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

afib

Unstable

Urgent
Cardiovert

Stable

S
s
Rate vs
rhythm
Control

Anticoagulate**

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
100
to
120

SBP
90-110

DIGOXIN
Load: 0.5mg
IV6 hrs later;
0.25mg IV6 hrs
later; 0.25 mg IV
Maintenance:
0.125 mg daily

B-Blocker
Initial: Metoprolol 5mg
IVP q5min x3doses
Prn: metoprolol 5mg IV
q6hr prn
Maintenance:
Metoprolol 25 mg po
BID (max 100mg BID)

SBP
>120

Ca2+ Blockers
Initial and prn:
Diltiazem 10mg
IVP q6hrs
Maintenance:
Diltiazem 30mg
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;
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

Which Agent to

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