AF RVR + levophed

2210485 · Feb 7, 2018

Nope, sounds about right.

If the docs familiar with the patient, confident in the anticoagulation strategy and familiar with the burden and onset of the afib they should know if TEE is necessary.

Those at greatest risk for embolism are people who go into AFib at home, without any measure of their burden and don't have/are not compliant with an antithrombotic strategy.

Once they've had a TEE however, if you can verify that they only just recently went into AFib (past hour or so) you know it is unlikely they've developed anything new.

If you did everything right and anticoagulated after cardioverting you'll feel even better than that! If they have a pacemaker you can see precisely how often they go into the rhythm and be even more assured!

The only thing I didn't necessarily like is the choice of Dig. Dig gets alot of shade thrown at it, lots of complications, drug interactions, mediocre performance etc.

It has its place, unfortunately that place is more like a very fine niche. Noteworthy here is that the patient was already on amiodorone, which is highly effective at suppressing afib but comes with the drawback of limiting further treatment options and risking toxicity.

As we all know theres also that half life consideration. Once you give Amio you're pretty much committed.

Personally I am more fond of Ibutilide and Propafenone for Afib. Amiodorone would be the third pick.

As an augment to electric cardioversion Ibutilide has been studied as had a conversion rate of 95%. It has a half life as low as 2 hours. Plus its a single dose vial delivered by IVP, so there's no messy dosage calculations and infusion rates/loading doses. You just take the drug out of the vial, put it into the body and you convert to sinus. Doesn't get much better.

Oral Propafenone is not as effective as oral Amiodorone, but the advantage of Amiodorone sits at around 5% in most trials (regardless of the endpoint). Not really a significant margin.. Half life of around 10- 35 hours vs like.. Months.

Now there is an exception to this:

Emergency treatment, or cases where treatment might be delayed in favor of another drug. Amio is king here and I am a big advocate of just diving in head first on this one. It's common, relatively cheap, well known by all the staff, can go home with the patient and most importantly; it has the highest conversion rate.

Ibutilide isn't a drug that you see being used on the floor too much... At my facility its' use is confined to the electrophysiology lab.

But hey, you know what you won't find in the lab? Amiodorone.. Whatever's locked in the crash cart.. Probably approaching expiration and buried in sone drawer.. Only place we keep amio. That's saying something there.

So in conclusion:

Some choices were probably made with the drugs that could be different, but all in all looks fine.

2210485 · Feb 7, 2018

MAZE procedure or ablation would be definitive treatment.

Dang.. Old school. I actually had to review the HRS consensus on this, another thing we don't do here. Do you ever actually see these?

It would seem only the cox-maze 4 with accompanying ablation is the way to go. Big stigma with Maze in general due to its history/ high morbidity. There's just so many skeptics and so few new cases in this corner of the world that I kind if just assumed at some point they gave up on it. Behind the curve I spose.