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Acute Management of Atrial Fibrillation

Acute Management of Atrial Fibrillation. Case.

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Acute Management of Atrial Fibrillation

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  1. AcuteManagement of Atrial Fibrillation UCLA Family Medicine Department IMG Program Carlos Yoo

  2. Case • A 66 year-old man comes to the emergency department complaining of a several-day history of an intermittent sensation of fluttering in the chest. He feels weak when the episodes occur but denies chest pain or shortness of breath. He has had hypertension for 20 years, controlled well with enalapril, and he takes albuterol for asthma. He denies any alcohol use. UCLA Family Medicine Department IMG Program Carlos Yoo

  3. Case- cont’ • VS: Temperature 36.8C (98.3F), Blood pressure 140/80, pulse 140/min, respirations 12/min • PE: supple neck, no jugular vein distension or thyromegaly. • CV: irregularly irregular rhythm with no rubs or gallops. • Chest: clear sounds • Abd: Benign • Extremities: no edema UCLA Family Medicine Department IMG Program Carlos Yoo

  4. Differential Diagnosis • Atrial Fibrillation • Multifocal atrial tachycardia • Supraventricular tachycardia • Pulmonary Embolism • Thyrotoxicosis UCLA Family Medicine Department IMG Program Carlos Yoo

  5. Diagnostic plan • EKG • Thyroid Function tests • Cardiac enzymes • Echocardiogram • ABGA Within Normal limits Normal Normal Ejection fraction, left atrial enlargement Within Normal limits UCLA Family Medicine Department IMG Program Carlos Yoo

  6. Elderly patient Palpitation Fatigue/weakness Long term hypertension Tachycardia Irregularly irregular rhythm EKG: atrial fibrillation waves, inconsistent R-R intervals, absence P waves. ATRIAL FIBRILLATION UCLA Family Medicine Department IMG Program Carlos Yoo

  7. Management • GOALS • Hemodynamic stabilization • Ventricular rate control • Prevention of embolic complication UCLA Family Medicine Department IMG Program Carlos Yoo

  8. Patient with diagnosis of atrial fibrillation Hemodynamically stable Yes No • Unstable… • Hypotension • Confusion • Angina • …. Control ventricular rate: Diltiazem Cardioversion • Beta Blockers • Calcium Channel blockers • Digoxin • Amiodarone Long standing HTN Ischemic heart dz CHF Hyperthyroidism PE Lung ca Alcohol Hypothermia Electrolytes imbalance Etc. . Spontaneous conversion to sinus rhythm Yes No Assess cause of atrial fibrillation Contraindication to cardioversion? Cont’

  9. Cont’ Yes No Cardiversion Start Heparin IV Warfarin Aspirin Consider long-term anticoagulation <48hs >48hs • Immediate medical or electrical cardioversion • Later elective cardioversion after 3weeks of warfarin • Early TEE-guided cardioversion Long standing HTN Ischemic heart dz CHF Hyperthyroidism PE Lung ca Alcohol Hypothermia Electrolytes imbalance Etc. . Yes Atrial fibrillation persist? No Assess cause of atrial fibrillation UCLA Family Medicine Department IMG Program Carlos Yoo

  10. References • http://www.chestjournal.org/content/135/3/849.full.html • http://www.aafp.org/afp/20020715/249.html • http://www.aafp.org/afp/20020715/261.html • http://www.americanheart.org/downloadable/heart/222_ja20017993p_1.pdf UCLA Family Medicine Department IMG Program Carlos Yoo

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