Afib w/ RVR

• Check for WPW

• Do not start any medications that could slow conduction through the AV node

• Stable

• Check to see if it is a physiologic response (fever, hypoxia, …)

• RACE-II trial showed that HR <110 is noninferior to <80 bpm

• Unstable (defined as hypotension, acute AMS, acute pulmonary edema, ischemic chest pain)

• Synchronized cardioversion @ 200J

• Symptoms <48hr

• New diagnosis

• No history of similar episodes

• No LV dysfunction

• No mitral valve disease

• No prior thromboembolic event

• Already Anticoagulated

• If shock does not convert, increase diastolic BP

• Push dose phenylephrine

• Or drip (can do norepi as well)

• Give amiodarone, esmolol, or diltiazem. 

• Meds

• Diltiazem

• Don't use in HF or if significant hypotension

• 0.25mg/kg push

• If not adequate response, can try 0.35mg/kg

• Make sure to give PO 60mg

• Metoprolol

• Don’t use in COPD, Asthma, HF, or hypotension

• 2.5-5mg IVP and load with 25-50mg PO

• Digoxin

• Adjust for renal failure

• 250-500mcg load, then 250mcg q6h, max of 1500mcg

• Amio

• Use if BB, CCB, or digoxin are not effective

• 3-7 mg/kg IV, load to 1200mg over next 24 hours

• Mag Sulfate

• Synergistic effect when combined with BB or CCB

• 4.5g IV over 30 minutes (LoMagHi Trial)