Source: Sanoski CA, Bauman
JL. The Arrhythmias. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells
BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic
Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7972803.
Accessed June 30, 2012.
- Supraventricular arrhythmia characterized by extremely
rapid (atrial rate of 400–600 beats/min) and disorganized
atrial activation resulting in irregularly irregular pulse (120–180
- Predominant mechanism is reentry, usually associated with
organic heart disease causing atrial distention (e.g., ischemia
or infarction, hypertensive heart disease, valvular disorders).
- Prevalence in United States, 0.4–1%; increases
- Prevalence expected to increase to 12–15 million
Americans by 2050.
- Lifetime risk for AF in persons at least 40 years of age estimated
to be 1 in 4.
- Rapid heart rate
- Worsening symptoms of heart failure (shortness of breath,
- Sign: Irregularly irregular pulse.
- Embolic stroke potential complication of AF.
Means of Confirmation
- Electrocardiogram (ECG) shows irregularly irregular supraventricular
rhythm with no discernible, consistent atrial activity (P waves);
ventricular response usually 120–180 beats/min.
- Atrial flutter
- Atrial tachycardia
- Atrioventricular nodal reentry tachycardia (AVNRT)
- Multifocal atrial tachycardia
- Paroxysmal supraventricular tachycardia
- Wolff-Parkinson-White syndrome
- Restore sinus rhythm.
- Prevent thromboembolic complications.
- Prevent further recurrences.
- Evaluate need for acute treatment (usually with drugs
that slow ventricular rate).
- Consider methods to restore sinus rhythm, considering risks
involved (e.g., thromboembolism).
- Consider ways to prevent long-term complications (e.g., recurrent
Algorithm for the treatment of atrial fibrillation (AF)
and atrial flutter. (BB, β-blocker; CCB, calcium
channel blocker [i.e., verapamil or diltiazem];
DCC, direct-current cardioversion.) aIf AF <48 hours,
anticoagulation prior to cardioversion is unnecessary; may consider
transesophageal echocardiogram (TEE) if patient has risk factors
for stroke. bAblation may be considered for patients who
fail or do not tolerate one or more antiarrhythmic drugs (AADs). cChronic
antithrombotic therapy should be considered in all patients with
AF and risk factors for stroke regardless of whether or not they
remain in sinus rhythm. Reprinted with permission from Wells BG,
DiPiro JT, Schwinghammer TL, et al. Pharmacotherapy Handbook. 8th
ed. New York: McGraw-Hill, 2012.
- Direct-current cardioversion (DCC) indicated to restore
sinus rhythm immediately in new-onset AF with signs/symptoms
of hemodynamic instability (e.g., severe hypotension, angina, pulmonary
- Control ventricular rate if patient hemodynamically stable
with drugs that slow conduction and increase AV node refractoriness.
- IV β-blockers (propranolol, metoprolol,
esmolol), diltiazem, or verapamil first-line in patients with normal
- Avoid IV diltiazem and verapamil and use IV β-blockers
with caution if left ventricular ejection fraction (LVEF) ≤40%.
- IV digoxin ...