Atrial Fibrillation

Question 1

Rate control goals in A fib

Answer 1

<110 if asx with preserved LV fx

<80 in sx at higher HR, or impaired LV fx

Question 2

A fib with CVD, HTN, HFpEF, or COPD Tx

Answer 2

• Beta Blockers
• Diltiazem
  -Verapamil

A fib with most other factors can be treated with those

Question 3

A fib with LV dysfunction or HfrEF tx

Answer 3

BB
Digoxin

NOT CCB

Question 4

DDIs for CCBs

Answer 4

CYP3A4 inhibitor

Question 5

DDIs for Digoxin

Answer 5

p-gp substrate

Question 6

Tx of choice for unstable a fib

Answer 6

-DCCV- direct current cardioversion
Fast, done at bedside

• Radiofrequency ablation
• Surgical ablation

Question 7

Tx of choice for stable a fib cardioversion

Answer 7

• IV Amiodarone (class 3 antiarrhythmic)
• Flecainide or propafenone (1c pill in the pocket). Contraindicated in structural heart disease. Give with CCB(class 4) or BB(Class 2) for AV blocking agent.
• IV procanamide (Class 1a)
• IV Ibutilide (Class 3). Need very close bedside monitering. Risk of TdP or QT prolongation.

Question 8

Stroke prevention with cardioversion

Answer 8

Get rid of clot before cardioverting. Put on Xerelto for 3 weeks and then cardiovert if the clot is gone.
If in a fib for 1-2 days, could have clot that forms.
Give xorelto for 4 weeks, let atrial fx recover post cardioversion.

Question 9

Tx for A flutter with RVR in acute setting

Answer 9

• IV BB (Metoprolol, esmolol) or IV non-DHP CCB (Diltiazem, verapamil)

If they don’t respond:
- IV amioderone or IV digoxin)

Question 10

Which PO options can be used for a fib cardioversion

Answer 10

Take a few days to work, but do work.
Dofetilide, amiodarone, sotalol. Rhythym control long term. Also consider clot-risk then.