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Atrial Fibrillation - ED Management Algorithm

Atrial Fibrillation - ED Management Algorithm - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Cardiovascular, Related


Brief Chart Review
& Medical Screening Exam
ü ECG Confirmed
Atrial Firbrillation
Compensated?
A,B
Low Immediate
CVA Risk?
C
Yes
Duration
< 48 Hours?
Yes
On Prior OAC for
> 3 weeks?
E
Option for
Cardioversion
D
(including
pharmacologic)
Yes
Nodal Blocking Agent
F
No
Heart Rate
< 110 bpm?
Yes
Initiate Anticoagulation if
CHA
2
DS
2
VASc ≥ 2
G
Yes
Sinus
Rhythm?
Yes
Yes
No
Not a Pathway
Candidate
No
Discharge
Follow-up contact within
24-48 hours
No
No
No or Unsure
ED Management of Atrial Fibrillation Algorithm
Additional Details
1
A.
History, vitals, TSH, CBC, BMP and CXR rules out
hyperthyroid, infection, new/severe anemia, renal failure,
PE, etc. (SBP<80, T>100.5, O
2
sat<90%, GFR<40)
B.
Signs and symptoms of heart failure (pulmonary edema,
elevated JVP, elevated BNP), hemodynamic instability, ST
depressions ≥ 2mm or STE, trop >0.1. Ask about orthopnea,
PND, edema.
C.
High risk= prior TIA or stroke, thromboembolism
rheumatic heart disease, artificial valve, systolic heart
failure
D.
Option per MD and patient.
2,3
Zoll defibrillator: start 75J,
repeat with 120J then 150J if does not convert. Lifepak
defibrillator: 200J biphasic synchronized shock, repeat 360J
if 200J does not convert. Pre-procedural SC enoxaparin if
not therapeutic on oral anticoagulation.
E.
Target-specific anticoagulant with no missed doses or
warfarin with consistent INR> 2. (AHA Class I, LOE B) Consider
TEE if unclear with therapeutic anticoagulation peri and
post procedure. (AHA Class IIa, LOE B)
F.
Metoprolol 2.5-5mg IV +/- 50mg PO. Diltiazem 0.25mg/kg
IV bolus then 5-15mg/hr +/- 30mg PO. Repeat IV prn. Home
dose per HR/BP
See Rate Control Dosing Table for options.
G.
With

some exceptions, anticoagulation for ≥4 weeks post
cardioversion. (AHA Class I, LOE B) If warfarin used for
cardioversion patients, consider bridging with enoxaparin
until INR is therapeutic. Cardiologist to determine duration.
If warfarin is used in a patient that is being rate controlled,
an enoxaparin bridge is not needed.
See Anticoagulation Flow Diagram for options.
NOTE: For low risk patients (CHA
2
DS
2
VASc < 1) with atrial
fibrillation < 48 hours, give pre-procedural enoxaparin.
Post-procedure anticoagulation is not necessary in patients
with CHA
2
DS
2
VASc = 0. (AHA Class IIb, LOE C) Post-procedure
anticoagulation may be considered in patients with
CHA
2
DS
2
VASc = 1.
4
No or Unsure
Last revised/reviewed: 04/2015
Contact CCKM for revisions.
Atrial Fibrillation- Adult- Inpatient/
Ambulatory Guideline
References
1. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2014.
2. Decker WW, Smars PA, Vaidyanathan L, et al. A prospective, randomized trial of an emergency department observation unit for acute onset atrial fibrillation. Ann Emerg Med. 2008;52(4):322-328.
3. Zimetbaum P, Reynolds MR, Ho KK, et al. Impact of a practice guideline for patients with atrial fibrillation on medical resource utilization and costs. Am J Cardiol. 2003;92(6):677-681.
4. Airaksinen KE, Grönberg T, Nuotio I, et al. Thromboembolic complications after cardioversion of acute atrial fibrillation: the FinCV (Finnish CardioVersion) study. J Am Coll Cardiol. 2013;62(13):1187-
1192.
Suggested Post-Discharge Follow-up
NOTE: All patients may be considered for referral to Cardiology.
By Primary Care Provider:
ξ Patients with known AF w/o heart failure or high risk
features previously managed by PCP
ξ Patients with new onset (first occurrence)
By Cardiology:
ξ Patients with known AF and regularly followed by
cardiologist (or seen by cardiologist within the last 2 yrs.)
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org

Table 1. Common Medications for Atrial Fibrillation Rate Control
IV Administration Oral Maintenance Dose
Beta blockers
Metoprolol tartrate 2.5-5.0 mg IV bolus over 2 min; up to 3 doses 25 - 100 mg BID
Metoprolol XL (succinate) --- 50 - 400 mg QD
Atenolol --- 25 - 100 mg QD
Esmolol 500 mcg/kg IV bolus over 1 min, then 50 -300 mcg/kg/min IV ---
Propranolol 1 mg IV over 1 min, up to 3 doses at 2 min
intervals
10 - 40 mg TID or QID
Nadolol --- 10 - 240 mg QD
Carvedilol --- 3.125 - 25 mg BID
Bisoprolol --- 2.5 - 10 mg daily
Nondihydropyridine
calcium channel
antagonists
Verapamil
(0.075 -0.15 mg/kg) IV bolus over 2 min, may give
an additional 10mg after 30 min if no response,
then 0.005 mg/kg/min infusion
180 - 480 mg QD (ER)
Diltiazem 0.25 mg/kg IV bolus over 2 min, then 5 -15 mg/h 120-360 mg QD (ER)
Digitalis glycosides Digoxin
0.25 mg IV with repeat dosing to a maximum of
1.5 mg over 24 hrs. 0.125 – 0.25 mg QD
Others Amiodarone 300 mg IV over 1 hr, then 10-50 mg/hr over 24 hrs. 100 - 200 mg QD
BID = twice daily; ER = extended release; QD = once daily; QID = four times a day; TID = three times a day
Last revised: 04/2015
Last reviewed: 04/2015
Contact CCKM for questions or revisions.
UW Health Atrial Fibrillation – Adult – Inpatient/Ambulatory Clinical Practice Guideline
Reference: January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College o f
Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2014.
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org

Start
Any type of
prosthetic valve,
rheumatic mitral
steno sis or mitral
valve repair?*
Us e warfarin
CrCl
(mL/min )
Use warfarin˄
Age
(years)
His tory of GI
bleed?
His tory of GI
bleed?
Us e warfarin or
apixab an
Us e warfarin ,
dabigatran,
rivaroxa ban , or
apixab an
Us e warfarin or
apixab an
Us e warfarin ,
rivaroxa ban , or
apixab an
Yes No
> 15 < 15
> 75
< 75
Yes No Yes No
Anticoagulation Flow Diagram
*Th e use of TSOAC s with mechan ical valves is contraind icated . There are no data in patien ts with biopro sthetic valves .
Last revised: 09/2014 Contact CCKM for revisions.
Atrial Fibrillation – Adult – Inpatient/Ambulatory Guideline
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org