|
|
| Line 46: |
Line 46: |
| ''Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.''<ref name="Fuster-2011">{{Cite journal | last1 = Fuster | first1 = V. | last2 = Rydén | first2 = LE. | last3 = Cannom | first3 = DS. | last4 = Crijns | first4 = HJ. | last5 = Curtis | first5 = AB. | last6 = Ellenbogen | first6 = KA. | last7 = Halperin | first7 = JL. | last8 = Kay | first8 = GN. | last9 = Le Huezey | first9 = JY. | title = 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal = Circulation | volume = 123 | issue = 10 | pages = e269-367 | month = Mar | year = 2011 | doi = 10.1161/CIR.0b013e318214876d | PMID = 21382897 }}</ref> | | ''Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.''<ref name="Fuster-2011">{{Cite journal | last1 = Fuster | first1 = V. | last2 = Rydén | first2 = LE. | last3 = Cannom | first3 = DS. | last4 = Crijns | first4 = HJ. | last5 = Curtis | first5 = AB. | last6 = Ellenbogen | first6 = KA. | last7 = Halperin | first7 = JL. | last8 = Kay | first8 = GN. | last9 = Le Huezey | first9 = JY. | title = 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. | journal = Circulation | volume = 123 | issue = 10 | pages = e269-367 | month = Mar | year = 2011 | doi = 10.1161/CIR.0b013e318214876d | PMID = 21382897 }}</ref> |
|
| |
|
| ==Pharmacological Cardioversion==
| |
|
| |
|
| ===Cardioversion upto7 Days===
| |
|
| |
| <table class="wikitable">
| |
| <tr class="v-firstrow"><th>Drug</th><th>Class of Recommendation/<br>Level of Evidence</th><th> Dosage </th></tr>
| |
| <tr><th>Agents with proven efficacy</th></tr>
| |
| <tr><td>Dofetilide</td><td>I A</td><td><table class="wikitable">
| |
| <tr class="v-firstrow"><th>Creatinine clearance(ml/min)</th><th>Dose (mg)</th></tr>
| |
| <tr><td> >60</td><td>500</td></tr>
| |
| <tr><td> 40 to 60 </td><td>250 </td></tr>
| |
| <tr><td>20 to 40 </td><td>125 </td></tr>
| |
| <tr><td> <20</td><td>Contraindicated</td></tr>
| |
| </table></td></tr>
| |
| <tr><td>Flecainide</td><td> I A</td><td>'''Oral:''' 200 to 300 mg <br>
| |
| '''Intravenous:''' 1.5 to 3.0 mg/kg over 10 to 20 min</td></tr>
| |
| <tr><td>Ibutilide</td><td>I A </td><td>1 mg over 10 min; repeat 1 mg when necessary</td></tr>
| |
| <tr><td>Propafenone</td><td>I A</td><td>'''Oral:''' 600 mg <br>
| |
| '''Intravenous:''' 1.5 to 2.0 mg/kg over 10 to 20 min</td></tr>
| |
| <tr><td>Amiodarone</td><td>IIa A</td><td>'''Oral:'''
| |
| : Inpatient: 1.2 to 1.8 g per day in divided dose until 10 g total <br> then 200 to 400 mg per day maintenance or 30 mg/kg as single dose <br>
| |
| : Outpatient: 600 to 800 mg per day divided dose until 10 g total <br> then 200 to 400 mg per day maintenance. <br>
| |
| '''Intravenous:'''
| |
| : 5 to 7 mg/kg over 30 to 60 min then 1.2 to 1.8 g per day continuous IV or <br>
| |
| : in divided oral doses until 10 g total then 200 to 400 mg per day maintenance.</td></tr>
| |
| </table>
| |
|
| |
| ===Cardioversion after 7 Days===
| |
|
| |
| <table class="wikitable">
| |
| <tr class="v-firstrow"><th>Drug</th><th> Dosage </th></tr><tr><td>Dofetilide (I A)</td><td><table class="wikitable">
| |
| <tr class="v-firstrow"><th>Creatinine clearance(ml/min)</th><th>Dose (mg)</th></tr>
| |
| <tr><td> >60</td><td>500</td></tr>
| |
| <tr><td> 40 to 60 </td><td>250 </td></tr>
| |
| <tr><td>20 to 40 </td><td>125 </td></tr>
| |
| <tr><td> <20</td><td>Contraindicated</td></tr>
| |
| </table></td></tr>
| |
| <tr><td>Amiodarone (IIa A)</td><td>'''Oral:'''
| |
| : Inpatient: 1.2 to 1.8 g per day in divided dose until 10 g total <br> then 200 to 400 mg per day maintenance or 30 mg/kg as single dose <br>
| |
| : Outpatient: 600 to 800 mg per day divided dose until 10 g total <br> then 200 to 400 mg per day maintenance. <br>
