Atrial Fibrillation, help.

[NoHero]

Hi,

I'm a medstudent in Canada. Trying to figure out treatment pattern for AF.

The specific question I have is what to do with a relatively young patient (let's say 40) presents with palpitations started 2 weeks ago, has no particular history.

Normally we try to control the rate before controlling the rhythm unless the patient has important symptoms or can't tolerate rate controlling Rx. What I'm trying to figure out is whether or not we do cardioversion on that kind of patient? Normally we do when it's de novo AF under 48h with ACO therapy.

In a patient like this there is a CHADS2 score of 0, normally we should not add ACO therapy.



I think I'm really really confused now. If anyone can help out, it would be great!

Thanks!

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[Instatewaiter]

Hi,

I'm a medstudent in Canada. Trying to figure out treatment pattern for AF.

The specific question I have is what to do with a relatively young patient (let's say 40) presents with palpitations started 2 weeks ago, has no particular history.

Normally we try to control the rate before controlling the rhythm unless the patient has important symptoms or can't tolerate rate controlling Rx. What I'm trying to figure out is whether or not we do cardioversion on that kind of patient? Normally we do when it's de novo AF under 48h with ACO therapy.

In a patient like this there is a CHADS2 score of 0, normally we should not add ACO therapy.



I think I'm really really confused now. If anyone can help out, it would be great!

Thanks!

In real life, we usually give people a chance at sinus rhythm before opting for rate control.

While yes there was "no difference" between rate and rhythm control, I have seen a slew of tachycardia induced cardiomyopathies from AF and many people feel very lousy in AF. Plus many will stay in sinus for years which is beneficial

If they've been in AF for more than 48 hours, many will opt to do a TEE to make sure there is no atrial thrombus before cardioversion (TEE/Cardioversion) to prevent causing a stroke. If < 48h, pop'em and drop em.

 

[Plasmatron88]

Dont do cardioversion unless unstable vitals are present

 

[Instatewaiter]

Dont do cardioversion unless unstable vitals are present

Wrong on many levels in real clinial practice (and on the USMLE). On the USMLE, new onset AF could be cardioverted for the reasons I listed above. It would be rare if they were to give you that option because most cardiologists would give someone in new AF a chance to be in sinus.

Normally, on the USMLE they will give you the option for cardioversion if it is obvious that you need to cardiovert them (heart failure from the new AF or they are unstable) or obvious you shouldnt.

- Your neighborhood cardiology fellow.

 

[Plasmatron88]

Wrong on many levels in real clinial practice (and on the USMLE). On the USMLE, new onset AF could be cardioverted for the reasons I listed above. It would be rare if they were to give you that option because most cardiologists would give someone in new AF a chance to be in sinus.

Normally, on the USMLE they will give you the option for cardioversion if it is obvious that you need to cardiovert them (heart failure from the new AF or they are unstable) or obvious you shouldnt.

- Your neighborhood cardiology fellow.

It doesn't matter what you do in clinic or in real life in your hospital, in USMLE Step 2 CK we only cardiovert if unstable vitals or symptoms are present and rate control is always the best step prior to cardioversion. Please don't confuse people with other guidelines you may be following in your hospital

 

[cbrons]

It doesn't matter what you do in clinic or in real life in your hospital, in USMLE Step 2 CK we only cardiovert if unstable vitals or symptoms are present and rate control is always the best step prior to cardioversion. Please don't confuse people with other guidelines you may be following in your hospital

In cases of severe hemodynamic instability such as the test vignettes you mention, DC cardioversion is the best method of rate control. Do you know what overdrive suppression is?

 

[Instatewaiter]

It doesn't matter what you do in clinic or in real life in your hospital, in USMLE Step 2 CK we only cardiovert if unstable vitals or symptoms are present and rate control is always the best step prior to cardioversion. Please don't confuse people with other guidelines you may be following in your hospital

Seriously, stop fighting with the senior cardiology fellow at the top heart hospital in the country who did very well on step 2.

What do you mean by other guidelines I may follow in my hospital (again the #1 heart hostpial)? Do you mean the 2014 ACC/AHA/HRS recommendations on atrial fibrillation? Because directly from those guidelines:

• Class I indiciation: In pursuing a rhythm-control strategy, cardioversion is recommended for patients with AF or atrial flutter as a method to restore sinus rhythm.

So there are other reasons both in real life and on step 2 why you would cardiovert atrial fibrillation besides just unstable vital signs.

 

[Plasmatron88]

Chill out man, it doesn't matter what ranking you have, what I care is telling stuff here about Step 2 that gets people to mark incorrect answers. You wrote your step 2 ck several years ago, write it again and lets see how many questions you get correct in the Cardio section. Its nothing personal and your top heart hospital doesn't have anything to do with it, this is a standardized exam that tests specific parameters, by answering 'real life' experience answers you get a low score, I'm not saying anything unusual, its the exam guidelines, everyone says that.

and what you've mentioned;

"Class I indiciation: In pursuing a rhythm-control strategy, cardioversion is recommended for patients with AF or atrial flutter as a method to restore sinus rhythm"

IN PURSUING, what this means is elective cardioversion which would only be done if patient specifically requests it, but this is is not a step 2 ck scenario, on step 2 you don't PURSUE cardioversion only severe hemodynamically unstable patients get cardioverted, case closed, do any Qbank on the planet, I am telling you the right thing.

