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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. 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 beats/min).

  • 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 with age.
  • 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.

Signs and Symptoms

  • Symptoms:
    • Rapid heart rate
    • Palpitations
    • Worsening symptoms of heart failure (shortness of breath, fatigue)
  • Sign: Irregularly irregular pulse.
  • Embolic stroke potential complication of AF.

Means of Confirmation and Diagnosis

  • Electrocardiogram (ECG) shows irregularly irregular supraventricular rhythm with no discernible, consistent atrial activity (P waves); ventricular response usually 120–180 beats/min.

Differential Diagnosis

  • 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 arrhythmia, thromboembolism).

Figure 1.

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 edema).

  • 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 LV function.
    • Avoid IV diltiazem and verapamil and use IV β-blockers with caution if left ventricular ejection fraction (LVEF) ≤40%.
    • IV digoxin ...

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