Last Updated on May 18, 2023
Classification / Types
Haemodynamically stable AF
Haemodynamically unstable AF
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Fast AF
Rate controlled AF
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First detected AF
Paroxysmal AF
Persistent AF
Permanent AF
Causes
Cardiovascular causes | Non-cardiac causes |
• Hypertension | • Electrolyte imbalance: hypokalaemia, hypomagnesaemia |
Presentation
Symptomatic
• Palpitations, SOB on exertion
Asymptomatic
• Identified from features in cardiac monitor / ECG
Investigations
ECG
• Rate: can be >150 bpm
• Rhythm: Irregularly irregular
• P wave: absent
• QRS complex: narrow
Echocardiogram
• TRO valvular heart disease
Management
Initial management
Haemodynamic unstable
Features of unstable atrial fibrillation
• Hypotension (SBP <90 mmHg)
• Acutely altered mental status
• Cardiac ischaemia / Ischaemic chest discomfort
• Severely decompensated heart failure
Management
• Proceed with synchronised cardioversion
• If synchronised cardioversion is successful, provide PO amiodarone
• If synchronised cardioversion is unsuccessful, provide IV amiodarone
Haemodynamic stable
Normal left ventricular function (no underlying CCF)
• Onset <48 hours: rate control / rhythm control
• Persistent ≥48 hours or uncertain: rate control + anticoagulation
Reduced left ventricular function (underlying CCF)
• Rhythm control
• Cardioversion
• Anticoagulation
Rate control
- First line treatment strategy
- Medications
- Beta-blockers
- Exception: sotalol
- Beware of the contraindications
- Non-dihydropyridine calcium-channel blockers
- Avoid non-dihydropyridine CCB if patient has underlying heart failure, as it has negative inotropic effect
- Digoxin
- Beta-blockers
Rhythm control
- Amiodarone
- Especially if patient has underlying heart failure
- Beta blocker e.g. sotalol
Anticoagulation
Indication
• Presence of valvular heart disease
• Based on CHA2DS2VASc score
Options
• Warfarin
• NOAC e.g. apixaban, rivaroxaban, dabigatran
Medications for pharmacotherapy (rate / rhythm control) in emergency
- IV Digoxin 0.25 – 0.50 mg in 100 mL normal saline over 1 hour
- IV Verapamil 2.5 – 5 mg slow bolus
- IV Amiodarone 150 – 300 mg in 50 mL D5% over 30 minutes
- IV Esmolol 0.5 mg/kg
Related Scoring
- CHA2DS2-VASc score to assess the need for anticoagulation
- ORBIT score to assess bleeding risk
- Previously, HAS-BLED score to assess bleeding risk
Q&A
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Take Home Message
1. The first step in managing atrial fibrillation is to identify haemodynamic stability
2. Search and treat identifiable underlying causes