Ver el código de «Atrial fibrillation with RVR»

==Unstable==
*Synchronized cardioversion (100-200J)
*Indications: ischemic CP, SBP < 90, acute pulmonary edema, AMS
*If shock doesn't work:
#Verify not preexcitation
#Incr diastolic BP to perfuse the heart
##Push-dose phenyleprhine
###Will maintain BP when give rate-control meds
###50-200mcg q2-5min w/ goal DBP >60
#Amiodarone 150mg over 10min OR diltiazem 2.5mg/min until HR<100 or max 50mg

==Stable==
*Goal <120bpm
**Make sure you not slowing down a normal physiologic response (e.g. fever, hypoxia, etc)
===Cardioversion===
*Consider for:
**Symptoms <48hr
**New diagnosis
**No history of similar episodes
**No LV dysfunction
**No mitral valve disease
**No prior thromboembolic event
**Already Anticoagulated


==Calcium-Channel Blockers==
*Preferred in patients with chronic lung such as [[Asthma]] and [[COPD]]<ref>Short PM, Lipworth SI, Elder DH, Schembri S, Lipworth BJ. Effect of beta blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study. BMJ. 2011 May 10;342:d2549</ref>
'''Contraindications:'''
#Decompensated heart failure
#Preexcitation (especially in pediatrics)
#*Significant hypotension
===Diltiazem===
*Bolus 0.25 mg/kg (average adult dose 20mg) over 2 min
*If, after 15min 1st dose is tolerated but inadequate re-bolus 0.35 mg/kg 
*If patient responds start infusion at 5-15mg/hr or give PO dilt 30mg QID


==Beta-Blockers==
*Particularly useful when A-fib a/w exercise, after acute MI, or w/ thyrotoxicosis
*Also long-term beta blocker improves patient survival whereas non-dihydropyridine calcium channel blockers may even worsen outcomes. Important to consider if a patient will most likely be started on a beta blocker upon discharge then strongly consider using the agent for acute conversion if they do not have any relative contraindications.<ref>Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet. 1999 Jun 12;353(9169):2001-7</ref><ref>Effect of verapamil on mortality and major events after acute myocardial infarction (the Danish Verapamil Infarction Trial II–DAVIT II). Am J Cardiol. 1990 Oct 1;66(10):779-85</ref>

'''Contraindications:'''
#COPD
#Asthma
#Decompensated heart failure
#Hypotension

===Metoprolol===
*Bolus 2.5-5mg IVP over 2min q5min up to 3 doses
*If patient responds orally load with 25-50mg
===Esmolol===
*Use if unsure whether patient will tolerate a beta blocker since the duration of action is only 10 minutes
*Bolus 0.5 mg/kg over one minute, followed by 50 µg/kg/min
*If, after 4min response is inadequate, re-bolus followed by infusion of 100 µg/kg/min
*If, after 4min response is still inadequate, try final bolus followed by infusion of 150 µg/kg/min
*If necessary, infusion can be increased to maximum of 200 µg/kg/min after another four minutes

==Digoxin==
*Consider as initial therapy for pts with LV dysfunction who:
**Do not achieve rate control targets on beta blockers alone
**Cannot tolerate addition of or increased doses of beta blocker due to decompensated CHF
**Would have digoxin added anyway to improve CHF symptoms independent of A-fib
*Consider as initial therapy in pts with severe hypotension
*Consider as 2nd agent in pts in whom IV BB or IV CCB has failed to control their rate
*May take up to 6-8 hours to work
*Dosing
**0.25 mg IV q2hr up to 1.5 mg, then 0.125-0.25 mg PO or IV QD
**Adjust dose in presence of renal failure, amiodarone, etc

==Amiodarone==
*Consider for pts with decompensated heart failure or those with accessory pathways
*2nd-line agent for chronic rate control when BBs and CCBs, alone, combined, or when used with digoxin, are ineffective
*Load 5-7 mg/kg IV over 30 min; then 1200 mg over 24hr via continuous infusion or in divided oral doses

==Stable and Asymptomatic==
If mild or no symptoms and pulse only mildly elevated (<120bpm) ok to manage with PO meds

== Evidence of preexcitation ==
#Avoid AV nodal agents
#Unstable:
##Unsynchronized cardioversion (200J)
##Procainamide (if cardioversion unsuccessful)
###20-50 mg/min until arrhythmia is controlled, hypotension occurs, QRS complex widens by 50% of original width, or total of 17 mg/kg is given; followed by continuous infusion of 1-4 mg/min
#Stable:
##Try to avoid cardioversion without adequate anticoagulation

== See Also ==
*[[Atrial Fibrillation (Main)]]

==External Links==
[[http://www.aliem.com/beta-blockers-vs-calcium-channel-blockers-atrial-fibrillation-rate-control-thinking-beyond-ed/ ALiEM - BB vs CCB]]
[[http://emcrit.org/podcasts/crashing-a-fib/ Crashing Afib - EMCrit]]

== Source ==
<references/>

[[Category:Cards]]