Atrial Fibrillation

tan-atrial-fibrillation-heartbeat-imageAtrial 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.

tanenbaum-atrial-fibrillation-chart

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.

Page Last Updated: July 19, 2022

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Headshot of Eric Tanenbaum, MD · Assistant Professor, WSU College of Medicine; Nocturnist, Swedish Hospital Medicine
Eric Tanenbaum
MD · Assistant Professor, WSU College of Medicine; Nocturnist, Swedish Hospital Medicine
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