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ACLS pearls: acute therapy of atrial fibrillation/flutter in the year 2000/2001 l Since atrial fibrillation is one of the ost co on arrhyth ia seen in !"/hospital# you should be fa iliar with its therapy. $ will tell you how y institution typically handles each situation. %his is a si plified approach that differs fro officail ACLS slightly. %ry out scenarios in code case & for practice. Abbre'iation: (CC)*electrical cardio'erison+ A/C* anticoagulate+ !,*e-ection fraction+.olff/0ar1inson/.hite 2.0.3

Step 1. if the patient is unstable 2chest pain# C4,# hypotension3 due to rapid rate 25 1603# cardio'ert. Step 2. 4istory# physical# and 12 leads to rule out .0. and C4,.
(elta/wa'e or shortened 0" on resting !78# 9" irregular wide co plex rhyth rate 5260: thin1 .0.. $n .0. a'oid adenosine# beta/bloc1er# Ca/channel bloc1er# digoxin. $f !, 97 choice of drug* procaina ide 21st line3# a iodarone propafenone#sotalol#flecainide. %his situation is rare. $f !, low use a iodarone. .idened :"S5;0 sec at rest# suspect low !,: drugs li ited to digoxin# diltia<e # and a iodarone. A'oid 'erapa il# bata/bloc1ers# ibutilide# procaina ide 2and propafenone/flecainide3# and sotalol3

Step =. $

ediate priority: rate control.

(iltia<e i' is our drug of choice in ost situations except in .0. and hypotension+ 97 e'en if L) is oderately i paired+ 2nd line: beta bloc1er if !, nor al but if patient tenuous# use short ter agent es olol+ =rd line: digoxin# onset delayed but useful in C4,+ Certain agents that can cardio'ert can also slow rate 2a'oid if onset5 >? hs3: drug of choice: a iodarone. Alternati'e: sotalol 2do not use in low !,3.

Step >. Should the patient be anticoagulated for stro1e pre'ention@

Al ost always anticoagulate if electrical or phar acological cardio'ersion planned. Aou donBt need to A/C if cardio'erted within C>? hours of onset though any people would. ,or patients at ris1 of fall/bleeding# you do not need to anticoagulate but consider short ter anticoagulation for cardio'ersion+ ,or the patient with structurally nor al heart D ageCE6 D no other stro1e ris1 2e.g. diabetes# hypertension# C4,# pre'ious thro boe bolis 3 D not going for

cardio'ersion: anticoagulation ay not be necessary# use aspirin. 0ost/9p A fib: A/C if possible# depends on what surgery. Fote: Atrial flutter also increase stro1e: hence A/CG

Step 6. Should cardio'ersion be electi'ely atte pted and how@

The key question here is the time of onset: If onset< 2 days# either obser'e 2 any will self/con'ert3 or try phar acolgical cardio'ersion up to >? hours55 if not cardio'erted by >? hrs# electrical cardio'ersion. Can also proceed straight to (CC). If onset >2 days but probably <60 days: either adeHuately A/C x > wee1s then cardio'erted then A/C x > wee1s post (CC)# 9" 2especially in sy pto atic patients3 %ransesophageal echo to rule out atrial clot# then (CC)# then A/C x > wee1s. If > 8 weeks: cardio'ersion ay not be useful

Choi e of ardio!ersion a"ent: %he choice depends on the !,# and whether patient has asth a. #ow $%: li ited to a iodarone and dofetilide 2new agent# not in ACLS3+ &ormal $%: for rapid cardio'erison use ibutilide 27#Ig :%c ust be nor al# onitor > hours post ad insitration# ust be ready to cardio'ert as 2J ris1 of torsade in patients with nor al heart# =1J success for A fib# E0J for a flutter+ also useful to increase chance of success of (CC)3 if cardio'ersion can be done slowly: sotalol or fecainide Also can consider: propafenone# procaina ide# a iodarone# dofetilide.

Step E: After proble fixed: should you start an antiarrhyth ic agent to pre'ent recurrence@
Ksually after second episodes of a fib/flutter. A iodarone is the ost effecti'e and can be used regardless of !, but other agents be preferred due to side effects. (ofetilide useful in low !, patients with nor al :%c. $f !, nor al: flecainide 2follow :"S inter'al and do exercise test as outpatient to "/9 :"S prolongation with exercise3# sotalol 2watch :%c in/hospital x 2 days D outpatient in 1 and 2 wee1s# a'oid in asth a3# propafenone 2a'oid in asth a3+ a iodarone and dofetelide also acceptable but are second line agents

Step 7: Should the patient be referred to an electrophysologist for A flutter or atrial fib ablation?
%his depends on the freHuency of the episodes and the a'ailability of local expertise. Atrial flutter ablaton is relati'ely si ple# but atrial fibrillation is rather difficult and in'ol'ed transeptal puncture.


ary of special situation:

Low !,: diltia<e # a iodrone# dofetelide. .0.: 1st line procaina ide+ Also a iodarone# propafenone#sotalol#flecainide . Asth a: a'oid propafenone# beta/bloc1er# and sotalol.