Atrial fibrillation is a common tachycardia. It is significant, as having the condition increases the risk of stroke.
Managing acute atrial fibrillation is a very common problem in the emergency department with many different approaches – and is a very common exam scenario!
Atrial fibrillation is present in:
- 5% of the over 65’s
- 10% of over 70’s
- 15% of all stroke patients
- Stroke is a major complication of AF (see below)
- Hyperthyroidism (fast AF) –
- Sometimes hypothyroidism can also cause slow AF
- High caffeine intake
- Antiarrhythmic drugs!
Lone AF – refers to cases where no cause can be found. Many cases initially labelled as lone AF have a cause discovered upon further investigation.
Atrial fibrillation is often asymptomatic– especially in chronic AF – but acutely it can present with:
- Chest pain
- Dizziness / syncope
Irregularly irregular pulse – you should do an ECG on everybody with an irregular pulse!
- Apical pulse rate > radial pulse rate
- 1st heart sound of variable intensity
- Signs of LV dysfunction
- No p waves – just an irregular baseline
- Irregular QRS – between 75-190bpm
- Normal shape QRS – because conduction through the AV node is normal
- In V1 the trace resembles atrial flutter
- Normal T waves
- U+E’s – check for renal dysfunction
- TFT’s – AF can be secondary to hyperthyroidism
- Cardiac enzymes
Acute Atrial Fibrillation
- Treat the underlying condition (e.g. MI, pneumonia).
- Control the ventricular rate (see below)
- Initiate anticoagulation – with heparin (5000-10000U IV). This prevents thrombus formation – and thrombi are a contraindication for cardioversion. If anticoagulants are contra-indicated, then do a TOE (trans-oesophageal ultrasound) before mechanical cardioversion to rule out the presence of a thrombus.
- Consider DC or drug cardioversion (see below)
- Acutely ill patient – DC cardioversion – Don’t delay treatment to give anticoagulants! Cardioversion should be performed in an ITU setting, with sedation. The patient should be shocked at 200J initially. if this is unsuccessful, try two further attempts at 360J.
Chronic Atrial Fibrillation
Control the ventricular rate
- Rate control is as good as rhythm control in chronic AF – i.e. generally you don’t need to cardiovert – as the outcomes are the same as if the rate only is well controlled. Exceptions include:Young patients, 1st episode of AF
- 1st line – β-blocker OR Ca2+ blocker
- using both together is contraindicated as it can cause heart block
- 2nd line – same as above, but add digoxin, or amiodarone.
Anticoagulate – with warfarin (INR 2-3) – long term therapy
- Aspirin is an inferior alternative, but may be acceptable in low risk patients (See CHADS2 score below). Usually only used if warfarin is contraindicated, or in very low risk patients (CHADS ≤1)
- Check platelets and blood count, and be wary in patients with past bleeds, low Hb, high risk of falls, and on NSAID therapy.
- For more info on warfarin therapy see the Anticoagulant Therapy article
This is a condition where short spells of AF come and go, and upon investigation, the patient may often be in sinus rhythm.
Use the ‘pill in the pocket’ treatment – i.e. flecainide or sotalol PRN – these drugs control the rhythm. Only suitable if systolic BP >100, and no underlying LV dysfunction
- 1st line – Sotolol / bisoprolol (β-blockers)
- Young patients – flecainide / verapamil – 1st line in younger patients, but avoided in older ones, as they are negatively ionotropic – i.e. they cause vasodilation.
- 2nd line – amiodarone – tends to be used in those with some LV dysfunction
- 3rd line – digoxin – has a weak effect, and takes several weeks to become effective, but useful in those with severe LV dysfunction, as it is positively ionotropic.
Anticoagulate (as for chronic AF)
Acute AF – the symptoms have been ongoing for <48h. Often amiodarone will also have been given to these patients.
- Patient has had >3 weeks of anticoagulant therapy
- TOE has proven no thrombus
- Unlikely if AF has been apparent for >12 months, although if it is a first attempt at cardioversion, many consultants may still ‘give it a go’
- LV dilation is a good predictor of outcome. Those with a LV of diameter >5.5cm are unlikely to have a successful cardioversion – although, again, some consultants may still try.
- If the patient is on digoxin, make sure you stop the digoxin a few days before the treatment.
- Should be done in an ITU or CCU setting
- Give O2
- Give sedation
- Give monophasic DC cardioversion, increasing the voltage if normal rhythm is not obtained:
- 100J (not commonly used, only effective in 20% of patients)
- 360J (two attempts)
- DC cardioversion has a success rate of about 70%
- The procedure
- The defibrillator needs to be in ‘sync mode’ as the shock has to be delivered at a certain point in the cycle – the R wave. If you give the shock at the T wave, you risk causing VF. Thus, in practice, make sure you hold down the shock button until the shock is delivered.
- Perform a full 12-lead ECG afterwards to check whether the procedure was successful.
Amiodarone is usually the drug of choice. Can be given:
- IV – 5mg/Kg in 1 hr, then a further 900mg up to 1.2g in a 24hr period
- PO –200mg/8hr for 1 week, then 200mg/12hr for 1 week, then 200mg/day maintenance.
Flecainide may also used, but it is negatively ionotropic (reduces the strength of contractions). Used in patients with no known IHD or WPW syndrome.
- Sinus rhythm
- No RF’s for emboli (CHADS = 0)
- AF recurrence unlikely (e.g. no previous failed cardioversions, no structural heart disease, AF duration <12 months)
Stroke! – the risk of thrombo-embolic stroke, and thus the degree of anticoagulant therapy required in atrial fibrillation can be assessed using the CHA2DS2-VASc score. Any score above 2 requires anticoagulation:
|C||Congestive heart failure / LV dysfunction||1|
|S2||Stroke (previous stroke, TIA or thromboembolic disease)||2|
|V||Vascular disease (e.g. peripheral vascular disease, ischaemic heart disease, previous MI)||1|
- Score <2 – low risk – no specific anticoagulation
- Score ≥ 2 – high risk warfarin (target INR 2-3)
- Don’t use warfarin if contraindicated. Also be aware that warfarin itself can be a stroke risk(can cause a bleed), thus it should not be given to low risk patients.
- Be wary of giving warfarin to patients at high risk of falls (typically, very old patient with many co-morbidities), s the risk from fall (and subsequent bleed) may be greater than the risk of stroke. The decision to prescribe in such instances should be taken by a senior medical practitioner and discusses with the patient and their family.
- Warfarin reduces stroke risk by about 70% – risk in AF patients is about 4% / year. With warfarin, this is about 1% / year.
- Aspirin reduces stroke risk by about 20%. Aspirin was previously recommended for low risk (score = 1 on the old CHADS2 scoring system, but this was proven to be of no benefit).
- Thrombus formation most commonly occurs in the left atrial appendage – which is very hard to view on transthoracic echo. Hence the reason why many AF patients undergo TOE – as here the echo transducer is right next to the left atrium, and can get a very good view.