Mount Carmel Health Partners Clinical Guidelines Atrial Fibrillation

Definition: Atrial fibrillation is a supraventricular tachyarrhythmia characterized by uncoordinated atrial activation with consequent deterioration of atrial mechanical function documented continually on an ECG or for at least 30 seconds on monitoring. Classification • Paroxysmal AF: AF that ends in less than 7 days and can be recurrent • Persistent AF: Continuous AF (present on every ECG) that is sustained beyond 7 days or requires cardioversion • Longstanding persistent AF: Continuous AF of greater than a 12-month duration with continued efforts to restore sinus rhythm • Permanent AF: Continuous AF of a greater than 12-month duration when no further interventions to restore to sinus rhythm are planned • Nonvalvular AF: AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair Physical Exam and Diagnostic Testing • Physical exam • Vital signs, including oximetry • ECG to verify AF and identify other cardiac concerns • Labs: CBC, CMP, and thyroid function • Transthoracic echocardiogram • Consider chest x-ray if there are pulmonary signs or symptoms • Consider nocturnal oximetry to assess for sleep apnea; may consider STOP-BANG obstructive sleep apnea questionnaire (see page 10 of this guideline) • Imaging stress test if antiarrhythm ic medications are considered or if there is a moderate to high CHD risk History and Evaluation • Description of the symptoms: onset or date of discovery, frequency and duration, severity, and qualitative characteristics • Symptoms may include: palpitations, tachycardia, fatigue, weakness, dizziness, lightheadedness, reduced exercise capacity, increased urination, or mild dyspnea Severe symptoms: dyspnea at rest, angina, presyncope, or syncope • Precipitating causes: exercise, emotion, alcohol, or sleep apnea • Other medical history: underlying heart disease, comorbidities and possible reversible conditions such as hyperthyroidism, electrolyte imbalance, or pulmonary disease Rate Control Medications to meet the goal of 60 to 100 BPM include Carvedilol, Metoprolol, Diltiazem, and Verapamil. Consider additional medications based on the patient’s circumstances: • If the patient’s ejection fraction is less than 35% (chronic), add digoxin or a beta blocker. • If the patient’s heart rate is high at rest and the patient is already taking a calcium channel blocker or beta blocker, add digoxin. • If the patient’s elevated heart rate is exertion-induced, add a beta blocker or a calcium channel blocker. Table A: Preferred Rate Control Medications Medication Dosing Special Considerations Carvedilol (Coreg, Coreg CR) (immediate release: IR or extended release: ER) IR: 3.125 mg to 25 mg, twice daily ER: 10 mg to 80 mg, once daily Major potential ADRs: bradyarrhythmia, hypotension, hyperglycemia, fatigue, dizziness, or headache; preferred for patients with heart failure and diabetes due to increases in insulin sensitivity Toprol XL: 25 mg to 300 mg, once daily Lopressor: 25 mg to 100 mg, twice daily Major potential ADRs: bradyarrhythmia, dizziness, dyspnea, fatigue, heart block, and decompensated heart failure; Succinate (Toprol XL) preferred for patients with heart failure Diltiazem (Cardizem CD, Dilacor CD, Tiazac) 120 mg to 360 mg, once daily Major potential ADRs: bradyarrhythmia, dizziness, headache, cough, fatigue, heart block, and heart failure; causes less constipation or edema Verapamil (Calan, Isoptin, Verelan, Covera-HS) IR: 60 mg to 80 mg, 3 to 4 times a daily SR: 120 mg to 360 mg, once daily Major potential ADRs: AV block, edema, constipation, dizziness, and headache; consider for AF driven by hypertension and patients with PVCs Metoprolol succinate (Toprol XL) Metoprolol tartrate (Lopressor) AFib - 3

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