Undiagnosed A Fib w/ RVR Medication?

[SweetMelissaRN]

Had a 78 yr old pt come in today c/o SOB and being easily fatigued x 1 week. EKG showed A Fib w/ RVR. My ER doc ordered a cardizem drip. Pr tolerated well (no significant hypotension or decrease in CO). Pt did not convert and major change to heart rate.

My question is, what do your ER docs order for this and is there another medication that possibly could have possibly worked better? I suggested amiodarone and doc told me no, but never gave me a real answer as to why? The pt went up to ICU so I don't know if the medication was ever changed.

[Esme12, ASN, BSN, RN]

Cardizem may not immediately convert the Afib to sinus in the same way you see Adenocard work for SVT. Amiodarone is another choice but without knowing the patient it's impossible to say why he said no but it is further down the food chain after other drugs have failed.

[emtb2rn, BSN, RN, EMT-B]

Controlled? No bolus mentioned so I'm guessing the rate wasn't excessive.

Cardizem is the gold standard drug for afib. I don't see a need for amiodarone for this pt in the ER setting.

[Altra, BSN, RN]

If the rate was not excessive and the patient was not hypotensive or otherwise symptomatic at rest, I would not expect more aggressive attempts to convert in the ER setting. Lots of people out there chronically living in a fib.

[SweetMelissaRN]

If the rate was not excessive and the patient was not hypotensive or otherwise symptomatic at rest I would not expect more aggressive attempts to convert in the ER setting. Lots of people out there chronically living in a fib. [/quote']

We had an old ECG from 1 month ago and he was NSR

[psu_213, BSN, RN]

We had an old ECG from 1 month ago and he was NSR

I think the point was that the ER is not going to work excessively hard to actually convert the pt back into sinus rhythm (e.g. by electric cardioversion) unless the pt is hemodynamically unstable. In most cases, we will start a dilt gtt (most with boluses), bring the HR down, admit them to a tele floor and cardiology will decide where to do from there.

We will occasionally use amio for A fib. This is usually on pts. bound for the ICU--the ICU docs seem to prefer amio over dilt--my guess is because of BP issues. Usually A fib pts. go to the ICU for reasons other than the A fib alone--in addition to the A fib they had a stroke, PNA, respiratory failure, etc. Since amio has more negative side effects--such a lung damage--than dilt, dilt is the most common treatment for A fib in our ER.

[mcknis]

Like someone else mentioned, without knowing the pts history, it is difficult to know why the provider ordered Cardizem over Amio. Amiodarone is an option, but many will attempt Cardizem and then titrate/change accordingly. Like someone else mentioned, adjustment of these medications is usually left to the cardiologist/internist to decide what they would like. Amiodarone has some negative side effects, and in younger pts who may have a drug history (especially cocaine), the effects can be fatal immediately. Just google cocaine and amiodarone to find out a little more on this...its interesting! The gold standard is certainly Cardizem, but some of your old (and I mean "OLD") school docs may still go to amiodarone as first line treatment, however this is no longer recommended.

The following is from Rosenthal, et al (Medscape...Medscape: Medscape Access). Hope this helps. Seeing and understanding the rationale for something I did not get, always helped me further understand the problem. Some docs are better at explaining than others. Google is always my friend :) Good luck!

From Medscape:

Beta-blockers and calcium channel blockers are first-line agents for rate control in AF. These drugs can be administered either intravenously or orally. They are effective at rest and with exertion. Intravenous diltiazem or metoprolol are commonly used for AF with a rapid ventricular response. Caution should be exercised in patients with reactive airway disease who are given beta-blockers.

Digoxin can be used in the acute setting but does little to control the ventricular rate in active patients. As such, it is rarely used as monotherapy. Caution should be exercised in elderly patients and those with renal failure receiving digoxin. Digoxin is indicated in patients with heart failure and reduced LV function.

Amiodarone has a class IIa recommendation from the ACC/AHA/ESC for use as a rate-controlling agent for patients who are intolerant of or unresponsive to other agents, such as patients with CHF who may otherwise not tolerate diltiazem or metoprolol. Caution should be exercised in those who are not receiving anticoagulation, as amiodarone can promote cardioversion.

Extreme care must be taken in patients with preexcitation syndrome and AF. Blocking the AV node in some of these patients may lead to AF impulses that are transmitted exclusively down the accessory pathway, and this can result in ventricular fibrillation. (If this happens, the patient will require immediate defibrillation.) Calcium channel blockers and digoxin are contraindicated in these patients; flecainide or amiodarone can be used instead.^[36]

[CoolhandHutch, MSN, RN]

In the ED, there seems to be a favor of rate control over rhythm control for AFib, hence the use of cardizem. Plus, you mentioned your patient having symptoms for a week- it's possible he has been in afib that long and you wouldn't want to convert him without making sure he is nice and anticoaglated....stable people will get a TEE as well.

[psu_213, BSN, RN]

In the ED, there seems to be a favor of rate control over rhythm control for AFib,

Having worked on a tele floor, cardiologists also seem fairly content to control rate in new onset a fib. Eventually they might cardiovert or do an ablation, but it starts out with rate control and anticoagulation.

[SweetMelissaRN]

Thank you all for your input! Cardizem definitely does seem to make the most sense... I plan on doing a bit more research on different rhythms and medication choices! :)

[MunoRN, RN]

Amiodarone, or any other attempts at cardioversion, should actually be avoided in patients with A-fib of unknown duration who have not been anticoagulated. This is why elective cardioversions are often combined with a TEE; confirm no atrial thrombi first, then cardiovert, otherwise you're significantly increasing the risk of throwing a clot by cardioverting.

[psu_213, BSN, RN]

This is why elective cardioversions are often combined with a TEE; confirm no atrial thrombi first, then cardiovert

I my experience (which I realize is not all encompassing), a TEE was always done before a scheduled cardioversion.