Defer rhythm control until pericardioversion anticoagulation for Afib is complete or TEE for Afib has ruled out thrombi.If the diagnosis is uncertain, follow the approach for undifferentiated stable, irregular narrow-complex tachycardia. Stable Afib with RVRĬlinical decision-making resembles the approach to a new diagnosis of Afib without RVR. Do not delay emergency electrical cardioversion for anticoagulation. Manage unstable Afib with immediate synchronized electrical cardioversion. Begin pericardioversion anticoagulation for Afib as soon as possible if Afib onset ≥ 48 hours or unknown and the patient is not already anticoagulated.Consider procedural sedation for cardioversion.Immediate hemodynamic support with judicious IV fluids and cautious use of vasopressors.Irregular WCT (e.g., due to preexcited Afib): Consider unsynchronized cardioversion.Atrial flutter with RVR: 50–100 J biphasic.Most patients: Perform synchronized electrical cardioversion.Unstable Afib with RVR Emergency electrical cardioversion Identify and treat reversible causes of Afib.Obtain confirmatory 12-lead ECG and other Afib diagnostics.Begin continuous cardiac monitoring and pulse oximetry.Evaluate hemodynamic stability using the ABCDE approach.For long-term therapy, see “ Management of atrial fibrillation” and “Treatment” in “ Atrial flutter.” Initial management The following focuses on acute management of Afib with RVR and atrial flutter with RVR. Clinical features of acute heart failureĬonduct a careful clinical evaluation to determine whether the tachycardia is the primary cause of hemodynamic instability or a response to shock due to an underlying condition (e.g., sepsis, hypovolemia, massive PE), especially in patients with longstanding Afib.Unstable Afib with RVR: more likely to occur in patients with underlying cardiopulmonary disease and/or higher heart rates.Stable Afib with RVR: can occur in patients without underlying cardiopulmonary disease and with HR Patients with a new diagnosis of Afib are more likely to be symptomatic at a given RVR rate.RVR > 200/min suggests preexcited Afib (usually with wide QRS) or an alternate diagnosis (e.g., VT).Typically RVR in Afib is no greater than 150–170/min.RVR is often but not always associated with hemodynamic instability, depending on the patient's physiological reserve and the degree of tachycardia.Rapid ventricular response ( RVR): a ventricular rate > 100–110/minute occurring in response to a supraventricular tachyarrhythmia.See also “ Clinical features of atrial fibrillation” and “Clinical features” in “ Atrial flutter.” See “ Atrial fibrillation” for a comprehensive diagnosis and long-term management of Afib and atrial flutter. Although the ECG findings of atrial flutter with RVR differ (e.g., usually a regular rhythm with a rate dependent on the conduction ratio), its initial management and stabilization are the same as the treatment of Afib with RVR. Treatment typically involves rate control or rhythm control followed by the identification and management of reversible Afib triggers. Acute management depends on clinical stability, symptom duration, and comorbid conditions. The presence of a wide-complex tachycardia ( WCT) raises the likelihood of preexcited Afib, Afib with aberrant conduction, and other WCTs, e.g., ventricular tachycardia ( VT). The typical appearance of Afib with RVR is an irregularly irregular narrow-complex tachycardia ( NCT) without discernable P waves. Affected individuals typically present with palpitations, but may be asymptomatic or also have signs of hemodynamic instability. Long-term Afib with RVR may lead to tachycardia-induced cardiomyopathy. Afib with RVR can lead to impairment of cardiac output and hemodynamic instability due to shortened ventricular filling time and increased myocardial oxygen demand. Atrial fibrillation with rapid ventricular response ( Afib with RVR) is Afib with a ventricular rate > 100–110/minute.
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