Episode 4 - Emergent Treatment of Rapid A-Fib & A-Flutter

Resus Now

Emergent treatment of rapid atrial fib/flutter with Dr. Dave Zull. Please see below for Evidence based annotated articles
Arrigo M. New Onset Atrial Fibrillation in critically ill patients and it’sassociation with mortality. Int J Cardiol 266:95-99, Sept 2018

Bosch, NA, et al. Atrial Fibrillation in the ICU CHEST 154:1424-1434. Dec 2018

Nice review of A fib in the critically ill patient. Emphasis first on correcting precipitants like sympathomimetics, electrolytes, volume and intercurrent illness. Esmolol implied to be best rate control drug

DeSouza IA, et al. Pharmacologic Cardioversion of recent onset Atrial Fibrillation and Flutter in the Emergency Department. Ann Emerg Med 76:14-30. July 2020

Looking at 360 patients with acute a fib. Ibutilide converted 50% of A fib and 75% of A flutter patients. Two patients had VT as a complication, but none received Magnesium prophylaxis.

Nikki, AHA, et al. Early or Delayed Cardioversion in recent onset Atrial Fibrillation. N Engl J Med 380:1499-1508, Apr 2019

Oral H, et al. Facilitating Transthoracic Cardioversion of atrial Fibrillation with Ibutilide pretreatment. N Engl J Med 340:1849, Jun 1999

72% converted to NSR with electrical cardioversion without pretreatment whereas 100% converted with Ibutilide pretreatment before electicity

Patsilinakos S, et al. Effect of high doses of Magnesium on converting Ibutilide to a safe and more effective agent. Am J Cardiol 106:673, Sept 2010

Magnesium sulfate 4-5 gm infused over one hour before Ibutilide prevents Torsades

Sleeswijk ME, et al. Efficacy of Magnesium-Amiodarone step-up scheme in critically ill patients with new onset atrial fibrillation. J Intensive Care Med 23:61, Jan/Feb 2008

Magesium infusion followed by Amiodarone infusion in A fib with RVR in the ICU. Half had acceptable rate or rhythm control with Mag alone. At the end of 24 hours 90% of patients converted to NSR.

Stiell, Ian, et al. Electrical vs Pharmacologic cardioversion for emergency department patients with acute Atrial Fibrillation. RAFF2 Lancet 395:339-349, Feb 2020

Canada’s aggressive protocol for conversion of acute A fib in the ER. IV Procoinamide infusion converted 50% to NSR. Electrical cardioversion worked in 92%. Only 3% of new A fib patients required admission

Tercius AJ, et al. Intravenous Magnesium sulfate enhances the ability of intravenous Ibutilide to successfully convert atrial fibrillation or flutter. Pacing Clin Electrophysiol 30:1331, Nov 2007

Vinson DR, et al. Ibutilide effectiveness and safety in the Cardioversion of atrial fibrillation and flutter in the community emergency department. Ann EmergMed71:96, Jan 2018

Wyse DG, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation (AFFIRM trial). N Engl J Med 247:1825-33, Dec 2002

Internists and cardiologist love to quote the AFFIRM trial as proof that attempts to convert are fruitless and we stick to rate control only. These patient were all in chronic a fib and of course we would never convert these patients unless there is life threat. This study has NO application to acute a fib less than 48 hours

Zimetbaum P. Atrial Fibrillation. Annal Intern Med. March 2017

Everything you ever wanted to know about atrial fibrillation