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How do I manage the rate and rhythm in my patient with atrial fibrillation?

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Acute management of atrial fibrillation is based on hemodynamic stability and chronic management at preventing symptoms, thromboembolism and heart failure.

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HPI: Duration and severity of symptoms (palpitations, dyspnea, fatigue, lightheadedness, or syncope). Any history of atrial fibrillation and has cardioversion been attempted before.

PMH: Hyperthyroidism, hypertension, myocardial infarction, mitral stenosis.

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Irregularly irregular pulse, jugular venous distension, rales, peripheral edema.

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Absent P waves, irregularly irregular R-R interval.

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Figure 55–1

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ECHO: Atrial enlargement, left ventricular function, mitral valve function, left atrial appendage velocity, left atrial thrombus.

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AFIB = Atrial FIBrillation.

RVR = Rapid Ventricular Rate: ventricular rate > 100 bpm.

HU = Hemodynamically Unstable: hypotension (systolic BP < 90 mm Hg) and evidence of shock (mental status changes or decreased urine output).

HS = Hemodynamically Stable: normotensive, normal mentation, no evidence of shock.

SDUR = Patient with AFIB < 48 hours (Short DURation). If unknown or doubt as to genuine duration, assume LDUR.

LDUR = Patient with AFIB > 48 hours (Long DURation) or unknown duration.

CDV = Direct current CarDioVersion.

EL-CDV = ELective CDV: There is time to plan for procedure including informed consent, monitored anesthesia care, and assessing for intracardiac thrombus. If AFIB is LDUR, obtain a transesopheageal echocardiogram prior to CDV. Abort CDV if any thrombus found and reassess after 3 weeks of anticoagulation.

EM-CDV = EMergent CDV: Performed to save the life of the patient at the risk of thromboembolism.

SAE = Search Alternate Etiology of shock: Being in AFIB with a normal ventricular rate does not cause shock.

FAIL-CDV = Patient has had CDV in past and reverted back into AFIB.

RC = Rate Control with goal of resting HR of 60–80 bpm, and < 110 bpm with mild exertion. For RVR, consider metoprolol 5 mg IV Q15 minutes (max 15 mg) or diltiazem IV bolus 0.25 mg/kg IV followed by 10 mg/hr IV infusion (titrate over the range of 5 to 15 mg/h IV for goal heart rate). For non-acute setting, consider metoprolol PO 25 to 100 mg twice daily or diltiazem 30 to 90 mg 3–4 times daily.

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See chapter on anticoagulation for AFIB in all cases.

AFIB + RVR + HU = EM-CDV

AFIB + HU + (NO RVR) = SAE

AFIB + HS + (NO FAIL-CDV) = RC + EL-CDV

AFIB + HS + FAIL-CDV = RC

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The primary cause of morbidity and mortality in patients with AFIB is thromboembolism (ex. stroke) that occurs due to stasis of blood in the atria and subsequent thrombus formation that ejects from the heart. Even if a patient reverts back to sinus rhythm, anticoagulation should be continued as AFIB may be paroxysmal and there is still risk for stroke. Rate control is important to prevent cardiac remodeling and the development heart failure (tachycardia-induced cardiomyopathy).

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Avoid beta blockers in patients with active reactive airway disease (ex. COPD, asthma). Avoid nondihydropyridine calcium channel blockers (ex. diltiazem) for long term management in patients with left ventricular systolic dysfunction.

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The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial showed there was no statistically significant difference in mortality with rate vs. rhythm control.

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  1. Wann LS, et al. 2011 ACCF/AHA/HRS focused update on the management of patients ...

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