CHADS₂ Score

Calculates stroke risk for patients with atrial fibrillation, possibly better than the CHADS₂ Score.

  Unstable atrial fibrillation – ED management

The most common alternate management strategy I have encountered focuses on just using fluid boluses to support the pressure while loading amiodarone. There is no evidence that vasopressors help patients, so I can’t argue, but I have a hard time not temporarily making the numbers better while I wait for rate control to occur. Maybe I am treating my own anxiety more than the patient?

 More Atrial Fibrillation Management Pearls in the ED

Amiodarone or digoxin can be given if beta blockers or calcium channel blockers are unsuccessful or contraindicated, as in the setting of heart failure and/or hypotension.

 Recent-Onset Atrial Fibrillation

Determine whether the AF is in response to another underlying process (see causes above) or is simply lone atrial fibrillation. In patients where AF is a response to another underlying process, management should be directed at treating the underlying process NOT at the dysrhythmia.

Management of atrial fibrillation in the emergency room and in the cardiology ward: the BLITZ AF study

Atrial fibrillation still represents a significant burden on health care system. Oral anticoagulant use increased over time even if compliance with guidelines, with respect to prevention of the risk of stroke, remains suboptimal.

Outcomes After Aggressive Management of Recent-Onset Atrial Fibrillation in the ED

Atrial fibrillation (AF) is one of the most common dysrhythmias encountered in the ED. The management of recent-onset AF and atrial flutter (AFl) in the ED continues to be debated. The discussion centers on whether patients with recent-onset AF should be rhythm controlled (e.g. converted back to sinus rhythm) or rate controlled only.

Tachydysrhythmias with Amal Mattu and Paul Dorion

Why is amiodarone contraindicated in patients with WPW associated with atrial fibrillation? What are the important differences in the approach and treatment of atrial fibrillation vs. atrial flutter? How can we safely curb the high bounce-back rate of patients with atrial fibrillation who present to the ED? and many more...

Ottawa Aggressive Atrial Fibrillation Protocol

Atrial fibrillation (AF) is one of the most common dysrhythmias encountered in the ED. Patients with chronic AF often present with increased heart rates, chest pain and weakness among other presentations. However, it’s the patients with new onset AF that really peak our interest.

An Update: Rate Control in Atrial Fibrillation

Rate control strategy: First line therapy with either CCB IV (Diltiazem) or BBer IV (Metoprolol) is acceptable.

Episode 20: Atrial Fibrillation

Beta-blocker (works in 70% of patients): metoprolol 5mg IV q20min up to 15mg, followed by 25-50mg PO – consider using if patient has HTN, CAD, diabetes, prior MI or hyperthyroidism, but do NOT use in asthmatics or patients in acute heart failure. Calcium-channel blocker (works in 54% of patients): diltiazem 10-20mg IV, followed by PO.

Just Beat It (Atrial Fibrillation) with Diltiazem or Metoprolol?

I agree with the authors’ conclusions. Despite the above limitations, they did demonstrate non-inferiority of diltiazem to metoprolol for rapid rate control in patients with AF with RVR and this goes along with my clinical experience.

AFib in Wolff-Parkinson-White Syndrome

Treatment with AV nodal blocking drugs e.g. adenosine, calcium-channel blockers, beta-blockers may increase conduction via the accessory pathway with a resultant increase in ventricular rate and possible degeneration into VT or VF.

Afib with WPW

Treatment: · DO NOT give: adenosine, verapamil, diltiazem, digoxin, beta blocker or amio. Due to the presence of accessory pathway blocking down the AV node, may cause the accessory pathway to become the primary driver of conduction. · Treated with IV procainamide if clinically stable. Dose is 15-16 mg/kg given at a rate no faster than 50 mg/min. · If unstable: Immediate DC cardioversion.

Atrial Fibrillation in WPW Syndrome – Pearls and Pitfalls

AF in WPW – it looks similar to polymorphic VT but lacks the undulating baseline seen in torsades de pointes.

Atrial Fibrillation Rate Control in the ED: Calcium Channel Blockers or Beta Blockers?

From an ED standpoint, both CCBs and BBs appear to be effective. The highest quality study seemed to demonstrate that diltiazem performed better than metoprolol, though the metoprolol dose may have been too low.

Calcium before Diltiazem may reduce hypotension in rapid atrial dysrhythmias

Although most of the data is with verapamil, administering calcium before diltiazem may prevent some of the hypotension. There currently isn’t much published data for diltiazem. The one study, which was a negative one, had some limitations. The appropriate calcium dose is unknown, but 90 mg of elemental calcium (calcium gluconate 1 gm or calcium chloride 0.333 gm) is often used. We use 1 or 2 gm of calcium gluconate.

Irregular Wide Complex Tachycardia: VTach?

The differential diagnosis of irregularly irregular WCT is essentially limited to three main dysrhythmias. Dr. Littmann calls these FBI: Fast, Broad, and Irregular: Afib with LBBB Afib with RBBB Afib with WPW

Magnesium infusions for atrial fibrillation & torsade

The use of magnesium for AF has been a controversial topic for decades. Magnesium is a normal electrolyte, so it is cheap and has an excellent safety profile. Ironically, this is also magnesium's Achilles heel, because this has caused the pharmaceutical industry to have no interest in it. This leaves us with relatively sparse clinical evidence.

Managing Atrial Fibrillation

Rate or Rhythm Control... Both options are available in the stable patient who has been in atrial fibrillation (clear onset of palpitations) for fewer than 48 hours. After 48 hours, rate control is generally the only option because of the increased risk of stroke.

Patients with Atrial Fibrillation in the Emergency Department: Strategies to Achieve Best Outcomes

Atrial fibrillation (AF) and atrial flutter are two of the most common narrow complex tachyarrhythmias diagnosed in the ED.

Rapid Refresher: Atrial fibrillation (AF)

Be careful using these atrioventricular (AV) node–blocking agents in patients with AF and a wide QRS complex. This is because patients with preexcitation syndromes (eg, Wolff-Parkinson-White [WPW] syndrome) plus AF will have a wide complex and using these types of AV node–blocking agents may cause the accessory pathway to conduct at the atrial rate of 400 to 600 beats/min. Look at old ECGs.

Shock Through the Heart (Ottawa Aggressive Atrial Fibrillation Protocol)

Ottawa Aggressive Atrial Fibrillation Protocol: Once the patient is assessed and it’s determined that their symptoms began <48 hours prior to presentation, they were entered into the protocol. Rate control was given if either the patient was highly symptomatic while awaiting cardioversion or if cardioversion was not going to be pursued. Rhythm control was then initiated with an infusion of procainamide 1000 mg over 60 minutes. If procainamide worked, great the protocol was completed. If it didn’t work, the patient moved on to electrical cardioversion.

Sirens to Scrubs: Wolff-Parkinson-White Syndrome

As you begin to coach her through vagal maneuvers and reach for your adenosine she advises you ‘I have something called Wolff-Parkinson-White – does that change anything?’ You think maybe it does, but you’re not sure...

Why Don’t More Emergency Departments Cardiovert?

Cardioversion and discharge of recent onset AF is pretty much the accepted treatment in almost every country in the world with the exception of the United States.

Wolff-Parkinson Wait

It is imperative to recognize AF with WPW, as incorrect treatment with AV nodal blocking agents can be fatal. Blocking the AV node in these patients will result in preferential use of the accessory pathway. Rates may exceed 300 or 400 bpm and are at extreme risk for degeneration into ventricular fibrillation (VF).