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Acute Management of Atrial Fibrillation: Part I. Rate and Rhythm Control DANA E

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Acute Management of Atrial Fibrillation: Part I. Rate and Rhythm Control DANA E COVER ARTICLE PRACTICAL THERAPEUTICS Acute Management of Atrial Fibrillation: Part I. Rate and Rhythm Control DANA E. KING, M.D., LORI M. DICKERSON, PHARM.D., and JONATHAN L. SACK, M.D. Medical University of South Carolina, Charleston, South Carolina Atrial fibrillation is the arrhythmia most commonly encountered in family practice. Serious complications can include congestive heart failure, myocardial infarction, and thromboembolism. Initial treatment is directed at controlling the ventricular rate, most often with a calcium channel blocker, a beta blocker, or digoxin. Medical or electrical cardioversion to restore sinus rhythm is the next step in patients who remain in atrial fibrillation. Heparin should be administered to hospitalized patients undergoing med- ical or electrical cardioversion. Anticoagulation with warfarin should be used for three weeks before elective cardioversion and continued for four weeks after cardioversion. The recommendations provided in this two-part article are consistent with guidelines published by the American Heart Association and the Agency for Healthcare Research and Quality. (Am Fam Physician 2002;66:249-56. Copyright© 2002 American Academy of Family Physicians.) n recent years, management ness of breath, dizziness, or palpitations. strategies for atrial fibrillation The arrhythmia should also be suspected have expanded significantly, and in patients with acute fatigue or exacer- new drugs for ventricular rate bation of congestive heart failure.3 In control and rhythm conversion some patients, atrial fibrillation may be Ihave been introduced.1-3 Family physi- identified on the basis of an irregularly cians have the challenge of keeping cur- irregular pulse or an electrocardiogram rent with recommendations on heart rate (ECG) obtained for the evaluation of control, antiarrhythmic drug therapy, car- another condition. dioversion, and antithrombotic therapy. Cardiac conditions commonly associ- Atrial fibrillation is the most common ated with the development of atrial fibril- sustained arrhythmia encountered in the lation include rheumatic mitral valve dis- primary care setting. Approximately 4 per- ease, coronary artery disease, congestive Members of various cent of persons in the general U.S. popula- heart failure, and hypertension. Noncar- family practice depart- tion have permanent or intermittent atrial diac conditions that can predispose ments develop articles fibrillation, and the prevalence of the patients to develop atrial fibrillation for “Practical Therapeu- arrhythmia increases to 9 percent in per- include hyperthyroidism, hypoxia, alco- tics.” This article is one 2 4 in a series coordinated sons older than 60 years. Atrial fibrillation hol intoxication, and surgery. by the Department of can result in serious complications, The ECG is the mainstay for diagnosis Family Medicine at the including congestive heart failure, myocar- of atrial fibrillation (Figure 1). An irregu- Medical University of dial infarction, and thromboembolism. larly irregular rhythm, inconsistent R-R South Carolina. Guest Recognition and acute management of interval, and absence of P waves are usu- editor of the series is William J. Hueston, M.D. atrial fibrillation in the physician’s office or ally noted on the cardiac monitor or emergency department are important in ECG. Atrial fibrillation waves (f waves), This is part I of a two- preventing adverse consequences. which are small, irregular waves seen as a part article on atrial rapid-cycle baseline fluctuation, indicate fibrillation. Part II, “Pre- Diagnosis rapid atrial activity (usually between 150 vention of Thrombo- embolic Complications,” The diagnosis of atrial fibrillation and 300 beats per minute) and are the appears in this issue should be considered in elderly patients hallmark of the arrhythmia. on pages 261-4. who present with complaints of short- When the fibrillation waves reach 300 JULY 15, 2002 / VOLUME 66, NUMBER 2 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 249 { { FIGURE 1. Atrial fibrillation. The tracing demonstrates the absence of P waves (long arrow), as well as the presence of the fine f waves of atrial fibrillation (short arrows). Note the irregularity of the ventricular response, as seen from the variable R-R interval (brackets). beats per minute, they may be difficult to see rate of approximately 150 beats per minute. In (fine versus coarse fibrillation).5 These waves this condition, the atrial rate is regular (unlike may be even harder to detect on a cardiac the irregular disorganized f waves of atrial fib- monitor in a busy emergency department rillation), but conduction to the ventricles is because of interference