might seem a stupid question but...

[whasupmd2]

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someone comes in afib c rvr, you rate control them with dilt, whcih also converts them. never been in afib before, and you're going to admit them. WOuld you anticoagulate?

 

[DropkickMurphy]

Diltiazem doesn't convert AFib most of the time (in my experience), it's good for rate control, but normally they require cardioversion or amiodarone for conversion back to sinus rhythm. But if you are certain that there is relatively recent onset (I believe the cutoff is 24 hrs) then there is little need for anticoagulation.

 

[whasupmd2]

same with mine, I didn't even give mag, and they converted, but no good hx regarding onset. so would you anticoaguate? and then the next ? is really a floor ?, but if you check TEE and it's neg for clot, start on coumadin anyhow, in case the person goes back into afib? or just monitor and if remains in nsr, then no?

Diltiazem doesn't convert AFib most of the time (in my experience), it's good for rate control, but normally they require cardioversion or amiodarone for conversion back to sinus rhythm. But if you are certain that there is relatively recent onset (I believe the cutoff is 24 hrs) then there is little need for anticoagulation.

 

[DropkickMurphy]

same with mine, I didn't even give mag, and they converted, but no good hx regarding onset. so would you anticoaguate? and then the next ? is really a floor ?, but if you check TEE and it's neg for clot, start on coumadin anyhow, in case the person goes back into afib? or just monitor and if remains in nsr, then no?

The reason for the anticoagulation is due to blood pooling in the atria for a longer period of time, and honestly I think the risks involved with coagulation would be greater than the likelihood of benefit in the event of recurrence of AFib. If you have a poor history, then either anticoag or a TEE prior to cardioversion is indicated. If it is definitely new onset AFib, then conversion followed by antiarrhythmic therapy maybe indicated (our cardiologists have a love for using amiodarone in this setting that borders on a fetish). A TEE can be done in the ED, but I've only seen it done to rule out aortic injury, never to check for atrial thrombi. Normally the issue isn't something that needs immediate attention, since most of the time you can simply control the rate and let the docs on the floor worry about whether to attempt conversion. In this case, I would not see a need for anticoagulant therapy but keep in mind, I'm not a doc, I'm an echocardiographer, respiratory therapist and EMT-Intermediate, so this is just my opinion and based on what I have been taught by the EM and cards docs I work with. Perhaps one of the EM docs can provide a little more insight......

 

[NinerNiner999]

First, rate control then, anticoagulate. Some suggest anticoagulation if sustained afib for 48 hours or more. Cardioversion should be reserved for the unstable patients. When cardioverting, adenosine or amiodarone can be useful (prefer amio).

 

[docB]

I think Whasupmd2 is asking a really interesting question. I've wondered about this myself occasionally. I'm going to ask it in a different way and see what you guys think.

A person with Afib and RVR comes in. No good timeline for onset of the afib is available. Rate is 170. You give some dilt for the purpose of rate control. They then convert. You have not anticoagulated them. Have you screwed up? Is it anyone's practice to give Lovenox or heparin BEFORE the rate control?

 

[DropkickMurphy]

I think Whasupmd2 is asking a really interesting question. I've wondered about this myself occasionally. I'm going to ask it in a different way and see what you guys think.

A person with Afib and RVR comes in. No good timeline for onset of the afib is available. Rate is 170. You give some dilt for the purpose of rate control. They then convert. You have not anticoagulated them. Have you screwed up? Is it anyone's practice to give Lovenox or heparin BEFORE the rate control?

Just out of curiosity: how quick is the onset of anticoag following Lovenox?

 

[NinerNiner999]

Actually, I've recently researched this. UpToDate.com is generally my resource of choice and they suggest anticoagulation if persistant afib for 48 or more hours. In the case of the patient with unknown duration of afib, there is probably no harm to anticoagulating (that's what they will do on the floor if the rhythm does not normalize). If their rate converts to sinus, they may or many not warrant admission, but I probably would not anticoagulate them (I try to anticoagulate as few patients as possible in the ED, including pre-emptive management). Of note, this is generally the bulk of the admission reasoning for afib - to monitor the patient and look for either (a) new arrhythmia or (b) conversion back to NSR. If there is no change, the patient will be started on anticoagulaion anyways.

DropKick - Lovenox will start working after about 2 hours, and is generally effective for 24-36 hours before requiring new dosing if required (although daily dosing is not detrimental).

Of note, some will say that reversal of lovenox is not possible, but 1:1 dosing with protamine is successful in reversing its effects by as much as 75%.

