CLINICAL MANAGEMENT GUIDELINE

Atrial fibrillation

ICD10: Unspecified atrial fibrillation and atrial flutter [I48.9]

Treatment: Rate & rhythm control; hemodynamic stable w/ HF

Identified as electrical chaos; it is a from of unpatterned depolarization of atrial tissues caused by multiple micro reentry circuits.

ECG findings: absent P waves, fibrillatory waves, and irregularly irregular QRS complexes.

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May manifests as palpitations, dyspnoea, angina, dizziness, syncope, and/or features of congestive heart failure, stroke, and death.

Risk factors:

  • Coronary artery disease.

  • Cardiac hypertrophy.

  • Rheumatic heart disease.

Refernce


Success criteria:

  1. Relieve the patient's symptoms.

  2. Reduce HR < 120 bpm.

  3. Retain sinus rhythm (SR), if possible.

Note:

in younger patients; < 65 y/o with new-onset AF, starting with cardioversion is preferred to retain SR.

Using antiarrhythmic as an adjunct therapy to rate controllers may help to retain normal SR.

If diuretics and vasodilators failed to reduce HR in decompensated HFrEF, antiarrhythmic is indicated.

Pretreatment with antiarrhythmics increases the success rate of electrical cardioversion and reduces the risk of recurrence.

Anticoagulation coverage (INR= 2-3) for 3-4 weeks is conditional to start electrical cardioversion.


Contraindications for cardioversion:

  1. More than 48 hours of onset or unknown onset. DC
  2. Structural heart diseases. Antiarrythmics
  3. Recent stroke, TIA. Relative CI
  4. Atrial clot, or INR < 2. Absolute CI
  5. Severe hypomagnesemia, hypokalemia, digoxin toxicity. Absolute CI for antiarrhythmics.

Treatments

Level 1 / 2
pharmacological
Metoprolol
ROUTE
IV
DOSE
2.500 mg
FREQUENCY
q2-5 min; 3 times; PRN
pharmacological
Digoxin
ROUTE
Oral
DOSE
500.000 Mcg /2 min
FREQUENCY
STAT
pharmacological
Amiodarone
ROUTE
IV Infusion
DOSE
150.000 mg/min
FREQUENCY
STAT
procedures
Referral to cardiologist

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