Prehospital Care

Care of hemodynamically unstable patients is guided by ACLS protocols, including

direct current (DC) cardioversion.
Symptomatic patients may benefit from intravenous (IV) rate-controlling agents, either
calcium-channel blockers or beta-adrenergic blockers.

Emergency Department Care

Immediate interventions ABCs

Patients placed on cardiac monitor, O2, and ABCs are being assessed, ECG, IV access
Unstable patients require immediate DC cardioversion.8
o Hypotension
o Decompensated CHF
o Ongoing ischemia or infarction
These initial interventions occur simultaneously by the team of physicians and nurses
taking care of the patient.

Routine care9,10

In most circumstances, the patient is stable but has an elevated ventricular response and
will require rate-controlling medications, with a heart rate goal of under 80. This
recommended heart rate target was challenged in the RACE II study that examined HR of
110 versus less than 80. The lenient arm had no difference than the strict control arm per
a composite outcome of cardiac death, CHF, stroke, systemic bleeding, and lifethreatening arrhythmic events.11
If there is another clinical condition driving the tachycardia, such as fever, infection, or
dehydration, then efforts at temperature control and restoration of normovolemia will aid
in controlling the tachycardia.
Consideration of anticoagulation based upon patient risk factors may also begin in the
emergency department.

Cardioversion12
Cardioversion can be pharmacologic based or electrical.
Anticoagulation and cardioversion may be indicated. Since there is a risk of thrombus formation
and fragmentation, patients in atrial fibrillation for greater than 48 hours should receive
therapeutic anticoagulation (INR 2-3 range) for 3 weeks prior to cardioversion. Alternatively,
these patients can undergo heparinization, and TEE, and cardioversion if no thrombus is
detected. In each case, anticoagulation needs to be continued for an additional 4 weeks.
Electrical cardioversion13

DC cardioversion is the treatment of choice in the unstable patient with atrial fibrillation.
Cardioversion is indicated in patients with first time atrial fibrillation or in patients with
paroxysmal atrial fibrillation.
Since atrial fibrillation begets atrial fibrillation, one may delay or prevent permanent
atrial fibrillation by decreasing the overall time spent in atrial fibrillation in these early
clinical stages.
There is little utility in cardioverting stable patients with permanent atrial fibrillation, and
the goal in this group is rate control.
Placement of pads or paddle positions include anterior-lateral (ventricular apex and right
infraclavicular) and anterior-posterior (sternum and left scapular), with at least one study
suggesting increased efficacy with the anterior-posterior method.
Biphasic waveforms are proved to convert atrial fibrillation at lower energies and higher
rates than monophasic waveforms.
Strategies include dose escalation (70, 120, 150, 170J for biphasic) or (100, 200, 300,
360J for monophasic) versus beginning with single high energy/ highest success rate for
single shock delivered.
Patients who are stable and/or awake and can tolerate sedation should be pretreated, with
typical regimens involving midazolam, fentanyl, and propofol.
Cardioversion of patients with implanted pacemakers and defibrillator devices is safe
when appropriate precautions are taken. Keeping the cardioversion pads in an AP
orientation ensures that the shocks are not directly over the generator. Alteration in pacer
programmed data has been reported, as well as heart block and elevated enzymes if the
current gets conducted through a pacer lead.
Stunning of the atria and stasis can occur after cardioversion, and this can lead to
thrombus formation even though the patient is in sinus rhythm. Therefore, patients would
undergo anticoagulation for several weeks afterwards.
Risks of cardioversion
o Risks with sedation
o Risk of thromboembolism (<1% with anticoagulation)
o Postcardioversion arrhythmias

Pharmacologic cardioversion
Pharmacologic cardioversion is selected for patients who are symptomatic, who have had a short
duration atrial fibrillation, or as an adjunct in patients who have failed electrical cardioversion.
Alboni et al studied outpatient treatment of atrial fibrillation with a "pill-in-the-pocket" approach
in 268 patients with little or no structural heart disease presenting to the ED with symptomatic
AF.14 Out of hospital self-administration of either flecainide 300 mg or propafenone 600 mg
(weight based dosages if >70 kg) was evaluated. This treatment was successful in terminating
AF in 94% of episodes (mean time to symptom resolution of 133 minutes).
Rate control
In most instances, patients presenting to the ED have preexisting atrial fibrillation and a rapid
ventricular response. These individuals may already be on beta-blockers or calcium channel

blockers, and initial attempts at rate control should be initiated with same class medications
given intravenously, trying to avoid mixing classes of nodal blocking agents.