 

[DropkickMurphy]

Actually, I've recently researched this. UpToDate.com is generally my resource of choice and they suggest anticoagulation if persistant afib for 48 or more hours. In the case of the patient with unknown duration of afib, there is probably no harm to anticoagulating (that's what they will do on the floor if the rhythm does not normalize). If their rate converts to sinus, they may or many not warrant admission, but I probably would not anticoagulate them (I try to anticoagulate as few patients as possible in the ED, including pre-emptive management). Of note, this is generally the bulk of the admission reasoning for afib - to monitor the patient and look for either (a) new arrhythmia or (b) conversion back to NSR. If there is no change, the patient will be started on anticoagulaion anyways.

DropKick - Lovenox will start working after about 2 hours, and is generally effective for 24-36 hours before requiring new dosing if required (although daily dosing is not detrimental).

Of note, some will say that reversal of lovenox is not possible, but 1:1 dosing with protamine is successful in reversing its effects by as much as 75%.

So...if it takes two hours, wouldn't that preclude what DocB is suggesting?

 

[whasupmd2]

DocB, thanks clarifying my question. That's exactly right. My attending was saying b/c the pt converted, it's a greater reason to anticoagulate (likely the person was in afib > 48hrs since no previous ekg, and no hx pt was able to given regarding timing). I wasn't too sure even understanding all that you said before regarding, first anticoagualte then convert, etc.... However, I was not trying to convert, just rate control. Thoughts?

also, are you guys giving enoxaparin for these afibbers? That's what I gave and medicine flipped saying that you should be giving heparin. That's there's no indication for afib and lovenox....

In any case, my thought was to 1) rate control 2) hm... converted? considered anticoagulation, but let's hold off, and see if the person goes back to NSR (let medicine decide this after monitoring) 3) if going to anticoagulate then use enoxoparin, easier dosing and less screw ups, pt not going to surgery so need to have heparin gtt.

Actually, I've recently researched this. UpToDate.com is generally my resource of choice and they suggest anticoagulation if persistant afib for 48 or more hours. In the case of the patient with unknown duration of afib, there is probably no harm to anticoagulating (that's what they will do on the floor if the rhythm does not normalize). If their rate converts to sinus, they may or many not warrant admission, but I probably would not anticoagulate them (I try to anticoagulate as few patients as possible in the ED, including pre-emptive management). Of note, this is generally the bulk of the admission reasoning for afib - to monitor the patient and look for either (a) new arrhythmia or (b) conversion back to NSR. If there is no change, the patient will be started on anticoagulaion anyways.

DropKick - Lovenox will start working after about 2 hours, and is generally effective for 24-36 hours before requiring new dosing if required (although daily dosing is not detrimental).

Of note, some will say that reversal of lovenox is not possible, but 1:1 dosing with protamine is successful in reversing its effects by as much as 75%.

 

[dhb]

The basis for anti-coagulation is to avoid clot formation or disolve a clot that has already formed so even if you do give anti-coagulation you will not disolve a potential clot. If the patient converts he's not at risk for clot formation any more and if you don't know if his been in Afib for more than 48h you can't do much except monitor them neurologicaly.
If you want to convert to sinus rhythm amiodarone is a poor choice for someone with an otherwise healthy heart: flecainide or propaferone should be your 1st choice
with amiodarone you have to give high doses before getting to therapeutic values and iv it hurts like hell trust me 😱 plus it's action is very slow: why wait half an hour if you want to convert the patient?

 

[dhb]

In any case, my thought was to 1) rate control 2) hm... converted? considered anticoagulation, but let's hold off, and see if the person goes back to NSR (let medicine decide this after monitoring) 3) if going to anticoagulate then use enoxoparin, easier dosing and less screw ups, pt not going to surgery so need to have heparin gtt.

I'd do the same, i have yet to see a patient correctly anti-coagulated with heparine: it's always a mess

 

[southerndoc]

someone comes in afib c rvr, you rate control them with dilt, whcih also converts them. never been in afib before, and you're going to admit them. WOuld you anticoagulate?

Why admit them?

If they've never been in afib before, and if they can give you a clear cut start of their symptoms (a lot of patients can), then either chemically or electrically cardiovert at the bedside, observe for 4 hours, and then discharge with Lovenox and warfarin. (We still discharge our converted patients on anticoagulation. Cardiology wants at least 6 weeks of anticoagulation in case they go in and out of a-fib.)

RVR that is controlled and observed can go home.

 

[southerndoc]

Just out of curiosity: how quick is the onset of anticoag following Lovenox?

90 minutes generally, but the manufacturer claims it only takes 30 seconds to start seeing the effects. 90% anticoagulant activity in 60 minutes, and >95% in 90 minutes.

