Related | Emergency Department Management of Atrial Fibrillation
Patient presents to ED with ECG confirmed AF
Candidate
for early electrical
cardioversion?A
Cardioversion
Sinus
rhythm?
Patient to observation unit
for rate control
Adequate rate
and symptom control?
NO
YES
YES
Nodal blocking therapyB
Adequate rate and
symptom control?
NO
NO
YES
Adequate rate and
symptom control?YES
Consult cardiology,
consider inpatient admission
Afib Team available M‐F 8am‐4pm,
Sat 8am‐2pm, Sun 8am‐12pm
Adequate rate
and symptom
control?
Cardioversion
candidate? A
NO
YES
Anticoagulation
(Enoxaparin 1 mg/kg or UFH)
Ideally give 30‐60 mins before
cardioversion
Cardioversion
YES
Sinus rhythm ? YES
NO
Nodal blocking
therapyB
NO
Plan for
outpatient
anticoagulation
and follow‐up;C
Discharge
patient
NO
NO
Anticoagulation
(Enoxaparin 1 mg/kg or UFH)
Ideally give 30‐60 mins before cardioversion
YES
Plan for
outpatient
anticoagulation
and follow‐up;C
Discharge
patient
PATHWAY EXCLUSION CRITERIA
‐ ST depressions ≥2 mm or ST elevation
‐ Heart failure exacerbation (e.g., pulmonary
edema, elevated JVP, elevated BNP)
‐ New/worsening infection
‐ Troponin > 0.5 and/or increasing
‐ Hemodynamic instability
‐ New/severe anemia
‐ Renal failure
‐ Pulmonary embolism
‐ Hyperthyroidism
A. CARDIOVERSION CANDIDATE CRITERIA
AF duration <48 hours and patient not at high risk for clots (no prior TIA or
stroke, thromboembolism, rheumatic heart disease, artificial valve, or systolic
heart failure) OR
On stable anticoagulation therapy for >3 weeks:
‐ Direct oral anticoagulant/enoxaparin
‐ Warfarin with weekly INR >2 x 3 weeks
Consider TEE if unclear, w/therapeutic anticoagulation peri/post‐procedure
B. NODAL BLOCKING THERAPY (Metoprolol is 1st line)
Metoprolol 5 mg over 2 mins, every 5 minutes for up to total 15 mg.
IV to PO Metoprolol
Can start 1st oral dose within 20 mins of initial
IV to estimate dosing needs.
Total 5 mg IV→ start 12.5 mg PO Q6H
Total 10 mg IV→ start 2 5mg PO Q6H
Total 15 mg IV→ start 37.5 mg PO Q6H
Up‐titrate PO dose if HR>110
after 2 hours from 1st oral dose
12.5 mg PO Q6H→ 25 mg PO
Q6H
on 25 mg PO Q6H→ 37.5 mg
PO Q6H
on 37.5 mg PO Q6H→ 50 mg
PO Q6H
Diltiazem 0.25 mg/kg (Max dose 25 mg) IV bolus x1. Start drip at 5 mg/hr.
Consider addition 30mg PO IR diltiazem q6 hours or home dose to reduce need
for drip. Drip can be titrated to 15 mg/hr, with re‐bolus 0.25 mg/kg with each
increase. Caution use of diltiazem if known EF < 40% or clinical signs
hypoperfusion
IV to PO diltiazem: Oral dose = (IV drip rate [in mg/hr] x 3 + 3) x10
Steps to covert from diltiazem IV to PO
1. Calculate total daily oral dose
2. Round dose to a 30 mg increment, divide
this daily dose by 4 to give Q6H dosing
3. Give first PO dose 1 hour prior to
titrating drip
4. One hour after PO dose, titrate drip
down by 2.5 mg/hr until drip is running
at 0 mg/hour
Std rates for diltiazem generally
convert as follows:
3 mg/hour = 120 mg/day
5 mg/hr = 180 mg/day
7.5 mg/hr = 260 mg/day
10 mg/hr = 330 mg/day
15 mg/hr = 480 mg/day
Verapamil: 0.1 mg/kg bolus (Max dose 10 mg) IV bolus x1. Start drip at 5 mg/hr
and titrate to goal heart rate (max 20mg/hr) with re‐bolus of 0.1 mg/kg with each
increase
C. DISCHARGE PLANNING
‐ Cardioverted pts should have anticoagulation for at least 4 weeks
‐ Indefinite anticoagulation for all patients with a CHA2DS2VASc ≥ 2
‐ If warfarin is used for cardioverted patients, bridge w/enoxaparin until INR
is therapeutic. Bridge not needed unless patient is successfully cardioverted.
‐ Refer to Selecting Anticoagulation for Atrial Fibrillation Patient algorithm
Full guideline: Atrial Fibrillation: Management – Adult – Inpatient/Ambulatory/ED
Emergency Department Management of Atrial Fibrillation
Copyright © 2019 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2019CCKM@uwhealth.org
Effective 3/20/19. Contact CCKM@uwhealth.org for previous versions.
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