Episode 191: Rapid Atrial Fibrillation

We go over the treatment of rapid atrial fibrillation (afib with RVR).

Brian Gilberti, MD
Jonathan Kobles, MD

December 1st, 2023 Download One Comment Tags:

Show Notes

Understanding AF with RVR Categories

  • General AF with RVR: Definition and basic understanding.
  • Rapid AF with Pre-excitation: Characteristics and complications.
  • Chronic AF in Critical Illness: Identification and special considerations.

Stability Assessment in AF with RVR

  • ACLS Protocols: Distinction between unstable and stable patients.
    • Unstable Patients: Immediate need for synchronized cardioversion, standard dose at 200 J for adults.
    • Stable Patients: Rate vs. rhythm control strategies, consideration of underlying etiology.
  • Limitations in Chronic AF: Challenges in patients with AF secondary to critical illness.

ACLS Guidelines and ECG Findings

  • Tachycardia with a Pulse Approach: Initial assessment guidelines.
  • ECG Interpretation:
    • Irregularly Irregular Rhythm: Absence of discernible P waves.
    • Ventricular Rate: Typically over 100 bpm.
    • QRS Complexes: Usually narrow, alterations in the presence of bundle branch block or ventricular rate-related aberrancy.
  • Identifying Pre-Excitation Syndromes: Signs of shortened PR interval and slurred QRS, indication of Wolff-Parkinson-White Syndrome.

AF with Pre-Excitation (WPW Syndrome)

  • Risk Assessment: Dangers of using AV nodal blockers (BB/CCB, digoxin, adenosine).
  • Alternative Management: Utilization of procainamide or amiodarone for stable patients, synchronized electrical cardioversion for unstable patients.

Treatment Approaches for AF Types

  • General Rapid AF:
    • First Line Agents: Metoprolol vs. Diltiazem.
    • Metoprolol Considerations: Dosing (5 mg every 10-15 minutes, max 15 mg), benefits in CAD and HF, limitations in asthma/COPD patients.
    • Diltiazem Advantages: Faster action, suitability in asthma/COPD, typical dosing (0.25 mg/kg initial, followed by 0.35 mg/kg if needed).
  • Critically Ill Patients: Tailoring treatment to underlying pathology, avoiding typical AF pharmacologic treatments.

Systematic Evaluation of Tachycardia Causes (TACHIES Mnemonic)

  • Thyrotoxicosis, Alcohol withdrawal, Cardiac issues, Hemorrhage, Intervals (WPW), Embolus, Sepsis.
  • Application of the mnemonic for a comprehensive approach to differential diagnosis.

Ultrasound in Diagnostic Assessment

  • Application in Undiagnosed Tachycardia: Identifying EF, pericardial effusion, valvular pathology, and signs of pulmonary embolism.
  • Fluid Status Evaluation: Use of ultrasound for assessing b-lines in lung scans.

Management of Chronic AF with HD Instability

  • Assessment of Hemodynamic Impact: Effects of extreme tachycardia on cardiac output, preload and afterload considerations.
  • Chronic vs. Paroxysmal AF: Differentiation in clinical presentation and treatment response.

Approaches in Complex AF Cases

  • Addressing RVR of Unclear Etiology: Targeted therapies based on suspected underlying causes.
  • Medication Strategies:
    • Amiodarone: Bolus and drip approach, slow AV nodal without significant impact on contractility.
    • Esmolol: Titration for heart rate control, short-acting nature allowing for rapid cessation if adverse effects are observed.

Comprehensive Patient Disposition

  • Considerations: Hemodynamic stability, underlying cause, comorbidities, outpatient follow-up feasibility.
  • Decision-Making Process: Balancing acute management with long-term treatment strategies.

Take Home Points

  • Differentiation in AF with RVR Types: It’s essential to distinguish between primary AF with RVR, chronic AF with RVR related to other health issues, and new-onset AF (NOAF) with RVR in critically ill patients, as each type necessitates a unique approach to treatment.
  • ACLS Guidelines for AF with RVR: The ACLS guidelines provide a treatment framework, particularly recommending immediate synchronized cardioversion for unstable patients. However, these guidelines may have limited effectiveness for chronic AF with RVR patients suffering from underlying critical illnesses.
  • ECG Diagnosis in AF: Identifying AF on an ECG is crucial, with key indicators being an irregular rhythm without clear P waves and a ventricular rate exceeding 100 bpm. Accurate ECG interpretation guides effective treatment planning.
  • Special Cases like WPW Syndrome: WPW syndrome and similar conditions require careful treatment consideration, as standard AF treatments can worsen these conditions. Alternatives like procainamide or amiodarone are often more appropriate.
  • Patient-Centered Management of AF with RVR: Management should account for the patient’s overall health, underlying conditions, the chronicity of AF, and other comorbidities. Drugs like metoprolol and diltiazem offer benefits and risks, demanding personalized treatment plans.
  • Pathophysiology in Critical AF Patients: Understanding the underlying pathophysiology in critically ill patients is vital. Tachycardia in these cases might be compensatory, necessitating an investigation into causes like myocarditis, dehydration, or GI bleeding.
  • Systematic Evaluation with TACHIES Mnemonic: The mnemonic TACHIES (Thyrotoxicosis, Alcohol withdrawal, Cardiac issues, Hemorrhage, Intervals [WPW], Embolus, Sepsis) aids in systematically assessing and addressing emergent tachycardia causes in critically ill patients.

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