If you think I'm wrong well then take it up with NBME or USMLE, or write a recommendation to all the medicine review books to change it, I'll happily apply what you get changed in the exam.

 

[Instatewaiter]

Chill out man, it doesn't matter what ranking you have, what I care is telling stuff here about Step 2 that gets people to mark incorrect answers. You wrote your step 2 ck several years ago, write it again and lets see how many questions you get correct in the Cardio section. Its nothing personal and your top heart hospital doesn't have anything to do with it, this is a standardized exam that tests specific parameters, by answering 'real life' experience answers you get a low score, I'm not saying anything unusual, its the exam guidelines, everyone says that.

and what you've mentioned;

"Class I indiciation: In pursuing a rhythm-control strategy, cardioversion is recommended for patients with AF or atrial flutter as a method to restore sinus rhythm"

IN PURSUING, what this means is elective cardioversion which would only be done if patient specifically requests it, but this is is not a step 2 ck scenario, on step 2 you don't PURSUE cardioversion only severe hemodynamically unstable patients get cardioverted, case closed, do any Qbank on the planet, I am telling you the right thing.

If you think I'm wrong well then take it up with NBME or USMLE, or write a recommendation to all the medicine review books to change it, I'll happily apply what you get changed in the exam.

Dude, again you're fighting with a cardiology fellow about atrial fibrillation. Just admit you're wrong and don't know what you are talking about. All of the cardiology test questions conform to the ACC/AHA guidelines. There isn't some special knowledge only applicable to step II.

You can puruse EITHER a rate OR rhythm control stategy by guidelines. In pursuing a does NOT mean the patient has to request the cardioversion. It means if the doctor chooses a rhythm control strategy, then cardioversion is a CLASS I indication. For new onset AF, the vast majority of cardiologists will pursue a rhythm control stategy and give people a shot at sinus. Were they to give you cardioversion as an option and didn't want you to choose this, they would also likely give you things like a history of failed cardioversions, failed anti-arrhythmic medications, severe MR or a long history of permanent AF (all things that make rhythm control unlikely to be successful). There aren't 2 right answers with these questions.

Also, perhaps you're not the right person to give people advice on when and why to choose answers on step 2, given your performance.

 

[Plasmatron88]

Dude you really need to look at all the review books for the exam, like I said every Qbank on this planet including NBME would mark cardioversion incorrect unless in emergency or new onset elective cases after anticoagulation and TEE rules out clots, I'm not fighting with you or arguing that you don' t know about Atrial Fibrillation, you do know about it obviously but you got to understand its not what your attendings or fellows tell you what the correct answer is, its what USMLE tells you. Again you wont understand what I'm talking about till you redo UWorld or NBME or whichever qbank you want to refer to, Cardioversion for step 2 ck exam purposes has a limited scope, this isn't a Cardiology Board Exam.

My performance is not relevant to the question at hand, you should know that there are many contradictions to real life clinical situations that are dealt differently in hospitals than what the answers are in Official exams, writing exams solely based on clinical experience especially on step 2 is what causes a low score. Its agreed by everyone.

Do some Step 2 Qbanks you'll know what I'm talking about.

All of the cardiology test questions conform to the ACC/AHA guidelines

Not all questions conform to them, that is definite.

 

[1badvette]

Here's how i got to understand it it from the review book I'm currently using ...

ACUTE AFIB in stable pt

STEP 1 - ckeck pulse if to rapied then go for rate control using BB/CC..
STEP 2- Once pt rate is controlled to 60-100 bpm then go for cardioversion

But before going for cardioversion, you need to check the time of symptoms.

If less than 48hrs then your clear to start cardioversion

If more than 48 hrs , you can either do a TEE to rule out emboli, or start pt on anti coagulation for 3 week and do cardioversion after .

All pt need to be put on anticoagulation meds for atleast 4 week after cardioversion.

 

[1badvette]

So to sum it up , cardioversion is the choice for acute stable pt as long as you control the rate to 60-100 before hand .

 

[1badvette]

Chronic Afib is treated using BB/CC and anti coags following the CHAD2 score.

 

[Plasmatron88]

1badvette which review book are you using?
check the new Kaplan 2016 IM and MTB2 & 3, they clearly state that rate control is superior to rhythm control, and that rhythm control is not routinely done,
You are correct first step is rate control in acute stable patient (IF more than 48 hrs), cardioversion for hemodynamically unstable

But

So to sum it up , cardioversion is the choice for acute stable pt as long as you control the rate to 60-100 before hand

This isn't definite, and less than 48 hrs of Afib doesn't need Cardioversion unless symptomatic.

cardioversion would be used if person is symptomatic on rate control, is young with normal heart structure and function and rate control has totally failed.
Apart from these above indications and unstable vitals, rate control is the best first step and has a better outcome than cardioversion.