Extreme care must be taken in patients with preexcitation syndrome and atrial fibrillation.
Blocking the AV node in some of these patients may lead to AF impulses exclusively
transmitted down the accessory pathway, and this can result in ventricular fibrillation. (If
this happens, the patient will require immediate defibrillation.) Alternative therapies for
the treatment of arrhythmia in this group include procainamide and amiodarone.
Intravenous diltiazem or metoprolol are commonly used drugs for AF with RVR.
Amiodarone has been used in patients with CHF who may otherwise not tolerate
diltiazem or metoprolol. Digoxin may also be used, but its peak effect may not be for 6
hours.

Antiarrhythmic drugs
Antiarrhythmic drugs that can terminate atrial fibrillation include procainamide, disopyramide,
propafenone, sotalol, flecainide, amiodarone, ibutilide, and dronedarone. The efficacy of
antiarrhythmic drugs has been linked to the duration of atrial fibrillation.
The American College of Cardiology/American Heart Association/European Society of
Cardiology (ACC/AHA/ESC) Guidelines make the following recommendations regarding
pharmacologic conversion of atrial fibrillation (AF):

Conversion of AF less than or equal to 7 days15

o Agents with proven efficacy include dofetilide, flecainide, ibutilide, propafenone,
and to a lesser degree, amiodarone and quinidine.
o Less effective or incompletely studied agents in this scenario include
procainamide, digoxin, and sotalol.
Conversion of AF lasting greater than 7 days
o Agents with proven efficacy include dofetilide, amiodarone, ibutilide, flecainide,
propafenone, and quinidine.
o Less effective or incompletely studied agents in this scenario include
procainamide, sotalol, and digoxin.
Conversion of AF lasting greater 90 days - Oral propafenone, amiodarone, and dofetilide
have been shown to be effective at converting chronic AF to normal sinus rhythm (NSR).

The US Food and Drug Administration (FDA) mandates inpatient monitoring for dofetilide
initiation. Patients who start sotalol usually require inpatient monitoring (for torsade de pointes),
although patients with no heart disease, QT interval <450 msec, and normal electrolytes should
be started on outpatient medications.
In March of 2009, the FDA approved dronedarone (Multaq) for the suppression of atrial
fibrillation. The structure and mechanism of action are similar to those of amiodarone, and, in
fact, they differ mostly by the iodine groups, which have been removed from dronedarone to
decrease drug toxicity. However, in the ANDROMEDA study, there was an excess mortality of
patients (a double) in the subgroup of patients with decompensated CHF and EF <35%.16

Anticoagulation
ACC/AHA/ESC 2006 Guidelines for Antithrombotic Therapy in Patients with AF5,9,17
Open table in new window
[ CLOSE WINDOW ]
Table

High risk factor Moderate risk factor Low risk

Prior CVA/TIA
Age >75
Age 65-74
Mechanical heart valve HTN
Female gender
Mitral stenosis
CHF
CAD
EF <=35%
Thyrotoxicosis
DM
High risk factor Moderate risk factor Low risk
Prior CVA/TIA
Age >75
Age 65-74
Mechanical heart valve HTN
Female gender
Mitral stenosis
CHF
CAD
EF <=35%
Thyrotoxicosis
DM
Aspirin can be 81 mg or 325 mg
Warfarin - INR goal of 2-3

Risk factors - Aspirin or no therapy

One moderate risk factor - Aspirin or warfarin
More than one moderate risk factor or one high risk factor - Warfarin
Lone AF - Age 60-74 years, aspirin
Age 60-74 years, CAD Warfarin

The treatment of atrial fibrillation varies from person to person and depends on:

the type of atrial fibrillation,

symptoms,
treatment of any underlying cause,
age, and
overall health.

Some people may be treated by their GP, whereas others may be referred to a cardiologist (heart
specialist).
The first step is to try to find out the cause of the atrial fibrillation. If a cause is found, you may
just need treatment for this.
For example, medication to correct hyperthyroidism (an overactive thyroid gland) may cure
atrial fibrillation.
If no underlying cause can be found, the treatment options are:

medicines to control atrial fibrillation,

medicines to reduce the risk of stroke,
cardioversion (electric shock treatment),
ablation, or
having a pacemaker fitted.

Medicines to control atrial fibrillation

Medicines called anti-arrhythmics can control atrial fibrillation by:

restoring a normal heart rhythm, and/or

controlling the rate at which the heart beats.

The choice of anti-arrhythmic medicine depends on the type of atrial fibrillation, any other
medical conditions, side effects of the medicine chosen and how well the atrial fibrillation
responds.
Some people with atrial fibrillation may need more than one anti-arrhythmic medicine to control
it.
Restoring a normal heart rhythm

A variety of drugs are available to restore normal heart rhythm. These include:

flecainide (and other similar drugs),

beta-blockers (particularly sotalol), and
amiodarone.

