CLINICAL MANAGEMENT GUIDELINE

Atrial fibrillation

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

Treatment: Rate & rhythm control; hemodynamic stable w/out 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.

If monotherapy was not adequate, use dual therapy to control the heart rate.

Caution: both groups of medications may cause severe bradycardia, heart block, asystole, heart failure, or hypotension.

Continue heart rate control until you establish successful cardioversion.

CCBs are preferred in patients with chronic lung disease where bronchospasm may occur with beta-blockers.

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; for DC.

  2. Structural heart diseases; for antiarrhythmic.

  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
Diltiazem
ROUTE
IV
DOSE
0.250 mg
FREQUENCY
q15 min, 2 times
pharmacological
Metoprolol
ROUTE
IV
DOSE
2.500 mg
FREQUENCY
q2-5 min; 3 times; PRN
pharmacological
Propafenone
ROUTE
Oral
DOSE
450.000 mg
FREQUENCY
OD

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