TY  - CHAP
M1  - Book, Section
TI  - Arrhythmias
A1  - Higgins, John P.
A1  - Ali, Asif
A1  - Filsoof, David M.
PY  - 2016
T2  - Cardiology Clinical Questions, 2e
AB  - Table  Graphic  Jump  Location|Download  (.pdf)|PrintAcute  management  of  atrial  fibrillation  is  based  on  hemodynamic  stability  and  chronic  management  at  preventing  symptoms,  thromboembolism  and  heart  failure.HPI:  Duration  and  severity  of  symptoms  (palpitations,  dyspnea,  fatigue,  lightheadedness,  or  syncope).  Any  history  of  atrial  fibrillation  and  has  cardioversion  been  attempted  before.  Determine  if  Paroxysmal  (self-terminating)  versus  Persistent  (>7  days)  versus  Permanent  (>1  year,  failed  cardioversions)  and  Valvular  versus  Nonvalvular.PMH:  Hyperthyroidism,  hypertension,  myocardial  infarction,  mitral  stenosis.Irregularly  irregular  pulse,  jugular  venous  distension,  rales,  peripheral  edema,  absence  of  A  waves  on  neck  inspection.Absent  P  waves,  irregularly  irregular  RR  interval.Figure  55–1ECHO:  Atrial  enlargement,  left  ventricular  function,  mitral  valve  function,  left  atrial  appendage  velocity,  left  atrial  thrombus.AFIB  =  Atrial  FIBrillation.RVR  =  Rapid  Ventricular  Rate:  ventricular  rate  >100  bpm.HU  =  Hemodynamically  Unstable:  hypotension  (systolic  BP  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  transesophageal  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  5–15  mg/hr  IV  for  goal  heart  rate).  For  nonacute  setting,  consider  metoprolol  PO  25–100  mg  twice  daily  or  diltiazem  30–90  mg  3–4  times  daily.See  chapter  on  anticoagulation  for  AFIB  in  all  cases.AFIB  +  RVR  +  HU  =  EM-CDVAFIB  +  HU  +  (NO  RVR)  =  SAEAFIB  +  HS  +  (NO  FAIL-CDV)  =  RC  +  EL-CDVAFIB  +  HS  +  FAIL-CDV  =  RCThe  primary  cause  of  morbidity  and  mortality  in  patients  with  AFIB  is  thromboembolism  (e.g.,  stroke)  that  occurs  due  to  stasis  of  blood  in  the  atria  and  subsequent  thrombus  formation  that  ejects  from  the  heart.  Even  if  a  patient  self-reverts  back  to  sinus  rhythm,  anticoagulation  should  be  continued  depending  on  CHA2DS2-VASc  score  as  AFIB  may  be  paroxysmal  and  asymptomatic  and  there  is  still  risk  for  stroke.  Anticoagulate  for  4  weeks  post  cardioversion.  Rate  control  is  important  to  prevent  cardiac  remodeling  and  the  development  heart  failure  (tachycardia-induced  cardiomyopathy).Avoid  beta  blockers  in  patients  with  active  reactive  airway  disease  (e.g.,  COPD,  asthma).  Avoid  nondihydropyridine  calcium  channel  blockers  (e.g.,  diltiazem)  for  long-term  management  in  patients  with  left  ventricular  systolic  dysfunction  <40%.The  Atrial  Fibrillation  Follow-up  Investigation  of  Rhythm  Management  (AFFIRM)  ...
SN  - 
PB  - McGraw-Hill Education
CY  - New York, NY
Y2  - 2024/04/20
UR  - accesscardiology.mhmedical.com/content.aspx?aid=1173757734
ER  -