Atrial Fibrillation Acute Management

Aka: Atrial Fibrillation Acute Management, Emergency Management of Atrial Fibrillation, Atrial Flutter Acute Management, Atrial Fibrillation with Rapid Ventricular Response, Atrial Fibrillation with Rapid Ventricular Rate, Atrial Fibrillation RVR, Atrial Fib RVR

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II. Precautions

  1. Complex patients with Atrial Fibrillation with Rapid Ventricular Rate (compensatory Tachycardia)
    1. Secondary cause for Atrial Fibrillation (Alcohol Withdrawal, decompensated COPD, Sepsis, CHF exacerbation)
    2. In these cases, serious active comorbidity is resulting in rapid rate and Atrial Fibrillation is incidental in these cases
    3. Focus on treating the underlying severe illness (e.g. Sepsis, CHF, COPD, Alcohol Withdrawal)
    4. High rate of adverse events when Atrial Fibrillation rate or rhythm control are used in these patients
    5. Scheuermeyer (2014) Ann Emerg Med S0196-0644(14)01298-0 +PMID:25441768 [PubMed]
  2. Secondary Atrial Fibrillation with Rapid Ventricular Rate may require primary management
    1. Although management of underlying cause is paramount, refractory instability may be due to the RVR
    2. May contribute to hemodynamic instability despite management of underlying cause (e.g. Sepsis)
    3. Diastolic Dysfunction may be challenging to manage, as rate significantly limits Cardiac Output
      1. May require Vasopressors, as well as cardioversion or Antiarrhythmic (e.g. Amiodarone)
      2. See hemodynamically unstable management as below

