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Patients who are symptomatic (ie, palpitations, chest pain, shortness of breath, diaphoresis, dizziness) require urgent evaluation in an emergency care setting r37
Patients who are hemodynamically unstable require urgent treatment in an emergency care setting, often with IV nodal blocking medication and, sometimes, urgent cardioversion
Patients who are hemodynamically stable with minimal or no symptoms may be managed as outpatients
Patients with new-onset atrial fibrillation who undergo elective electrocardioversion in the emergency department are sometimes admitted for monitoring; regional practices vary, and younger, healthier patients are often discharged home afterward if they are stable
Initiation (or dose escalation) of dofetilide for rhythm control requires inpatient evaluation in an ECG-monitored bed; some experts prefer a monitored admission for initiation of sotalol r38
Patients with uncontrolled comorbid conditions that precipitate or exacerbate atrial fibrillation (ie, COPD exacerbation, sepsis, heart failure, trauma) often require hospital admission r39
Patients who are highly symptomatic despite adequate treatment may require hospital admission r40
Treatment of atrial fibrillation is organized around 2 main issues:
Anticoagulation decisions are based on risk stratification
Component of CHA₂DS₂-VASc score | Points assigned |
---|---|
Congestive heart failure | 1 |
Hypertension | 1 |
Age 75 years or older | 2 |
Diabetes mellitus | 1 |
Prior stroke (or transient ischemic attack) | 2 |
Vascular disease (eg, myocardial infarction, peripheral vascular disease) | 1 |
Age 65 to 74 years | 1 |
Sex category (female) | 1 |
Components of HAS-BLED score | Points assigned |
---|---|
Hypertension (systolic blood pressure over 160 mm Hg) | 1 |
Abnormal renal and liver function | 1 point each |
Stroke | 1 |
Bleeding (previous bleeding or predisposition to it) | 1 |
Labile INRs | 1 |
Elderly | 1 |
Drugs (concomitant aspirin or NSAIDs) or alcohol (excess consumption) | 1 point each |
Add points for total score (maximum 9 points) | |
Association of HAS-BLED score with bleeding risk per 100 person-years | |
HAS-BLED score of 0 to 1 | 1.02 to 1.13 |
HAS-BLED score of 2 | 1.88 |
HAS-BLED score of 3 or greater | 3.74 or greater |
Symptom management (control of rate and rhythm)
Drug | Dose |
---|---|
β-blockers | |
Metoprolol | 2.5 to 5 mg IV bolus over 1 to 2 minutes; may repeat every 5 minutes up to 3 doses |
Esmolol | 500 mcg/kg IV bolus over 1 minute, followed by an infusion of 50 mcg/kg/minute for 4 minutes If tachycardia is not controlled, may repeat loading dose and/or increase infusion to 100 mcg/kg/minute for 4 minutes Thereafter, repeat loading dose and increase infusion by 50 mcg/kg/minute increments every 4 minutes up to 200 mcg/kg/minute as required |
Propranolol | 1 mg IV over 1 minute, up to 3 doses at 2-minute intervals |
Nondihydropyridine calcium channel blockers | |
Verapamil | 5 to 10 mg (0.075-0.15 mg/kg) IV over at least 2 minutes If no adequate response after 30 minutes, may give an additional 10 mg (0.15 mg/kg) IV followed by a 0.005 mg/kg/minute continuous IV infusion |
Diltiazem | 0.25 mg/kg IV bolus over 2 minutes After 15 minutes, 0.35 mg/kg IV over 2 minutes may be given. Individualize as needed. Begin continuous infusion of 5 to 10 mg/hour after bolus. Max: 15 mg/hour |
Other agents | |
Digoxin | Not recommended for rapid ventricular rate control; onset of action is more than 1 hour with peak effect delayed 6 hoursr2 |
Creatinine clearance (mL/minute) | Dose |
---|---|
More than 60 | 500 mcg twice daily |
40 to 60 | 250 mcg twice daily |
20 to 40 | 125 mcg twice daily |
Less than 20 | Usage contraindicated |
If the starting dose based on creatinine clearance is: | Then the adjusted dose (for QTc or QT prolongation) is: |
---|---|
500 mcg twice daily | 250 mcg twice daily |
250 mcg twice daily | 125 mcg twice daily |
125 mcg twice daily | 125 mcg once daily |
Modify lifestyle and manage cardiovascular risk factors to decrease the burden of atrial fibrillation (secondary prevention) r3