Acute management of atrial fibrillation:First question - STABLE vs UNSTABLE?
(Instability rare if HR<150)>
Unstable if - hypotension, chest pain, altered mental status, other signs of shock
If Unstable - requires immediate synchronized cardioversion (with appropriate sedation, monitoring, etc).
If stable - consider rate control (oral or IV) with agents such as beta blockers, calcium channel blockers (Non-dihydropyridines) and amiodarone - depending on the clinical situation/contraindications.
The ACLS Tachycardia algorithim can be found here.
ANTICOUAGULATION in chronic/paroxysmal AFIB:
Initiated to prevent embolic stroke.
Risk similar in chronic vs paroxysmal AFib
CHADS2 score - used to risk stratify patients
C-Congestive Heart Failure (1point)
H-Hypertension (1point)
A-Age>75 (1point)
D-DM (1 point)
Stroke/TIA - (2 points)
CHADS2 score of 0 associated with 0.5%/year chance of stroke without coumadin
CHADS2 score >=3 associated with >5.3%/year chance of stroke without coumadin]
Patients with higher stroke risk will have greater benefit with anticoagualtion.
See the original article here.
Informed discussions should take place with patients to determine the risk/benefit of starting on anticoagulation with coumadin (target INR 2-3).
MDs are often concerned about starting anticoagulation in patients who fall. A decision analysis conducted in part by a Toronto based researcher suggested that patients with an average risk of stroke from AFib would have to fall 300 times in one year for the risk of anitcoagulation to outweigh its benefit - see article here.
