A-fib RVR and CHF

[Handsome Robb]

Not benign.

Funny guy!

Things that need fixin'

A symptomatic tachydysrhythmia needs fixin' but does necessarily need Edison medicine.


Personally someone would have to be peri-arrest for me to cardiovert AF with RVR unless there was a very clear cut recent onset. Our MD has been known to order cardizem in a drip over 10 minutes with a drip of calcium as well in hypotensive AF c/ RVR patients when they're in that grey area between actively trying to die and "stable".



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[VentMonkey]

Funny guy!

...carry on.

 

[RocketMedic]

I personally think around the same, I would rather try a CCB (diltiazem) for a symptomatic, acute, currently stable A-Fib than cardio version as a first line.

 

[TomB]

If your criterion for diltiazem is symptomatic but hemodynamically stable AF/RVR with symptom onset < 48 hours (as it should be) then it can wait.

Let the docs decide whether or not they want to perform an echo or give heparin prior to conversion. There's simply no rush.

If the patient's in heart failure NTG and CPAP goes a long way to relieving symptoms.

Tom

 

[E tank]

If your criterion for diltiazem is symptomatic but hemodynamically stable AF/RVR with symptom onset < 48 hours (as it should be) then it can wait.

Let the docs decide whether or not they want to perform an echo or give heparin prior to conversion. There's simply no rush.

If the patient's in heart failure NTG and CPAP goes a long way to relieving symptoms.

Tom

Lot's of ways to skin a cat. Going after the HR and rhythm here is very defensible, IMO, given the likelihood that they were contributing to the problem was high. If NTG and CPAP is all that is available, great, no argument. Bringing another dimension to the picture with rate control has a benefit too.

 

[RocketMedic]

If your criterion for diltiazem is symptomatic but hemodynamically stable AF/RVR with symptom onset < 48 hours (as it should be) then it can wait.

Let the docs decide whether or not they want to perform an echo or give heparin prior to conversion. There's simply no rush.

If the patient's in heart failure NTG and CPAP goes a long way to relieving symptoms.

Tom

The Plavix/xarelto/warfarin does affect that decision-making somewhat though.

 

[VFlutter]

The Plavix/xarelto/warfarin does affect that decision-making somewhat though.

If known therapeutic. I wouldn't trust warfarin without labs. Plavix is debatable

 

[TomB]

Lot's of ways to skin a cat. Going after the HR and rhythm here is very defensible, IMO, given the likelihood that they were contributing to the problem was high. If NTG and CPAP is all that is available, great, no argument. Bringing another dimension to the picture with rate control has a benefit too.

What was the benefit in this case? Looks to me like a clear-cut case of heart failure (it doesn't get any clearer based on the history that was provided). The patient's pressure bottomed out to 70/40. Let the ED attending and cardiologist decide how rate control is best achieved in a patient with a baseline EF of 28%, after lungs are clear and SpO2 is back in the 90s, or be prepared to see several more cases like this one. You can say, "if NTG and CPAP is all that's available, great...." but that is the mainstay of modern prehospital treatment of heart failure, and for good reason.

 

[TomB]

"Because of their favorable effect on morbidity and mortality in patients with systolic HF, beta-adrenergic blockers are the preferred agents for achieving rate control unless otherwise contraindicated. Digoxin may be an effective adjunct to a beta blocker. The nondihydropyridine calcium antagonists, such as diltiazem, should be used with caution in those with depressed EF because of their negative inotropic effect."

2013 ACCF/AHA Guideline for the Management of Heart Failure

 

[E tank]

What was the benefit in this case? Looks to me like a clear-cut case of heart failure (it doesn't get any clearer based on the history that was provided). The patient's pressure bottomed out to 70/40. Let the ED attending and cardiologist decide how rate control is best achieved in a patient with a baseline EF of 28%, after lungs are clear and SpO2 is back in the 90s, or be prepared to see several more cases like this one. You can say, "if NTG and CPAP is all that's available, great...." but that is the mainstay of modern prehospital treatment of heart failure, and for good reason.

 

[E tank]

What was the benefit in this case? Looks to me like a clear-cut case of heart failure (it doesn't get any clearer based on the history that was provided). The patient's pressure bottomed out to 70/40. Let the ED attending and cardiologist decide how rate control is best achieved in a patient with a baseline EF of 28%, after lungs are clear and SpO2 is back in the 90s, or be prepared to see several more cases like this one. You can say, "if NTG and CPAP is all that's available, great...." but that is the mainstay of modern prehospital treatment of heart failure, and for good reason.

Sorry for the above misfire... moving thru a couple of airports... anyway... just a couple of points. Be careful about hanging your hat on "mainstays"... they change regularly. As an example, the idea of treating chronic chf with beta blockers is only a couple of decades old.

Secondly, this scenario wasn't a straight forward presentation. The a fib/rvr complicated things a lot. Three things were impairing LV filling.... the cardiomyopathy/low ef, the a fib and the high HR.

This guy was "pre-load dependent" as they say and unloading the heart at that rate (as opposed to the 70 that he was given NTG) had the potential for disaster as well. Add CPAP to that and it has even worse potential. I think he needed a lower HR to tolerate any NTG. How much and when was the question here.

Even the doc on duty would have addressed the HR with DCCV, so the medic was thinking along the same lines.

As far as using a CCB here, it was a good trade off, I think because all the patient had going on was far worse in the setting of an ef in the high 20's than some diltiazem.