![]() ![]() 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. ![]()
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