1. Dismiss Notice
  2. Download free Tapatalk for iPhone or Tapatalk for Android for your phone and follow the SDN forums with push notifications.
    Dismiss Notice
  3. Hey Texans—join us for a DFW meetup! Click here to learn more.
    Dismiss Notice

Rapid Afib in PE

Discussion in 'Internal Medicine and IM Subspecialties' started by PinkLithe, Aug 19, 2015.

  1. PinkLithe

    2+ Year Member

    Joined:
    Apr 10, 2012
    Messages:
    57
    Likes Received:
    9
    Status:
    Resident [Any Field]
    How would you manage a patient who flipped into a rapid Afib (say HR persistently 130+) secondary to a new large PE? Otherwise stable and already on therapeutic anticoag.

    In reality I have just tried rate controlling, but my fear has always been dropping their HR too much and causing circulatory collapse/obstructive shock.
     
  2. Note: SDN Members do not see this ad.

  3. TimesNewRoman

    5+ Year Member

    Joined:
    May 14, 2013
    Messages:
    2,074
    Likes Received:
    1,621
    Status:
    Fellow [Any Field]
    I can't find it right now, but there was a paper in one of the EM journals recently that said of patients who presented to the ED in Afib with RVR and the RVR was a results of another process instead of the primary etiology (i.e. RVR 2/2 sepsis, PTE, dehydration, etc), they did worse if they were treated for their RVR.

    Others may disagree, and I obviously have a slightly different perspective on things, but I would treat RVR as a symptom rather than a problem. You wouldn't treat sinus tach in this patient, so why would you treat the AF with RVR as it could very well be simply a compensatory mechanism?

    This may be a patient that would benefit from half-dose lytics depending on the other factors.
     
  4. jdh71

    jdh71 epiphany at nine thousand six hundred feet
    Physician 10+ Year Member

    Joined:
    Dec 14, 2006
    Messages:
    66,691
    Likes Received:
    40,659
    Status:
    Attending Physician
    If their HR is above 130 persistently, I'd slow them with IV metoprolol. You're not going to get circulatory collapse by rate controlling Afib, plus slower rates equal more organized and better pump.

    The "size" of the embolism isn't the problem it's the RV strain and possible failure. Lots of patient's with big PE's but clinically fine with an RV that is hanging in there.
     
  5. PinkLithe

    2+ Year Member

    Joined:
    Apr 10, 2012
    Messages:
    57
    Likes Received:
    9
    Status:
    Resident [Any Field]
    So while I agree that the Afib may be a compensatory mechanism, you certainly also can't leave someone ticking along at a HR of 130-150. You're already treating the PE with anticoag so not much more you can really do except consider lytics. If pt had RV strain +/- trop bump I guess PEITHO says to go ahead with lytics, but still seems controversial.

    Yeah I've usually just rate controlled and hoped for the best. It does make sense that slower rate = more time in diastole = better CO, but I wonder why they flip into such rapid Afib to begin with? Is that high HR not compensating for poor stroke volume from the RV strain? I'm not sure.


    Thank you guys for the input.
     
  6. Raryn

    Raryn Infernal Internist / Enigmatic Endocrinologist
    Physician 10+ Year Member

    Joined:
    Apr 25, 2008
    Messages:
    6,810
    Likes Received:
    4,992
    Status:
    Attending Physician
    There's always amio...

    (Or, if they're hypotensive, the potential for electricity. But I like amio :p)
     
  7. PinkLithe

    2+ Year Member

    Joined:
    Apr 10, 2012
    Messages:
    57
    Likes Received:
    9
    Status:
    Resident [Any Field]
    ^ If they're hypotension/unstable with a PE why not just lyse? The point here isn't the Afib with RVR. It's Afib with RVR in the setting of PE with presumed RV strain/crap heart.
     
  8. EMT2ER-DOC

    EMT2ER-DOC Why so Serious?????
    Physician 10+ Year Member

    Joined:
    Oct 16, 2003
    Messages:
    2,406
    Likes Received:
    205
    Status:
    Attending Physician
    cardizem or digoxin. If you are concerned about the beta blockade, you can always try an esmolol drip since it is quickly metabolized. But this will also bring with it a lot of fluid from the drip
     
  9. jdh71

    jdh71 epiphany at nine thousand six hundred feet
    Physician 10+ Year Member

    Joined:
    Dec 14, 2006
    Messages:
    66,691
    Likes Received:
    40,659
    Status:
    Attending Physician
    Did you miss the part where the patient was "otherwise stable"?
     
  10. PinkLithe

    2+ Year Member

    Joined:
    Apr 10, 2012
    Messages:
    57
    Likes Received:
    9
    Status:
    Resident [Any Field]
    ^Um no? In my original case, the patient was otherwise stable. So rate control it seems is safe.

    But then another poster raised the possibility of using electricity if they were hypotensive, to which I would much rather consider lysing than cardioverting.
     
  11. Nivakia

    Joined:
    Mar 22, 2015
    Messages:
    67
    Likes Received:
    2
    Status:
    Non-Student
    How about you just leave the afib alone and treat the PE. Why does everyone have a knee jerk reaction to rate control every afib RVR they see.
     
  12. TimesNewRoman

    5+ Year Member

    Joined:
    May 14, 2013
    Messages:
    2,074
    Likes Received:
    1,621
    Status:
    Fellow [Any Field]
    That's what I said.
     
  13. Raryn

    Raryn Infernal Internist / Enigmatic Endocrinologist
    Physician 10+ Year Member

    Joined:
    Apr 25, 2008
    Messages:
    6,810
    Likes Received:
    4,992
    Status:
    Attending Physician
    Your point is true. I raised the possibility of electricity, but in this specific situation TPA would definitely be preferably to electricity.
     
  14. jdh71

    jdh71 epiphany at nine thousand six hundred feet
    Physician 10+ Year Member

    Joined:
    Dec 14, 2006
    Messages:
    66,691
    Likes Received:
    40,659
    Status:
    Attending Physician
    Ah. Yes. Lysis if not contraindicated would the right move not cardio version which wouldn't work in that situation.
     
  15. jdh71

    jdh71 epiphany at nine thousand six hundred feet
    Physician 10+ Year Member

    Joined:
    Dec 14, 2006
    Messages:
    66,691
    Likes Received:
    40,659
    Status:
    Attending Physician
    Gee. I don't know. Why do you think we try any make disorganized rhythm with rates above 130 better. I'm sure there is a reason.
     
  16. PinkLithe

    2+ Year Member

    Joined:
    Apr 10, 2012
    Messages:
    57
    Likes Received:
    9
    Status:
    Resident [Any Field]
    You definitely treat the PE. But most just get anticoagulated. That won't fix an Afib with RVR . Would you be comfortable just treating the PE if someone flipped into an Afib with a sustained HR of 150, 180? I'd think it's hard to leave that alone even if the patient were asymptomatic.
     

Share This Page