| |
| '''Intravenous:'''
| |
| : 5 to 7 mg/kg over 30 to 60 min then 1.2 to 1.8 g per day continuous IV or <br>
| |
| : in divided oral doses until 10 g total then 200 to 400 mg per day maintenance.</td></tr>
| |
| <tr><td>Ibutilide (IIa A)</td><td>1 mg over 10 min; repeat 1 mg when necessary</td></tr>
| |
| </table>
| |
|
| |
| Drugs which enhance the efficacy of cardioversion when given prior to the procedure: (Level of recommendation: IIa B)
| |
| * Amiodarone
| |
| * Flecainide
| |
| * Ibutilide
| |
| * Propafenone
| |
| * Sotalol
| |
|
| |
| ==Risk Factors for Stroke and Recommended Antithrombotic Therapy==
| |
| <table class="wikitable">
| |
| <tr class="v-firstrow"><th>Low Risk Factors</th><th>Moderate Risk Factors</th><th>High Risk Factors</th></tr>
| |
| <tr><td>Female gender</td><td>Age ≥ 75 years</td><td>Previous stroke, TIA or embolism </td></tr>
| |
| <tr><td>Age 65-74 years</td><td>Hypertension</td><td>Mitral stenosis</td></tr>
| |
| <tr><td>Coronary artery disease</td><td>Heart failure</td><td>Prosthetic heart valve</td></tr>
| |
| <tr><td>Thyrotoxicosis</td><td>LV ejection fraction ≤ 35%</td><td> - </td></tr>
| |
| <tr><td> - </td><td>Diabetes mellitus</td><td> - </td></tr>
| |
| </table>
| |
|
| |
| <table class="wikitable">
| |
| <tr class="v-firstrow"><th>Risk Category</th><th>Recommended Therapy</th></tr>
| |
| <tr><td>No risk factors</td><td>Aspirin, 81-325 mg daily</td></tr>
| |
| <tr><td>1 Moderate risk factor </td><td>Aspirin, 81-325 mg daily or <br> Warfarin (INR 2.0 to 3.0, target 2.5)</td></tr>
| |
| <tr><td>Any high risk factor or <br> more than 1 moderate risk factor</td><td>Warfarin<br> (INR 2.0 to 3.0, target 2.5)*</td></tr>
| |
| </table>
| |
|
| |
| ==Pharmacological Agents for Heart Rate Control==
| |
| <table class="wikitable">
| |
| <tr class="v-firstrow"><th>Drug</th><th>Class/LOE <br> Recommendations</th><th>Loading Dose</th><th>Maintenance Dose</th></tr>
| |
| <tr><th>Acute Setting</th></tr>
| |
| <tr><th>Heart rate control in patients without accessory pathway</th></tr>
| |
| <tr><td>Esmolol</td><td>I C</td><td>500 mcg/kg IV over 1 min</td><td>60 to 200 mcg/kg/min IV</td></tr>
| |
| <tr><td>Propanolol</td><td>I C </td><td>0.15 mg/kg IV</td><td>NA</td></tr>
| |
| <tr><td>Metoprolol</td><td>I C </td><td>2.5 to 5 mg IV bolus over 2 min; up to 3 doses</td><td>NA</td></tr>
| |
| <tr><td>Diltiazem</td><td>I B</td><td>0.25 mg/kg IV over 2 min</td><td>5 to 15 mg/h IV</td></tr>
| |
| <tr><td>Verampil</td><td>I B</td><td>0.075 to 0.15 mg/kg IV over 2 min</td><td>NA</td></tr>
| |
| <tr><th>Heart Rate Control in patients with accessory pathway</th></tr>
| |
| <tr><td>Amiodarone</td><td>IIa C</td><td>150 mg over 10 min</td><td>0.5 to 1 mg/min IV</td></tr>
| |
| <tr><th>Heart Rate Control in patients with heart failure and without accessory pathway</th></tr>
| |
| <tr><td>Digoxin</td><td>I B</td><td>0.25 mg IV each 2 h, up to 1.5 mg</td><td>0.125 to 0.375 mg daily IV or orally</td></tr>
| |
| <tr><td>Amiodarone</td><td>IIa C</td><td>150 mg over 10 min</td><td>0.5 to 1 mg/min IV</td></tr>
| |
| <tr><th>Non-Acute Setting and Chronic Maintenance Therapy</th></tr>
| |
| <tr><th>Heart rate control</th></tr>
| |
| <tr><td>Metoprolol</td><td>I C</td><td>Same as maintenance dose</td><td>25 to 100 mg twice a day, orally</td></tr>
| |
| <tr><td>Propanolol</td><td>I C</td><td>Same as maintenance dose</td><td>80 to 240 mg daily in divided doses, orally</td></tr>
| |
| <tr><td>Verampil</td><td>I B</td><td>Same as maintenance dose</td><td>120 to 360 mg daily in divided doses; slow release available, orally</td></tr>
| |
