In this section : Cardiac
Deactivation of Implantable Cardioverter Defibrillator
Extravasation of IV Amiodarone
Anticoagulation for AF, DVT and PE
Patients Returning from Interventional Cardiac Procedure
Cardiology Referrals
STEMI Thrombolysis Protocol
STEMI
Hypertensive Emergencies
Rate Control in AF
Heart Failure
Aortic Dissection
Non ST Elevation MI (NSTEMI)
Suspected Acute Coronary Syndrome
Pericardiocentesis
Pacemakers
Indications for Echocardiography
Bradycardia
Narrow Complex Tachycardia
Anti-Platelet Therapy in Coronary Heart Disease
Management of Acute AF
Rhythm Control in AF
Atrial Fibrillation
Hypertension
Ventricular Tachycardia
Cardiogenic Shock Complicating Acute Coronary Syndrome
Telemetry
Rhythm Control in AF
Last updated 3rd December 2020
Restoration of Sinus Rhythm
- Immediate electrical cardioversion indicated for AF with life threatening haemodynamic instability eg symptomatic hypotension, angina, heart failure that does not respond promptly to pharmacological measures, including MI patients with AF.
- For all other patients in whom rhythm control preferred eg new onset AF, AF with a reversible cause, symptoms that continue after heart rate has been controlled and when a rate control strategy has not been successful the key question is whether AF present for more or less than 48 hours.
- When duration <48 hours either pharmacological or electrical cardioversion may be offered
- Choice of pharmacological agent will depend on presence or absence of structural or CHD: Flecainide only suitable if structural and CHD both absent whereas amiodarone effective and safe whether present or absent
- If AF duration more than 48 hours electrical cardioversion is more likely to be effective. Timing of cardioversion depends on coagulation status and availability of trans-oesophageal echocardiography (TOE): proceed if adequately anticoagulated but if not then will require to be anticoagulated for minimum of 3 weeks before cardioversion unless TOE has confirmed there is no clot in left atrium .
- All our defibrillators are biphasic. Give single shock at each of the following energies, 100J – 150J – 200J. Benign self limiting arrhythmias common post cardioversion. There is a risk of VT and VF with hypokalaemia or digoxin toxicity. Transient ST elevation common, but not associated with myocardial damage.
- Consider amiodarone starting 4 weeks before and continuing for up to 12 months after electrical cardioversion to maintain sinus rhythm, and discuss the benefits and risks of amiodarone with the patient.
Persistent AF Suitable for Ryhthm Control
Drugs to Restore Sinus Rhythm
Maintenance of Sinus Rhythm
- Assess the need for drug treatment for long-term rhythm control, taking into account the person’s preferences, associated comorbidities, risks of treatment and likelihood of recurrence.
- If drug treatment for long-term rhythm control is needed, consider a standard beta-blocker (that is, a beta-blocker other than sotalol) as first-line treatment unless there are contraindications.
- Sotalol at doses greater than 240mg daily has class III anti-arrhythmic properties but is poorly tolerated, associated with prolongation of QT interval and no longer recommended by NICE to maintain sinus rhythm.
- If beta-blockers are contraindicated or unsuccessful, assess the suitability of alternative drugs for rhythm control, taking comorbidities into account.
- Choice of second line therapy will depend on presence or absence of structural or CHD: flecainide or propafenone suitable if no structural or CHD whereas amiodarone effective and safe whether present or absent. Combination of betablocker and flecainide is a good next choice after betablocker of flecainide alone.
- Dronedarone, which is related chemically to amiodarone, is recommended as an option for maintenance of sinus rhythm after successful cardioversion in paroxysmal or persistent AF when AF is not controlled by first-line therapy and who have at least 1 of the following cardiovascular risk factors:
- hypertension requiring drugs of at least 2 different classes
- diabetes mellitus
- previous transient ischaemic attack, stroke or systemic embolism
- left atrial diameter of 50 mm or greater or
- age 70 years or older and
- who do not have left ventricular systolic dysfunction and
- who do not have a history of, or current, heart failure.
- People who do not meet above criteria who are currently receiving dronedarone should have it stopped.
- Where people have infrequent paroxysms and few symptoms, or where symptoms are induced by known precipitants such as alcohol or caffeine, consider a ‘no drug treatment’ or a ‘pill-in-the-pocket’ strategy.
- Consider a ‘pill-in-the-pocket’ for those who
- have no history of structural or CHD and
- infrequent symptomatic episodes of paroxysmal AF and
- SBP >100 mmHg with a resting heart rate above 70 bpm and,
- are able to understand when and how to take the medication.