New drugs are in development that may restore normal heart rhythm, but they are not widely
available yet. If a particular drug does not work or the side effects are troublesome, another may
be tried.

Controlling the rate of the heartbeat

The aim is to reduce the resting heart rate to under 90 beats a minute, although in some people
the target is under 110 beats a minute.
A beta-blocker (such as bisoprolol or atenolol) or a calcium channel blocker (such as verapamil
or diltiazem) will be prescribed.
A medicine called digoxin may be added to help further control the heart rate. In some cases,
amiodarone may be tried.
Side effects

As with any medicine, anti-arrhythmics can cause side effects. Read the patient information
leaflet that comes with the medicine for more details.
The most common side effects of anti-arrhythmics are:

Beta-blockers: tiredness, coldness of hands and feet, low blood pressure, nightmares and
impotence.
Flecainide: nausea, vomiting and heart rhythm disorders.
Amiodarone: sensitivity to sunlight (high-protection sunscreen must be worn or skin covered
up), lung problems, changes to liver function or thyroid function (regular blood tests can check
for this) and deposits in the eye (these go away when treatment is stopped).
Verapamil: constipation, low blood pressure, ankle swelling and heart failure.

Medicines to reduce the risk of stroke

The way the heart beats in atrial fibrillation means that there is a risk of blood clots forming in
the heart chambers. If these get into the bloodstream, they can cause a stroke (see
Complications).
Your doctor will assess your risk to minimise your chance of a stroke. They will consider your
age and whether you have a history of any of the following:

stroke or blood clots,

heart valve problems,
heart failure,
high blood pressure,
diabetes, or
heart disease.

You will be classed as having a high, moderate or low risk of stroke and will be given
medication according to your risk.
Depending on your level of risk, you may be prescribed warfarin or aspirin.

Warfarin

People with atrial fibrillation who have a high or moderate risk of stroke are usually prescribed
warfarin, unless there is a reason they cannot take it.
Warfarin is an anticoagulant, which means it stops the blood from clotting. There is an increased
risk of bleeding in people who take warfarin, but this small risk is usually outweighed by the
benefits of preventing a stroke.
It is very important to take warfarin as directed by the doctor. People on warfarin need to have
regular blood tests and, following these, their dose may be changed.
Lots of medicines can interact with warfarin and cause serious problems, so check that any new
medicines are safe to take with warfarin.
Drinking more than moderate amounts of alcohol or drinking cranberry juice can also affect your
warfarin and is not recommended.
Aspirin

People with atrial fibrillation who have a low risk of stroke are likely to be given a low dose of
aspirin to take every day instead of warfarin.
People who are unable to take warfarin may also be given aspirin instead.

Cardioversion
Cardioversion may be tried in some people with atrial fibrillation. The heart is given a controlled
electric shock to try to restore a normal rhythm.
The procedure normally takes place in hospital, where the heart is carefully monitored.
In people who have had atrial fibrillation for more than two days, cardioversion is associated
with an increased risk of clot formation. If this is the case, warfarin is given for three to four
weeks before cardioversion and for at least four weeks afterwards to minimise the chance of
having a stroke.
If the cardioversion is successful, warfarin may be stopped. However, some people may need to
continue with warfarin after cardioversion if there is a high chance of their atrial fibrillation
returning and they have a moderate to high risk of stroke (see above).

Catheter ablation
Catheter ablation is a procedure that very carefully destroys the diseased area of your heart and
interrupts abnormal electrical circuits. It is an option if medication has not been effective or
tolerated.

Catheters (thin, soft wires) are guided through one of your veins into your heart, where they
record electrical activity. When the source of the abnormality is found, an energy source (such as
high-frequency radiowaves that generate heat) is transmitted through one of the catheters to
destroy the tissue.
This can be quite a long procedure and commonly takes two to three hours, so it may be done
under general anaesthetic (where you are put to sleep).
For more detailed information on catheter ablation for atrial fibrillation, go to the Arrhythmia
Alliance website

Having a pacemaker fitted

A pacemaker is a small, battery-operated device that is implanted in your chest (just below your
collarbone). It is usually used to prevent your heart rate going too slowly, but in atrial
fibrillation, it may help your heart beat regularly.
Having a pacemaker fitted is usually a minor surgical procedure performed under a local
anaesthetic (the area is numbed).
This treatment may be used when medicines are not effective or are unsuitable.
For more information, go to Health A-Z: pacemaker implantation.