Uworld qbanks and others confirm this too.

If less than 48hrs then your clear to start cardioversion

Not true unless vitals and symptoms say otherwise

 

[1badvette]

I'm using step up to medicine 3rd edition. Took a picture of the page , check attached file .

 

[Instatewaiter]

Dude you really need to look at all the review books for the exam, like I said every Qbank on this planet including NBME would mark cardioversion incorrect unless in emergency or new onset elective cases after anticoagulation and TEE rules out clots, I'm not fighting with you or arguing that you don' t know about Atrial Fibrillation, you do know about it obviously but you got to understand its not what your attendings or fellows tell you what the correct answer is, its what USMLE tells you. Again you wont understand what I'm talking about till you redo UWorld or NBME or whichever qbank you want to refer to, Cardioversion for step 2 ck exam purposes has a limited scope, this isn't a Cardiology Board Exam.

My performance is not relevant to the question at hand, you should know that there are many contradictions to real life clinical situations that are dealt differently in hospitals than what the answers are in Official exams, writing exams solely based on clinical experience especially on step 2 is what causes a low score. Its agreed by everyone.

Do some Step 2 Qbanks you'll know what I'm talking about.

All of the cardiology test questions conform to the ACC/AHA guidelines

Not all questions conform to them, that is definite.

A few points:
1) Review books for the exam are SECONDARY SOURCES. They are fallable and based on primary sources, like guidelines or trials. If the questions on the real thing diagreed with guidelines, they will be thrown out as questions.

2) TEE is only needed if more than 48 hours after onset.

3) Uworld. while a reasonable question source, is also a secondary source.

 

[Instatewaiter]

1badvette which review book are you using?
check the new Kaplan 2016 IM and MTB2 & 3, they clearly state that rate control is superior to rhythm control, and that rhythm control is not routinely done,
You are correct first step is rate control in acute stable patient (IF more than 48 hrs), cardioversion for hemodynamically unstable

But

So to sum it up , cardioversion is the choice for acute stable pt as long as you control the rate to 60-100 before hand

This isn't definite, and less than 48 hrs of Afib doesn't need Cardioversion unless symptomatic.

cardioversion would be used if person is symptomatic on rate control, is young with normal heart structure and function and rate control has totally failed.
Apart from these above indications and unstable vitals, rate control is the best first step and has a better outcome than cardioversion.

Uworld qbanks and others confirm this too.

If less than 48hrs then your clear to start cardioversion

Not true unless vitals and symptoms say otherwise

Here's a reasonable way to think about it:
If unstable, heart failure, significant symptoms- cardioversion is a no brainer.

Old Atrial fibrillation without significant symptoms- the answer is likely going to be rate control. While there was no difference in primary outcome (mortality) or secondary outcome (composite death, stroke etc) in the AFFIRM trial which compared rate and rhythm control, there was a higher incidence of side effects with anti-arrhythmics.

New Atrial fibrillation (first episode)- could be either rate control or rhyhtm control (cardioversion). You don't need to rate control first before cardioversion if you are going to do it right away. If there's going to be a long delay, sure, rate control could be attempted prior. Anticoaulate for at least 3- 4 weeks if you opt for cardioversion as electrical cardioversion stuns the atrium and puts you at higher risk for stroke than even AF does.

 

[cbrons]

A few points:
1) Review books for the exam are SECONDARY SOURCES. They are fallable and based on primary sources, like guidelines or trials. If the questions on the real thing diagreed with guidelines, they will be thrown out as questions.

2) TEE is only needed if more than 48 hours after onset.

3) Uworld. while a reasonable question source, is also a secondary source.

There are errors in uworld, and not just a few (contrary to what some think).

 

[colonelmustard]

Dude, again you're fighting with a cardiology fellow about atrial fibrillation. Just admit you're wrong and don't know what you are talking about. All of the cardiology test questions conform to the ACC/AHA guidelines. There isn't some special knowledge only applicable to step II.

You can puruse EITHER a rate OR rhythm control stategy by guidelines. In pursuing a does NOT mean the patient has to request the cardioversion. It means if the doctor chooses a rhythm control strategy, then cardioversion is a CLASS I indication. For new onset AF, the vast majority of cardiologists will pursue a rhythm control stategy and give people a shot at sinus. Were they to give you cardioversion as an option and didn't want you to choose this, they would also likely give you things like a history of failed cardioversions, failed anti-arrhythmic medications, severe MR or a long history of permanent AF (all things that make rhythm control unlikely to be successful). There aren't 2 right answers with these questions.

Also, perhaps you're not the right person to give people advice on when and why to choose answers on step 2, given your performance.

I don't even know where to begin on how smug this response is. If you have particular information to offer, great. But there's no need to make personal insults.

 

[Instatewaiter]

I don't even know where to begin on how smug this response is. If you have particular information to offer, great. But there's no need to make personal insults.

When someone who failed step 2 is telling a cardiology fellow how to treat AF on step 2 or otherwise, it deserves a good amount of smugness.