 

[DropkickMurphy]

If you want to convert to sinus rhythm amiodarone is a poor choice for someone with an otherwise healthy heart: flecainide or propaferone should be your 1st choice

with amiodarone you have to give high doses before getting to therapeutic values and iv it hurts like hell trust me plus it's action is very slow: why wait half an hour if you want to convert the patient?

I asked the same thing of one of our cardiologist ("Isn't there a better option?") because we seemed to have low rates of conversion on Cordarone and we wind up electively cardioverting a lot of their patients (either RT or anesthesia has to be present at all conscious sedations at our facility after an "incident" that happened a couple of years back and since the cards docs hate our anesthesiologists we get called in on most cases). I never did get a decent answer.....thanks for the info.

 

[Annette]

Why admit them?

If they've never been in afib before, and if they can give you a clear cut start of their symptoms (a lot of patients can), then either chemically or electrically cardiovert at the bedside, observe for 4 hours, and then discharge with Lovenox and warfarin. (We still discharge our converted patients on anticoagulation. Cardiology wants at least 6 weeks of anticoagulation in case they go in and out of a-fib.)

RVR that is controlled and observed can go home.

Hmm. Agree with anticoag for 4-6 weeks post conversion. People will often convert when the rate is controlled. WHen people are electively converted, they are anticoagulated beforehand. You don't know if someone is going to convert with rate control (usually young and otherwise healthy), so you should probably let them know that there is a small risk of stroking if they convert spontaneously.

I'm not so certain that I would send a patient home who had RVR. You want to know WHY they went into afib/RVR. Also, with people with known hx of afib and previously rate controlled, you need to figure out why they went into RVR (pneumonia, hypoxia, MI???)

I don't think I have seen a case of lone afib during my residency. Why are house patients always so complicated?????

 

[Dimoak]

Why admit them?

If they've never been in afib before, and if they can give you a clear cut start of their symptoms (a lot of patients can), then either chemically or electrically cardiovert at the bedside, observe for 4 hours, and then discharge with Lovenox and warfarin. (We still discharge our converted patients on anticoagulation. Cardiology wants at least 6 weeks of anticoagulation in case they go in and out of a-fib.)

RVR that is controlled and observed can go home.

Hey, I was just wondering how long you put the pt on Lovenox for post-discharge, as I've been reading alot about the dangers of prolonged use of lowmw heparins, as well as the need for careful monitoring of the pt for bleeding (especially in older pts who may have renal impairments), hx needs to be checked for thrombocytopenia, GI bleeds, etc. I thought it was moreso indicating for AC while also preventing DVT. Do you guys also educate the pt (or caregiver for older pts) on properly using the Lovenox syringe (ensuring it's not injected IM)? I'm no expert, but I personally always thought it safer to give Lovenox or Arixtra while a patient can be monitored ambulatorily, and then continue therapy at home with Warfarin when the stronger ACs can be d/ced. Can anyone provide further information?

 

[whasupmd2]

I'm surprised regarding the # of replies to this ?. We should put up more random clinical questions as they arise on the board, I think we could really continue to learn from each other. Things that come up, the we've wondered about, and never looked up... or even if we did look it up, what we found. I found these things really useful.

Hey, I was just wondering how long you put the pt on Lovenox for post-discharge, as I've been reading alot about the dangers of prolonged use of lowmw heparins, as well as the need for careful monitoring of the pt for bleeding (especially in older pts who may have renal impairments), hx needs to be checked for thrombocytopenia, GI bleeds, etc. I thought it was moreso indicating for AC while also preventing DVT. Do you guys also educate the pt (or caregiver for older pts) on properly using the Lovenox syringe (ensuring it's not injected IM)? I'm no expert, but I personally always thought it safer to give Lovenox or Arixtra while a patient can be monitored ambulatorily, and then continue therapy at home with Warfarin when the stronger ACs can be d/ced. Can anyone provide further information?

 

[southerndoc]

Lovenox is given in the ED along with 5 mg of warfarin. The patient is instructed on Lovenox injections, given a prescription for wafarin (2.5 mg daily), and a prescription for an INR check in 48 hours. Once the INR is therapeutic the patient discontinues Lovenox. This same philosophy is also followed with patients being discharged home with DVT's.

Annette brings up an interesting point of finding the underlying cause of the RVR. There was no mention of associated medical conditions in this patient. If the patient had a pneumonia, hyperthyroidism, or whatever underlying medical condition that was suspected, then of course this patient could not go home. With a thorough workup in the emergency department, the patient without any evidence of underlying cause and who has been rate controlled for a few hours is likely to be discharged home.

 

[dhb]

especially in older pts who may have renal impairments)

I think you only start to worry when Cre clerance is < 20ml/min