III. Management: Hemodynamically Unstable

  1. Criteria
    1. Rapid Heart Rate over 150 beats per minute
    2. Symptoms or signs of cardiovascular compromise
      1. Angina Pectoris
      2. Acute Myocardial Infarction
      3. Hypotension
      4. Congestive Heart Failure or Cardiogenic Shock
      5. Shortness of Breath
      6. Decreased Level of Consciousness
      7. Pulmonary Edema
  2. In complex presentations, consider compensatory Tachycardia for secondary cause (see precautions above)
    1. Although immediate cardioversion is indicated in unstable primary Atrial Fib RVR, it may be harmful in secondary cause
      1. In the Peri-Arrest patient, electrical cardioversion may be the only initial option
      2. However, try to otherwise distinguish instability due to secondary cause if suspected (e.g. Sepsis)
    2. If Hypotension is due to Atrial Fibrillation with rapid rate, expect the patient to be cool
      1. Contrast with Sepsis with vasodilation, in which the patient's skin will be warm
    3. Expect typical rates for Atrial Fibrillation rapid ventricular response (130-140 if younger, 110 if older)
      1. Heart Rate of 160 suggests compensatory Tachycardia for secondary cause (e.g. Sepsis)
      2. Treating Sepsis with volume replacement and lowering Temperature should start to correct Tachycardia
    4. Consider differential diagnosis of irregularly irregular Supraventricular Tachycardia
      1. Atrial Fibrillation
        1. Consider ventricular preexcitation (e.g. WPW) in QRS Widening with varied QRS morphology
      2. Multifocal Atrial Tachycardia
      3. Atrial fluttter with variable atrioventricular conduction
    5. Be alert for Diastolic Dysfunction (HFpEF)
      1. Rapid ventricular rate and Hypotension may be made paradoxically worse with fluid bolus in HFpEF
      2. Make early use of Vasopressors (see below)
      3. Be cautious with fluid administration
      4. Dr. Jacob Lentz (2020) email communication 12/26/2020
    6. Vasopressors may be indicated in refractory Hypotension due to secondary cause
      1. Options
        1. Vasopressin increases vascular resistance, without increasing Heart Rate or contractility
        2. Norepinephrine may also be used without significantly increasing Tachycardia
        3. Phenylephrine (as Push Dose Pressor)
      2. Response
        1. If Heart Rate improves with a Vasopressor, then it is likely compensatory Tachycardia
        2. If Heart Rate does not improve with Vasopressor, then Atrial Fib RVR may be the cause of Hypotension
  3. Atrial Fibrillation Electrical Cardioversion
    1. See Synchronized Cardioversion
    2. Preferred Procedural Sedation with Ketamine or Etomidate (to avoid Hypotension)
    3. Consider Adenosine 6-12 mg rapid IV (if no delay)
      1. Use only if regular rate and unclear diagnosis (possible PSVT)
      2. Not effective in Atrial Flutter (but will slow rate for closer EKG rhythm evaluation)
    4. Perform optimization if possible prior to attempted cardioversion
      1. Correct Electrolyte abnormalities (e.g. Hypomagnesemia, Hypokalemia)
      2. Consider Antiarrhythmic such as Amiodarone 150 mg bolus IV prior to cardioversion
        1. Risk of worsening Hypotension
    5. Synchronized Cardioversion
      1. Monophasic dose: 200 joules synchronized (up to 360 joules)
      2. Biphasic dose: 150 joules synchronized (up to 200 joules)
    6. Anticoagulation
      1. Indications
        1. Atrial Fibrillation of unknown duration or >48 hours or
        2. Emergent, unstable cases requiring immediate cardioversion or
        3. High risk for CVA (e.g. prior TIA or CVA, Rheumatic Heart Disease, Mechanical Heart Valve)
        4. Many cardiologists recommend Anticoagulation after any electrical cardioversion
      2. Protocol
        1. Unfractionated Heparin or Low Molecular Weight Heparin at the time of cardioversion
        2. Warfarin (or other Anticoagulant such as Rivaroxaban) for 3-4 weeks after cardioversion
  4. Unstable Patient and Failed Electrical Cardioversion (or longstanding Atrial Fibrillation and unlikely to respond to cardioversion)
    1. Administer Vasopressor (e.g. Norepinephrine) to increase mean arterial pressure above 70-75 mmHg
      1. Titrate dosing as needed in response to Hypotension with the following agents
    2. Rate control agent options (choose one)
      1. Amiodarone 150 mg bolus IV (may be repeated up to 6 times)
      2. Esmolol infusion
      3. Diltiazem infusion (without bolus)
    3. Other measures
      1. Consider Magnesium 2 g IV
        1. Use only with caution in unstable, hypotensive patients
        2. Magnesium may increase vasodilation, and worsen Hypotension
      2. Consider Calcium Gluconate 2 g IV
        1. Consider prior to Diltiazem IV in Hypotension
  5. References
    1. Weingart and Swaminathan in Herbert (2020) 20(1): 2-4
    2. Blackman et. al. (2020) EMDOcs, accessed 12/28/2020
      1. http://www.emdocs.net/unstable-atrial-fibrillation-a-guide-to-management/

