Rapid Afib in PE

[PinkLithe]

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.

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[deleted547339]

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.

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.

 

[jdh71]

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.

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.

 

[PinkLithe]

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.

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.

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.

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.

 

[Raryn]

There's always amio...

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

 

[PinkLithe]

^ 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.

 

[NontradICUdoc]

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

 

[jdh71]

^ 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.

Did you miss the part where the patient was "otherwise stable"?

 

[PinkLithe]

^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.

 

[Nivakia]

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.

 

[deleted547339]

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.

That's what I said.

 

[Raryn]

^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.

Your point is true. I raised the possibility of electricity, but in this specific situation TPA would definitely be preferably to electricity.

 

[jdh71]

^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.

Ah. Yes. Lysis if not contraindicated would the right move not cardio version which wouldn't work in that situation.

 

[jdh71]

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.

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.

 

[PinkLithe]

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.

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.