Atrial Fibrillation

Atrial fibrillation is a very common arrhythmia in the hospital. Fortunately, it is usually easy to manage. In general, I treat a-fib with RVR in the following way:

As you start to follow this algorithm, you should simultaneously try to identify the provoking factor for the atrial fibrillation (if new) or RVR.

- Is the patient septic?
- Volume depleted?
- Is the magnesium low?
- Do they have a PE?
- Etc.

Patients should have their volume status optimized and electrolytes checked with attention to magnesium and potassium.

More Specifics on the Medications

Metoprolol

Preferred in patients with heart failure or MI. Try up to 3 IV doses of 5mg. Esmolol is an IV beta blocker that comes as a titratable infusion, but it can only be used in the ICU and is rarely necessary.
Diltiazem

If a couple IV doses (10–20mg) are ineffective, can be given as a titratable IV infusion.
Amiodarone

Good for short-term use in critically ill patients, but the many potential toxicities limit long-term use.
Digoxin

If you are running into hypotension with metoprolol or diltiazem, a loading dose of digoxin can be a useful adjunct, especially for a patient with systolic heart failure. Not always a great long-term medication.

TSH is often abnormal in hospitalized patients. Only check this if you have a reasonable suspicion for hyperthyroidism. Consider MI, but in general, avoid checking a troponin for isolated a-fib w/ RVR. (However, if the patient is having new chest pain, and needs a work up for ACS independent of their a-fib, then troponin and EKG need to be checked.)

Image credit: Eric Tanenbaum.

More Specifics on the Medications

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