IV. Management: Hemodynamically Stable

  1. Asymptomatic, hemodynamically stable patients with Heart Rate <110 to 120
    1. No emergency management required
    2. Manage precipitating conditions (e.g. holiday heart)
    3. Initiate or adjust Atrial Fibrillation Rate Control
    4. See Atrial Fibrillation Anticoagulation
  2. Symptomatic patients or Heart Rate >110 to 120
    1. Initiate Atrial Fibrillation Rate Control
  3. Atrial Fibrillation Cardioversion to sinus rhythm
    1. See Atrial Fibrillation Cardioversion
      1. See Electrical Synchronized Cardioversion of Atrial Fibrillation
        1. See Synchronized Cardioversion
        2. See Conscious Sedation
      2. See Atrial Fibrillation Pharmacologic Cardioversion
        1. See Ottawa Aggressive Protocol in Atrial Fibrillation Cardioversion
    2. Conservative protocol for Safe Cardioversion Indications (CAEP)
      1. Adequate Anticoagulation for >3 weeks OR
      2. CHADS-65 >=2 AND onset <12 hours AND No stroke, TIA or valvular heart disease history OR
      3. CHADS-65 <2 AND onset <48 hours OR
      4. Negative transesophageal Echocardiography
      5. Stiell (2021) CJEM 23(5):604-10 +PMID: 34383280 [PubMed]
    3. Atrial Fibrillation less than 48 hours (acute Atrial Fibrillation)
      1. See Atrial Fibrillation Cardioversion for precautions
      2. Consider other CVA risks (e.g. CVA/TIA in last 6 months, Mechanical Heart Valve, rheumatic heart)
      3. Consider Heparin while considering cardioversion
      4. Consider early Atrial Fibrillation Cardioversion (esp. if age <65 years old)
        1. Many patients prefer this when presenting with recurrence of Atrial Fibrillation to the ED
        2. Atrial Fibrillation is uncomfortable (Dyspnea, Light Headedness)
        3. Rate control medications have adverse effects
      5. Endurance athletes with paroxysmal Atrial Fibrillation
        1. Self-cardioversion with aerobic Exercise (ventricular rates above a. fib rate) has been documented
          1. Ragozzino (2002) N Engl J Med 347(25):2085-6 +PMID: 12490699 [PubMed]
        2. Paroxysmal Atrial Fibrillation is at increased risk in endurance athletes
          1. More common in males, and athletes who started at a young age
          2. Stergiou (2018) Curr Treat Options Cardiovasc Med 20(12):98 +PMID: 30367267 [PubMed]
    4. Atrial Fibrillation more than 48 hours
      1. See Atrial Fibrillation Anticoagulation
      2. Protocol
        1. Warfarin (or other approved Anticoagulant/DOAC) for 3 weeks before cardioversion
        2. Atrial Fibrillation Cardioversion
        3. Continue Warfarin (or other approved Anticoagulant) for 4 weeks after cardioversion
      3. Early cardioversion may be acceptable if cleared with Transesophageal Echocardiogram (TEE) first
        1. Normal TEE does not exclude all Thromboembolism risk in anticoagulated patients
        2. See Atrial Fibrillation Cardioversion for precautions

V. Disposition: Hospitalization Indications

  1. Atrial Fibrillation with Rapid Ventricular Rate
    1. Requiring continuous intravenous Atrial Fibrillation Rate Control (e.g. Diltiazem infusion)
  2. Congestive Heart Failure (CHF)
  3. Angina, Acute Coronary Syndrome or Myocardial Infarction
  4. Hypotension
  5. Serious comorbidity
    1. Acute Renal Failure
    2. Pulmonary Embolism
    3. Hyperthyroidism
  6. Other possible indications for hospitalization
    1. Elderly
    2. Unreliable follow-up
    3. Structural heart disease
  7. New onset Atrial Fibrillation hospitalization indications
    1. Acute Coronary Syndrome symptoms (typical symptoms)
      1. Coronary Artery Disease suspected as cause of Atrial Fibrillation trigger
    2. Patients at higher risk of coronary disease who present with atypical ACS symptoms
      1. Elderly
      2. Diabetes Mellitus