from other electrical not regular. The resultant irregularly irregular equipment. The f waves may be easier to iden- rhythm may be difficult to differentiate from tify on a printed rhythm strip. In addition, atrial fibrillation.3 when the ventricular response to atrial fibril- lation is very rapid (more than 200 beats per Initial Management minute), variability of the R-R interval can Recent advances in treatment and the intro- frequently be seen more easily using calipers duction of new drugs have not changed initial on a paper tracing. management goals in patients with atrial fibril- Atrial flutter is included in the spectrum of lation. These goals are hemodynamic stabiliza- supraventricular arrhythmia. This rhythm tion, ventricular rate control, and prevention disturbance is usually distinguishable by its of embolic complications.4,6-8 When atrial fib- more prominent saw-tooth wave configura- rillation does not terminate spontaneously, the tion and slower atrial rates (Figure 2). Atrial ventricular rate should be treated to slow ven- fibrillation should also be distinguished from tricular response and, if appropriate, efforts atrial tachycardia with variable atrioventricu- should be made to terminate atrial fibrillation lar block, which usually presents with an atrial and restore sinus rhythm4,7,9 (Figure 3).8 FIGURE 2. Atrial flutter. Note the saw-tooth wave configuration, or flutter waves (arrows). 250 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 66, NUMBER 2 / JULY 15, 2002 Atrial Fibrillation Initial Management of Atrial Fibrillation Patient with diagnosis of atrial fibrillation Hemodynamically stable (no angina, no hypotension, etc.)? Yes No Control ventricular rate (goal = <100 beats per Electrical cardioversion: sedate, minute): administer diltiazem (Cardizem), then shock (100 J, 200 J, 300 J, 15 mg IV over 2 minutes, then 5 to 15 mg per 360 J) until sinus rhythm returns. hour by continuous IV infusion or administer other rate-control drug (see Table 1). Spontaneous conversion to sinus rhythm? Yes No Assess cause of atrial Contraindications to cardioversion? fibrillation; hospital discharge, follow-up Yes No Consider long-term Consider cardioversion, if indicated (see text): anticoagulation. Start heparin IV; then choose— Atrial fibrillation < 48 hours: immediate medical or electrical cardioversion Atrial fibrillation > 48 hours or unknown duration: Later elective cardioversion (electrical cardioversion with or without medical cardioversion) after 3 weeks of warfarin (Coumadin) Early TEE–guided cardioversion (electrical cardioversion with or without medical cardioversion) Atrial fibrillation persists? Yes No Consider long-term Assess cause of atrial fibrillation; anticoagulation. hospital discharge, follow-up FIGURE 3. Initial approach to the patient with acute atrial fibrillation. (IV = intravenous; J = joule; TEE = transesophageal echocardiography) Information from Falk RH. Atrial fibrillation. N Engl J Med 2001;344:1067-78. JULY 15, 2002 / VOLUME 66, NUMBER 2 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 251 Compared with beta blockers and calcium In patients with atrial fibrillation, the initial management channel blockers, digoxin is less effective for goals are hemodynamic stabilization, ventricular rate control, ventricular rate control, particularly during and prevention of embolic complications. exercise. Digoxin is most often used as adjunc- tive therapy because of its slower onset of action (usually 60 minutes or more) and its weak potency as an atrioventricular node– VENTRICULAR RATE CONTROL blocking agent.3,13 It can be used when rate Ventricular rate control to achieve a rate of control during exercise is of less concern.4,7,12 less than 100 beats per minute is generally the Digoxin is a positive inotropic agent, which first step in managing atrial fibrillation. Beta makes it especially useful in patients with sys- blockers, calcium channel blockers, and tolic heart failure.7 digoxin (Lanoxin) are the drugs most com- The calcium channel blockers diltiazem monly used for rate control3,4,7 (Table 1).3 (Cardizem) and verapamil (Calan, Isoptin) These agents do not have proven efficacy in are effective for initial ventricular rate control converting atrial fibrillation to sinus rhythm in patients with atrial fibrillation. These agents and should not be used for that purpose.4,7,10,11 are given intravenously in bolus doses until Beta blockers and calcium channel blockers the ventricular rate becomes slower.7 Dihydro- are the drugs of choice because they provide pyridine calcium channel blockers (e.g., nifed- rapid rate control.4,7,12 These drugs are effec- ipine [Procardia], amlodipine [Norvasc], tive in reducing the heart rate at rest and dur- felodipine [Plendil], isradipine [DynaCirc], ing exercise in patients with atrial fibrilla- nisoldipine [Sular]), are not effective for ven- tion.4,7,12
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