| <tr><td>Diltiazem</td><td>I B</td><td>Same as maintenance dose</td><td>120 to 360 mg daily in divided doses; slow release available, orally</td></tr>
| |
| <tr><th>Heart Rate Control in patients with heart failure and without accessory pathway</th></tr>
| |
| <tr><td>Digoxin </td><td>I C</td><td>0.5 mg by mouth daily</td><td>0.125 to 0.375 mg daily, orally</td></tr>
| |
| <tr><td>Amiodarone</td><td>IIb C</td><td>800 mg daily for 1 wk, orally <br> 600 mg daily for 1 wk, orally <br> 400 mg daily for 4 to 6 wk, orally</td><td>200 mg daily, orally</td></tr>
| |
| </table>
| |
|
| |
|
| * Dabigatran may be used as an alternative to warfarin in those wdo don't have: (I B) | | * Dabigatran may be used as an alternative to warfarin in those wdo don't have: (I B) |
| | | | | | | Newly discovered AF | | | | | | | | |
|
| | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | |
| | Paroxysmal | | | | | | | | Persistent | | | |
|
| | | | | | | | | | | | | | | | | | | |
|
| | Look for the presence of one of these severe symptoms
Hypotension
Heart failure
Angina pectoris
Severe symptoms absent:
No therapy needed
Severe symptoms present:
Attempt direct-current cardioversion | | | | | Permanent AF | | | | Anticoagulation as needed based on the risk of stroke
Click here for the risk of stroke and anticoagulation therapy
Control heart rate as an intial method to terminate AF
Click here for recommended pharmacological agents used for rate control | |
|
| | | | | | | | | | | | | | | | | | | |
|
| | Anticoagulation as needed based on the risk of stroke
Click here for the risk of stroke and anticoagulation therapy
Recommended in all cases except lone AF (I A)
Measure INR weekly initially, then monthly when stable (I A)
Reassess need for anticoagulation at periodic intervals (IIa C) | | | | | Anticoagulation as needed based on the risk of stroke
Click here for the risk of stroke and anticoagulation therapy
Control heart rate as an intial method to terminate AF
Click here for recommended pharmacological agents used for rate control | | | | | |
|
| | | | | | | | | | | | | | | | | | |
|
| | | | | | | | | | | | | | | | | | |
|
| | | | | | | | | | | | | | | | | | |
|
| | | | | | | | | | | | | | | | | | |
|
| | | | | | | | | | | | | | | | | | |
|
Antiarrhythmic Drug Therapy in Atrial Fibrillation
Shown below is an algorithm depicting the antiarrhythmic drug therapy for maintain sinus rhythm in patients with recurrent paroxysmal or persistent atrial fibrillation:
Drugs are listed alphabetically and not in order of suggested use.
The seriousness of heart disease progresses from left to right, and selection of therapy in patients with multiple conditions depends on the most serious condition present.
LVH indicates left ventricular hypertrophy.
Algorithm based on the 20011 ACCF/AHA/HRS updates for the management of atrial fibrillation.[1]
- Dabigatran may be used as an alternative to warfarin in those wdo don't have: (I B)
- Prosthetic heart valve
- Hemodynamically significant valve disease
- Severe renal failure (creatinine clearance <15 mL/min) or
- Advanced liver disease (impaired baseline clotting function).
- If patient on anticoagulants with AF sustains stroke or systemic embolism, target INR may be raised to 3.0 - 3.5 (IIb C).
- Anticoagulation therapy can be interrupted for upto 1 week, if patients needs a procedure that carries a risk of bleeding (IIa C). For periods > 1 week unfractionated or low molecular weight heparin may be given IV (IIb C).
- ↑ Fuster, V.; Rydén, LE.; Cannom, DS.; Crijns, HJ.; Curtis, AB.; Ellenbogen, KA.; Halperin, JL.; Kay, GN.; Le Huezey, JY. (2011). "2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines". Circulation. 123 (10): e269–367. doi:10.1161/CIR.0b013e318214876d. PMID 21382897.