VI. Disposition: Emergency Department Observation Unit

  1. Indications
    1. Atrial Fibrillation onset within last 48 hours AND
    2. Normotensive patients (SBP > 90 mmHg) AND
    3. No Acute Coronary Syndrome, Heart Failure or other comorbidity AND
    4. Heart Rate <130 after IV rate control
  2. Contraindications
    1. Chest Pain
    2. Ischemic EKG changes
    3. Respiratory distress
    4. Fluid Overload
    5. Hypoxia
    6. Hypotension
    7. Decompensated significant condition (e.g. Sepsis, GI Bleed)
    8. New onset Acute Kidney Injury
    9. Pregnancy
    10. Lack of close follow-up
    11. Unable to comply with medication management
  3. Discharge goals (choose one of three options)
    1. Spontaneous cardioversion on rate control agent OR
    2. Electrical Cardioversion (consider TEE first) OR
    3. Rate control on oral nodal blockade agent (e.g. Metoprolol, Diltiazem) for at least 1-2 hours
      1. Heart Rate <100-100 bpm at rest (<110-120 bpm with activity)
  4. Anticoagulation
    1. CHADS2-VASc Score 2 or more indicates oral Anticoagulants (Warfarin or DOAC)
    2. HAS-BLED Score 3 or more suggests high risk of bleeding
    3. Expert opinion: Anticoagulation (Warfarin or DOAC) for 3 weeks after electrical cardioversion
    4. Factor comorbidity (hepatic or renal disease) into Anticoagulant selection
      1. ED observation unit protocol should include decision tools for Anticoagulant selection
  5. Education
    1. Medication Compliance
    2. Drug Interactions (and dietary restrictions)
    3. Anticoagulant Safety
      1. Avoiding Trauma and identifying signs, symptoms of bleeding
  6. Discharge from observation
    1. Established follow-up within 3-5 days
    2. Prescriptions for 30 day supply for lowest effective dose of rate control agent
    3. Anticoagulation agent prescription and follow-up with Anticoagulation clinic
  7. Efficacy
    1. Successful discharge to home in 80% of cases (20% require inpatient care)
    2. Shortens mean hospital stay from 50 hours to 13 hours
  8. References
    1. Davenport and Baugh (2018) Crit Dec Emerg Med 32(7): 15-24
    2. Decker (2008) Ann Emerg Med 52(4): 322-8 [PubMed]

VII. Disposition: Emergency Discharge Plan

  1. Interventions
    1. See Atrial Fibrillation Anticoagulation
    2. See Atrial Fibrillation Rate Control
    3. Anticoagulation, if indicated is often initiated prior to ED discharge
    4. Abstain from Alcohol, Caffeine and other potential exacerbating factors
    5. Consider cardiology Consultation (see indications below)
  2. Discharge Indications
    1. Asymptomatic (or CCS-SAF Scale 0-3) AND
    2. Heart Rate <110 beats per minute AND
    3. Hemodynamically stable (e.g. systolic Blood Pressure >90/60) AND
    4. No indications for hospitalization (see above)
  3. Follow-up
    1. Consider arranging cardiology follow-up
    2. Primary care follow-up
    3. Anticoagulation clinic follow-up
  4. Safety of emergency department discharge after cardioversion
    1. Discharge rates after cardioversion: 86-100%
    2. Return rate within 1 week: 10%
    3. Burton (2004) Ann Emerg Med 44(1): 20-30 [PubMed]
    4. Jacoby (2005) J Emerg Med 28(1): 27-30 [PubMed]
    5. Lo (2006) Emerg Med J 23(1): 51-3 [PubMed]
    6. von Besser (2011) Ann Emerg Med 58(6):517-20 +PMID:22098994 [PubMed]

VIII. Disposition: Cardiology Consultation indications

  1. Patient chronically managed with Atrial Fibrillation Rhythm Control
  2. Atrial Fibrillation with refractory rapid ventricular rate
  3. Structural heart disease (e.g. valvular heart disease, Congenital Heart Disease)
  4. Wolff-Parkinson-White Syndrome (WPW Syndrome) or other accessory pathway
  5. Decompensated Congestive Heart Failure or Coronary Artery Disease

IX. References

  1. Casaletto (2014) Crit Dec Emerg Med 28(4): 10-19
  2. Orman and Berg in Herbert (2016) EM:Rap 16(2): 6-10
  3. Stiell (2011) Canadian J Cardiol 27(1): 38-46 [PubMed]
  4. Wann (2011) Circulation 123(1): 104-23 [PubMed]
  5. King (2002) Am Fam Physician 66(2):249-56 [PubMed]
  6. Gutierrez (2011) Am Fam Physician 83(1): 61-8 [PubMed]
  7. Falk (2001) N Engl J Med 344:1067-78 [PubMed]
  8. Li (1998) Emerg Med Clin North Am 16:389-403 [PubMed]
  9. King (2002) Am Fam Physician 66:249-56 [PubMed]

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