung +. Pasien tidak mau minum obat.
A. Amiodarone iv
B. Cardioversi 150 joule
C. Digoxin inj
D. Metoprolol inj
E. BSSD

5. Laki-laki 50thn. Demam 39C. App acute perforasi. EKG 1 jam yll masih sinus.
A. Amiodarone 150 iv  comfort rhythm
B. Cardioversi 150 joule
C. Digoxin inj
D. Metoprolol inj
E. BSSD

6. Wanita usia 94thn. Edema paru. On ventilator hari kedua, EKG 15 menit yll masih sinus. HR
105. On norepinephrine. Usulan?
A. Amiodarone iv
B. Cardioversi 150 joule
C. Digoxin inj
D. Metoprolol inj
E. BSSD

7. Wanita usia 80thn. Riwayat PJK. Kontrol rutin di poli jantung. Sejak 1 jam yll. Nyeri dada,
berdebar-debar. Berkurang dengan ISDN. EKG 1 minggu yll sinus. EKG: AF, ST depresi.
A. Amiodarone iv
B. Cardioversi 150 joule
C. Digoxin inj
 D. Metoprolol inj
E. BSSD

8. Pria 60thn. Sejak kemarin sering nyeri dada. Tidak ada Riwayat berdebar. PF dbn. Riwayat HT
lama. Minum amlodipine 5mg. Tensi 160/80.
A. Amiodarone iv
B. Cardioversi 150 joule
C. Digoxin tablet
D. Metoprolol tablet
E. BSSD

ABCD for Atrial Fibrillation for GP.

A  Are u sure it’s AF?
B  Before decide anything, pls answer this question
C  Choosing between rhythm or rate control
D  Do we need prescribe oral anti coagulant?

A. Are u sure it’s AF?

 Define symptoms
 Palpitation, fatigue, dizziness, dyspnea, chest pain, anxiety.
 Symptoms at the termination of AF episodes, such as presyncope or syncope, should
be determined.
 About 20% AF are asymptomatic
Modified EHRA (mEHRA) classification

mEHRA
score Symptoms Description

1  None   

2a  Mild  Normal daily activity not affected, symptoms not

troublesome to patient 

2b  Moderate  Normal daily activity not affected but patient troubled by

symptoms 

3  Severe  Normal daily activity affected 

4  Disabling  Normal daily activity discontinued 

Underlined text represents the modification to the original descriptions of EHRA
classes.
  Physical exam
 The hallmark of AF on physical examination is an irregularly irregular pulse.
 Short R-R intervals during AF do not allow adequate time for left ventricular diastolic
filling, resulting in a low stroke volume and the absence of palpable peripheral pulse.
 This result in a “pulse deficit,” during which the peripheral pulse is not as rapid as
the apical rate.
 Other manifestation of AF on the physical examination are irregular JVP and variable
intensity of the first heart sound.

*Pulsus deficit, di mana terdapat selisih jumlah nadi yang teraba dengan auskultasi laju jantung.

 ECG
 Define pattern and onset

*UGD: First diagnosed  Acute

Paroxysmal
Persistent

B. Before Decide Anything, Plz Answer This Question

1. Primary or secondary rapid AF?  Karena aritmia itu sendiri / karena kondisi yg lain?

2. Patient unstable?
3. Acute FIRST EPISODE AF?

*1st episode or short history  rhythm-control

4. Onset? Less than 12h? 12-48h? More than 48h?

*Pada pasien yg <12h, kalau dilakukan kardioversi, risiko stroke 0,3%.
* 12-24h, dilakukan kardioversi, risiko stroke 1,1%.
* 24-48h, dilakukan kardioversi, risiko stroke 1,1%.
5. Valvular Heart Disease (Mitral Stenosis or Mechanical Heart Valve)?

Karena kalau mitral stenosis, maka akan berisiko terjadi AF, dan jika LA dilatasi akan
memudahkan terjadinya thrombosis.
 6. CHADS2-VASc Score?

*berikan obat antikoagulan, terutama kalau pada laki2 >/2 dan wanita >/3

7. AF Rapid with WPW?

*WPW
*Tatalaksana AF dengan WPW  cardioversion

C. Choosing Between Rhythm or Rate Control

 Rhythm control strategy offers no survival advantage over rate control
 Lower risk of adverse drug effects, with the rate control strategy
  Anticoagulantion should be continued in this group of high risk patients

*Penelitian baru adalah… AF dengan rhythm control bisa menjadi baik terutama jika sudah
sampai ablasi. Tetapi jarang yg sampai terjadi ablasi.

tidak perlu terlalu lambat sampai 60, cukup <110.

*Kapan rhythm control? Kalau ada symptom dan quality of life.

In emergency room/clinic: First Choice  RATE CONTROL!

*Rate control dulu, jika di evaluasi beberapa hari belum membaik, baru rhythm control.
* <48 jam berikan rate control dulu, evaluasi dalam 6-12 jam (sebelum 48 jam) dan ternyata
pasien mengeluh tidak nyaman, baru berikan rhythm control.
*Rhythm control  Pada ada pasien dengan haemodynamic instability karena AF.
When Cardioversion in ED/ICU by GP?

1. Hemodynamically unstable rapid AF, related to acute AF less than 12h.

2. No mitral stenosis or mechanical heart valve.
3. No prior TIA or stroke.
4. Healthy patient <65yo. Low risk for stroke. Very symptomatic. Exact time <12h. Accept risk
for TE events 0.3-1%.
*beta-blocker or non-dihydropyridine calcium channel (bisoprolol/verapamil)
*digoxin is 2nd line  Ketika HR >110

Drug for RATE CONTROL:

 Investigate secondary cause of rapid AF. Treat properly.

 If primary rapid AF  aggressive rate control.
 First choice: beta blocker (bisoprolol or metoprolol inj). Contra ind: Acute HF, asthma,
hypotension.
 Digoxin (tablet or inj) esp for hypotension, acute HF, but: slow onset.
 Severe COPD or asthma? Diltiazem or verapamil.