Atiral fibrillation

Atrial fibrillation

three pillars of therapy:

1. rate control (slow it down)

2. anticoagulation

3. rhythm control (restoration of sinus rhythm)

Q's to ask:

1. is pt stable? or unstable?

2. (if stable,) is pt symptomatic or asymptomatic?

3. is there a thrombus or no thrombus (on trans-esophageal echo<TEE>)

Hemodynamically unstable AF (hypotension, SOB, chest pain)

-> DC cardioversion under short general anesthesia

if there's thrombus on TEE:

Heparin + warfarin (stop Heparin once INR 2-3) for 4 weeks before cardioversion.

Heparin + warfarin (stop Heparin once INR 2-3) for 4 weeks or more after cardioversion.

if there's no thrombus on TEE

AND:

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Symptomatic for < 48 hrs:

if low thromboembolic risk

-> DC cardioversion or pharmacological cardioversion

if high thromboembolic risk

-> Heparin before cardioversion.

Heparin + warfarin (stop Heparin once INR 2-3) till 4 weeks after cardioversion

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Symptomatic for > 48 hrs:

if low thromboembolic risk

-> Heparin (aPTT of 45-60 sec) before cardioversion.

long term aspirin after cardioversion

if high thromboembolic risk

-> Heparin + warfarin (stop Heparin once INR 2-3) for 4 weeks before cardioversion.

Heparin + warfarin (stop Heparin once INR 2-3) for 4 weeks or more after cardioversion.

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Asymptomatic:

if low thromboembolic risk

-> rate control & observe (usu. spontaneously revert to sinus rhythm in 24hrs)

-> if not recovered spontaneously  then cardioversion.

if high thromboembolic risk

-> anticoagulation & rate control for 4 wks before cardioversion

-> anticoagulation for 4 wks after cardioversion.

Mem Tip:

- thromboembolic risk = 0.5 점

- > 48 hrs = 0.5 점

합계가 0.5 점 인 경우-> heparin before cardioversion. anticoagulation for 4 wks after cardioversion

합계가 1 점 인 경우-> heparin + warfarin for 4 wks before and 4 wks after cardioversion



All pt get rate control:

if  no heart failure -> b blocker (metoprolol, esmolol) and/or CCB (diltiazem, verapamil)
if  heart failure -> amiodarone or digoxin