AF RVR + levophed

  1. How would you treat this patient in regards to rate control:

    Pt has been going in AF for a few days, and now they are in AF RVR with a rate of 130. The patient is also on Levophed at 5 mcg/min. BP is 100/60.
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    About zzyzx

    Joined: Dec '08; Posts: 45; Likes: 6
    from CA , US

    13 Comments

  3. by   Dakeirus
    Hard to say without a full background. Some chunk of the HR is probably caused by the levophed. Can they be switched to a phenylephrine drip?
  4. by   offlabel
    Cardizem...am I missing something?
  5. by   Charge200J
    We tend to treat pretty aggressively because our pts are often in cardiogenic shock with an EF of 10-15%, so they can't compensate well for tachyarrhythmias. In this situation I would use the bare minimum pressor requirement by titrating the Norepi for a MAP goal >60. Then TEE/anticoagulate with a Heparin gtt/Amio bolus/Cardiovert. If this wasn't working then I would try and just rate control the AF. Also, any obvious reasons the pt is tachycardic? Eg: In pain/need more sedation if intubated?
  6. by   Pheebz777
    Assuming you ruled out other reasons for being tachy, (dehydration, pain, fever, anxiety, etc,) has the patient been on any antiarrythmics? drips? Sometimes controlling the HR improves the blood pressure. For uncontrolled Afib RVR patients usually they're on Cardizem or amiodarone drips.
  7. by   PeekabooICU77
    In my unit, we'd try to get the patient to cardiovert because the loss of atrial kick is the huge factor in the low output. To attempt conversion to sinus rhythm with medication, we'd do amiodarone boluses and continuous drip. If unsuccessful, attempt electric cardioversion - hopefully they're already anti-coagulated if they've already been in and out of fib for days. Some of my docs would try to get an echo prior if patient is stable.

    Of course, so much depends on background and situation of patient. Post-surgery, or admitted for illness?
  8. by   zzyzx
    Thanks for your responses.

    We didn't want to do amio because she wasn't anticoagulated yet.

    The obvious thing to me was to do rate control, but I wasn't sure if Cardizem was the right thing to use since it would antagonize the Levophed. The doc didn't want to use it for that reason, though one of my experienced co-workers said she'd seen Cardizem and Levo used together and believed that that was the right thing to do. What do you guys think?
  9. by   Pheebz777
    Quote from zzyzx
    Thanks for your responses.

    We didn't want to do amio because she wasn't anticoagulated yet.

    The obvious thing to me was to do rate control, but I wasn't sure if Cardizem was the right thing to use since it would antagonize the Levophed. The doc didn't want to use it for that reason, though one of my experienced co-workers said she'd seen Cardizem and Levo used together and believed that that was the right thing to do. What do you guys think?
    I've never heard of holding Amiodarone because of not being anticoagulated, usually for elective cardioversion you would want to determine whether or not the patient is on anticoagulation. For symptomatic SVT/AFIB RVR, of course cardioversion is a must.

    Cardizem and Levophed will not counter each other so to speak. Levophed is a beta/alpha adrenergic stimulator while Cardizem is a CCB, You must be talking about a Beta-Blocker. You can use both and ease off on the levophed or switch to neosynephrine.

    Converting to a Sinus rhythm is not the main goal of treating AFIB RVR, rate control is what you should aim for. In certain cases converting to SR can be detrimental. That atrial kick could potentially send a dormant thrombus to god knows where.

    It's not uncommon to use both Cardizem and Amiodarone concomitantly for patients with poor response to both meds. MAZE procedure or ablation would be definitive treatment.
    Last edit by Pheebz777 on Jan 25
  10. by   offlabel
    Quote from zzyzx
    Thanks for your responses.

    We didn't want to do amio because she wasn't anticoagulated yet.

    The obvious thing to me was to do rate control, but I wasn't sure if Cardizem was the right thing to use since it would antagonize the Levophed. The doc didn't want to use it for that reason, though one of my experienced co-workers said she'd seen Cardizem and Levo used together and believed that that was the right thing to do. What do you guys think?

    If the MAP fell with the Cardizem, you'd just turn up the NE. But if the HR came down, it might all just even out. Odd concern...as far as the amiodarone goes, I wonder if there was a concern about a LA thrombus? Perhaps a sinus rhythm would cause that to embolize?
  11. by   MunoRN
    In general a pacemaker can add beats but take away beats. A common use of a pacemaker in A-fib is to facilitate rate control in the case of a tachy-brady A-fib. If a person's ventricular rate in A-fib ranges from say, 50 to 150 bpm, there is no pharmaceutical way to reduce the heart rate of 150 without reducing the rate of 50 as well, so if you're reducing the conduction to the ventricles by 30 bpm, then you're also reducing the rate of 50 bpm. A pacemaker creates an artificial low HR threshold, allowing for whatever rate control is necessary without having to worry about bradycardia. A pacemaker might also be used to protect against long pauses in A-fib, in which case paced beats are fairly rare and the rhythm will almost always be irregular.

    Generally any form of cardioversion, whether it be electrical or pharmaceutical, should be avoided when the presence of a clot is unknown and when the duration of A-fib is greater than 72 hours, usually cardioversion in these instances only occurs after a TEE.
  12. by   Cowboyardee
    I'm just going to rattle a few notions off. These are not really textbook suggestions for the patients's management in this situation, but more like what my experiences have been. A few thoughts:

    - A rate of 130 is often not a huge problem all on its own. You didnt say whether the pt was on levo prior to his hr rising, but im thinking that its likely that whatever is causing the patient to need levo is also driving the rvr (since 130 is seldom fast enough to seriously drop your pt's bp). Correcting the underlying cause will probably be most important, assuming its correctable.

    - neo is not a bad idea, but i dont always find it is as effective as youd like for dropping the HR in this situation. Also, obviously be careful for other conditions that make neo suboptimal - pulmonary hypertension foe example.
    - A lot of the time, it seems to me that amio slows down afib with rvr without actually converting the pt to nsr. I do not see it used only for anticoagulated pts.
    - i sometimes see digoxin used here.
    - i also sometimes see worsened tachycardia upon administration of levo (or epi) when a pt is a little dry. I dont know anything much about the pt, but it could be a factor.
  13. by   ambersky004
    So i had an experience where I came in to work and the patient was on Amio drip. The pt had a BP that is slightly low. She complains of chest pain when I came in and short of breath. HR was still afib with RVR in 136s. so I told the doc she consulted the Cardio. heart doc ordered to give load of Dig, then additional of Metoprolol. Prior to that pt did not respond to cardizem drip. She was anticoagulated per kg/wt q12h on lovenox. The heart doc said to prepare for cardioversion. I asked her should we do a TEE first?, she said no need because the pt was fully anticoagulated. History wise this was the pt first time to come to the hospital and she had never seen a PCP until she was feeling she had the "flu" and made her very sick. so who knows how long she was on Afib? And she had a prior MI which she did not sick a doc and waited for 2 days she said. That was my concern. But anyway we still did the cardioversion and pt converted to SB/SR. heart doc put her on Xarelto. I was wondering if there were any other different intervention I or we have done?
    Last edit by ambersky004 on Feb 1
  14. by   2210485
    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.

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