Resistant AF, depressed EF, cath first?

[DrMetal]

Was doing a questions.

In the case of resistant AF with RVR, say HR 150s, admitted, but otherwise completely stable. You try a dilt or esmolol drip, TTE shows EF of 40% and global hypokinesis, next step??? (patient still in Afib, still very stable, HR maybe a little reduces now in 120s).

If there's chronic suspected CAD (no acute symptoms, but some good risk factors), Would you cath first, then do the TEE--> electrical cardioversion? Or do the cardioversion first, then cath? I think you would do the cardioversion first, especially if no acute indications to cath, right?

Now, if an acute ACS, then definitely cath first, and if still in Afib, then cardiovert, right?

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[greatnt249]

Was doing a questions.

In the case of resistant AF with RVR, say HR 150s, admitted, but otherwise completely stable. You try a dilt or esmolol drip, TTE shows EF of 40% and global hypokinesis, next step??? (patient still in Afib, still very stable, HR maybe a little reduces now in 120s).

If there's chronic suspected CAD (no acute symptoms, but some good risk factors), Would you cath first, then do the TEE--> electrical cardioversion? Or do the cardioversion first, then cath? I think you would do the cardioversion first, especially if no acute indications to cath, right?

Now, if an acute ACS, then definitely cath first, and if still in Afib, then cardiovert, right?

If stable and no symptoms suspicious for ischemia, I would probably lean more toward TEE/cardioversion, goal-directed therapy for heart failure with reduced ejection fraction, and follow-up work-up to see if LVEF recovers following restoration of sinus rhythm. Really this all depends on the patient's history and whether you believe the reduced ejection fraction could be due to tachycardia-mediated cardiomyopathy or not. If concerned for ischemia in interim, could probably consider perfusion imaging or cardiac CT (if appropriate for patient) to see if there's anything that forces your hand toward catheterization.

Unclear if there's a slam-dunk "right answer" here; I'm sure someone else would have a different approach to this.

 

[nlax30]

If stable and no symptoms suspicious for ischemia, I would probably lean more toward TEE/cardioversion, goal-directed therapy for heart failure with reduced ejection fraction, and follow-up work-up to see if LVEF recovers following restoration of sinus rhythm. Really this all depends on the patient's history and whether you believe the reduced ejection fraction could be due to tachycardia-mediated cardiomyopathy or not. If concerned for ischemia in interim, could probably consider perfusion imaging or cardiac CT (if appropriate for patient) to see if there's anything that forces your hand toward catheterization.

Unclear if there's a slam-dunk "right answer" here; I'm sure someone else would have a different approach to this.

EP here and this would be my approach.

 

[timpview]

What I woukd do:

- load amio
- tee dccv
- no cath
- amio for a month
- cont BB/ACE
- repeat echo in one month
- if ef still low I would cath vs stress based on cad risk factors (lean towards cath since stresses are basically worthless)