Cardioverting A-fib

[brainfailure]

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Do you guys cardiovert A-fib? I mean, rapid a-fib that the patient is tolerating well, without hypotension/CP/SOB/AMS. I used ibutilide today for the first time and was impressed with how well it worked.

And I've always heard don't cardiovert for a-fib that's greater than 72hrs old, but how do you know if it's 72hrs old or not? I mean, if the nurse just hands you an EKG and its afib with rvr at 130, and the pt doesn't know anything about being in a-fib and just says their palpitations started that day, is that good enough to say its new a-fib less than 72hrs and cardiovert? And what if they're a paroxysmal a-fib person on chronic anti-coagulation and they're INR is like 3. Can you assume there's no atrial clot and just cardiovert?

 

[lemontilt]

I think you should cardiovert a-fib no matter what. The question is whether you should anti-coagulate first or not. If the a-fib is lobger than 48 hours, then you heparinise the patient (preferably using LMWH) and then cardiovert. If the a-fib is present longer than two days, there is a good chance that a thrombus is formed inside the left atrium and if the patient is cardioverted before administering heparine, the thrombus may end up in the CNS causing a stoke. In order to asses whether there is a thrombus or not, you could do transesophageal echocardiogram. If the echo is neg, then you can cardiovert without the heparine treatment. I don't think a patient on on chronic anti-coagulation with an INR 3 has a clot but the safest would be doing the echo I guess.

 

[Apollyon]

Well, therein lies the rub. You've just asked the questions which go to the art of medicine, instead of the science. I recently had a patient with a PE with an INR of 2.5, taking her Coumadin. People can clot through anticoagulation. What do you do then? If the pt's INR is 3, just rate control them. Remember, first do no harm - if you have any question about a clot, don't stroke them out. The VFib risk from R on T from AFib when the HR is lower is lower than your risk of inducing an ischemic stroke.

I've chemically converted people with presumed new-onset AFib - when they've given me a really precise time for onset, like 7:50pm. (Don't know when is 7:50pm? How about "the final Jeopardy! answer just went up when it started"?)

And ibutilide definitely is the bomb.

 

[xaelia]

Afib will be back; hearts that are unhealthy enough to fibrillate won't stay converted.

You certainly save them the morbidity associated with anticoagulation - but the stroke risk of paroxysmal afib is the same as sustained afib, so you might be giving them a false sense of security.

 

[deleted109597]

On of the throwaway mags just had a discussion about it. I think it was EMN, but not sure (threw it away, natch).

In Canada, the cardiovert people all the time. Not much risk has been shown. It saves hospital time to let them go home. Here, we don't do it as much. Of course, if we 'vert them and they stroke, we are on the hook. I bet if we don't 'vert them and they stroke, we are still on the hook. And if we anticoagulate them and they fall, or suffer coumadin skin necrosis, we are still further on the hook.

So in effect, do what lets you sleep at night.

 

[VALSALVA]

I generally used Diltiazem to rate control RVR. I would say that 2/10 patients convert to NSR shortly after I bolus the Dilt anyhow. The rest get converted later and out of the ED. I agree with Apollyon that if there's any question about Afib onset, "first do no harm."

 

[Tiger26]

I verbal cardiovertered somebody last week--just mentioned the details of the procedure and she went from 130s irregular to 70s and regular . . . kind of anticlimactic though since i really like pressing the button

 

[gutonc]

I verbal cardiovertered somebody last week--just mentioned the details of the procedure and she went from 130s irregular to 70s and regular . . . kind of anticlimactic though since i really like pressing the button

I've done it in the ICU just by placing the pads. Verbally is impressive.

 

[Hawkeye Kid]

Not as dramatic as the above Jedi mind tricks, but I converted someone with a CVL guidewire. I was an intern and didn't even notice until my attending said "Huh, never seen that before."

 

[nlax30]

Had a similar episode of telepathic cardioversion today. Was going to use ibutilide on a post surgery new onset afib pt and was told to go back and place pads, get a 12-lead, stop the amio gtts, and they basically converted as I walked in. So, send the med student first and see if that works.

On cardio this month and they seem to have good results with ibutilide. I also see cardizem used a good amount but response is iffy. In this case onset was around 12hrs ago and we just decided to try ibutilide first instead of shocking, but that was going to be the next step if pharm didn't work. Just make sure things like Mg and K are ok to minimize arrhythmogenic potential.

 

[VALSALVA]

Had a similar episode of telepathic cardioversion today. Was going to use ibutilide on a post surgery new onset afib pt and was told to go back and place pads, get a 12-lead, stop the amio gtts, and they basically converted as I walked in. So, send the med student first and see if that works.

On cardio this month and they seem to have good results with ibutilide. I also see cardizem used a good amount but response is iffy. In this case onset was around 12hrs ago and we just decided to try ibutilide first instead of shocking, but that was going to be the next step if pharm didn't work. Just make sure things like Mg and K are ok to minimize arrhythmogenic potential.

...Because Diltiazem is used as a rate control medicine in the setting of Afib with RVR. It does have anti-arrhythmic properties (class IV I think??) but lousy ones at that.

 

[erdocnyc]

I had a case of a fib in a 26 year old male who knew exactly when it started (after a run in the park on a hot day and then drinking a coffee drink) first dig for rate control, then propafenone for cardioversion.

he now stays very hydrated during workouts, doesn't drink coffee, and hasn't been in afib for almost two years.

 

[FDNewbie]

Do you guys cardiovert A-fib? I mean, rapid a-fib that the patient is tolerating well, without hypotension/CP/SOB/AMS.

Sometimes. Depends on the situation.

And I've always heard don't cardiovert for a-fib that's greater than 72hrs old, but how do you know if it's 72hrs old or not?

If less than 48 hrs of onset, yes, if the patient isn't against getting shocked. It's great cuz at that point, you can D/C the pt. & have 'em follow up with their PCP.

How do you know if it's been less than 48 hrs? If your patient is a reliable historian, and if they can sense when they went into A-fib w/ RVR, they're typically pretty darn specific, "I felt it it me at 3:30PM yesterday." If they can't feel it now or are vague in their history, chances are they don't know exactly when it began, and as others have mentioned, I wouldn't risk strokin 'em with electrical cardioversion.

I used ibutilide today for the first time and was impressed with how well it worked.

I know that's one of the drugs Cards likes, but I don't think we have it in our ED Pyxis - or at least I know I've never heard of anyone asking for it in the ED.

As VALSALVA mentioned, Dilt is more of rate control than cardioversion, but I have had it work prob. 50% of the time. Other times it just rate controls.

Another one you can use is Metoprolol. If the pt. is already on Dilt @ home, I stick w/ Dilt; if they're already on a beta-blocker, I use Metoprolol. I don't like mixing meds.

Having said that, sometimes pts are hemodynamically stable, but their BP is borderline - and Dilt typically drops your pressure pretty good (as will Metoprolol). So in those cases, Amio is pretty solid drug. Not a fav in the ED world from what I gather, but it's tried & true in Medicine, and it's never failed me yet. Plus you can re-load the pt, even when they're on the drip, MULTIPLE times as needed. Still won't affect their BP adversely. AND (most importantly) it's in our Pyxis.