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  #1  
Old 04-12-2013
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EKG Cardioversion Rate Control?

Confused about this: when do you rate control?

If a patient is < 2 days or > 2 days with A-fib or A-flutter you would rate control first correct then do your cardioversion and anticoagulantion as needed?
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  #2  
Old 04-12-2013
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I think I was able to figure it out if anyone would be kind to correct me:

A-fib/A-flutter with normal LV Ejection Fraction (stable)

Step 1 - rate control BB, CCB, Dig, and if all else fails amiodarone.
Did the pt return to sinus, if yes, then do normal follow up. If not, then Step 2.

Step 2 - Is it acute (<48hrs) or chronic (>48 hrs)
Acute -> cardiovert and do CHADS2 to see if Aspirin or Warfarin

Chronic -> Anticoag 3xweek -> cardiovert -> 4 more weeks of
anticoag

A-fib/A-flutter with LV Ejection Fraction 40% or less (unstable)

Step 1 - Acute or Chronic

Acute - Cardiovert and do CHADS2

Chronic -> Anticoag 3xweek -> cardiovert -> 4 more weeks of
anticoag


Pt needs cardioversion NOW (EF at any value)

-Heparin -> TEE -> Cardiovert
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Old 04-12-2013
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Quote:
Originally Posted by gear2d View Post
I think I was able to figure it out if anyone would be kind to correct me:

A-fib/A-flutter with normal LV Ejection Fraction (stable)

Step 1 - rate control BB, CCB, Dig, and if all else fails amiodarone.
Did the pt return to sinus, if yes, then do normal follow up. If not, then Step 2.

Step 2 - Is it acute (<48hrs) or chronic (>48 hrs)
Acute -> cardiovert and do CHADS2 to see if Aspirin or Warfarin

Chronic -> Anticoag 3xweek -> cardiovert -> 4 more weeks of
anticoag

A-fib/A-flutter with LV Ejection Fraction 40% or less (unstable)

Step 1 - Acute or Chronic

Acute - Cardiovert and do CHADS2

Chronic -> Anticoag 3xweek -> cardiovert -> 4 more weeks of
anticoag


Pt needs cardioversion NOW (EF at any value)

-Heparin -> TEE -> Cardiovert
let me try what i know

1)if pt . unstable (means with dyspnea/chest pain/low B.P/ confusion) with atrial fibrillation------------>directly go to syncronized cardioversion ----->then followed by rate control if it's controlled with the drugs as you told

2)if pt. stable with atrial fibrillation------>a) if <2days --->rate control by drugs ,if not controlled then cardioversion
b)if >2days-----> chronic type--->so add anticoagulation after the same rate control drugs till the therapeutic INR, and then still irregular beats cardiovert

3)CHAD score used for lone atrial fib---->low risk patients---->used only aspirin with no other drugs...


and regarding 4)atrial flutter-----> i dont think pt. would be that unstable presenting this(just my opinion)......> so no need to cardiovert, only rate control with drugs is sufficient---------->but there are chances that it might turn into atrial fib or sinus----->if turns into atrial fib,then above steps recommended

hope it helps...thanks
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  #4  
Old 04-13-2013
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Quote:
Originally Posted by venky2600 View Post
let me try what i know

1)if pt . unstable (means with dyspnea/chest pain/low B.P/ confusion) with atrial fibrillation------------>directly go to syncronized cardioversion ----->then followed by rate control if it's controlled with the drugs as you told

2)if pt. stable with atrial fibrillation------>a) if <2days --->rate control by drugs ,if not controlled then cardioversion
b)if >2days-----> chronic type--->so add anticoagulation after the same rate control drugs till the therapeutic INR, and then still irregular beats cardiovert

3)CHAD score used for lone atrial fib---->low risk patients---->used only aspirin with no other drugs...


and regarding 4)atrial flutter-----> i dont think pt. would be that unstable presenting this(just my opinion)......> so no need to cardiovert, only rate control with drugs is sufficient---------->but there are chances that it might turn into atrial fib or sinus----->if turns into atrial fib,then above steps recommended

hope it helps...thanks
Thank you for the clear up. Only concern was for emergent cardioversion now. Would you not anticog with heparin and do a TEE to make sure no clots thou? I can understand if this was new onset of A-fib and unstable person then go straight to cardioversion if unstable, but say some who one has had a history of this.

I completely forgot that CHADS2 was for the "Lone" A-fib only here.
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Quote:
Originally Posted by gear2d View Post
Thank you for the clear up. Only concern was for emergent cardioversion now. Would you not anticog with heparin and do a TEE to make sure no clots thou? I can understand if this was new onset of A-fib and unstable person then go straight to cardioversion if unstable, but say some who one has had a history of this.

I completely forgot that CHADS2 was for the "Lone" A-fib only here.
okay...nice doubt you've got there..

emergency cardioversion means emergency--->so directly cardiovert if not pt. may die in the limited time you have.......anticoagulation is not needed...

for chronic fibrillation,there will be risk of thrombus formation leading to embolic stroke ---->that's the reason for anticoagulate-----and even in chronic type too we control rate first and then followed by anticoagulation-----> we never do anticoagulation first then control heart rate....(hope my slang understands)...

but regarding your doubt,if any thrombus pt.(in any other site) with atrial fibrillation-----> then it's not the thrombus formed from fibrillation mostly --->then if unstable directly cardiovert

thanks
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Old 04-14-2013
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wanted to share with you....

just now done a question in uworld ---->a known case of atrial fibrillation on warfarin manifested by stroke with irregular heart rate----->in this scenario ,pt is already on warfarin so hemorrhagic stroke is dangerous risk than rate control therapy here( i hope you will understand)....so NCCT done 1st to evaluate the type of stroke and also pt. is not unstable with regarding his cardiac signs so cardioversion isnt needed here......


P.S- mainly focus on 4 unstable signs for atrial fib/vent. tachycardia/vent.fib (hypotension,dyspnea/SOB,chestpain/angina,confusion------hypertension isnt regarded as unstable here)
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Old 04-14-2013
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Quote:
Originally Posted by venky2600 View Post
wanted to share with you....

just now done a question in uworld ---->a known case of atrial fibrillation on warfarin manifested by stroke with irregular heart rate----->in this scenario ,pt is already on warfarin so hemorrhagic stroke is dangerous risk than rate control therapy here( i hope you will understand)....so NCCT done 1st to evaluate the type of stroke and also pt. is not unstable with regarding his cardiac signs so cardioversion isnt needed here......


P.S- mainly focus on 4 unstable signs for atrial fib/vent. tachycardia/vent.fib (hypotension,dyspnea/SOB,chestpain/angina,confusion------hypertension isnt regarded as unstable here)
Thank you. Definitely helped me clear up a lot here.
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