Acute management of Afib/flutter with RVR for dummies 


1. Are they hemodynamically stable? 
--> no --> synchronized electrical cardioversion (unsync'd may cause the rhythm to degenerate into vfib). You proooooobably should call MICU or cards if you're gonna do this. You know the whole, coding-someone-by-yourself-is-a-bad-idea thing. 
--> yes --> go to step 2. 

2. Is there any evidence that organs are being underperfused? 
--> yes --> be way more aggressive -- start with 5mg metop x3, and then go straight to esmolol gtt or dilt IV push x2 followed by dilt gtt if the BP Is good, or straight to amio load/gtt if BP Is not. Also, call for an ICU bed... few places allow this kind of thing to happen on the floor. 
--> no --> can let people hang out -- start with 5mg metop pushes, or maybe even just PO drugs depending on how fast the rate is and how healthy they are. 
which agent you pick depends on the BP and whether they have HF and what agents they are already on --> go to step 3/4/5 

3. Is the blood pressure good?
--> yes --> b-blocker preferred, then CCB 
--> no --> amio preferred, then dig (also give a bolus, unless HF)

4. Do they have horrible, decompensated HF? 
--> yes --> dig preferred, then amio -- amio is way faster, but dig has inotropic effect... depends on how sick/fast they are vs how bad their HF is. 
--> no --> beta blocker preferred, then CCB 

5. Are they already on something? 
--> yes --> increase the dose of that before you add additional agents. For example, if you're at 200mg/day of PO metop (50 q6) or 360 mg/day of PO dig (90 q6) and it's still not working, then add something else. 
--> no --> select first agent based on below system: 

Non heart failure patient with good blood pressure who isn't going that fast: 
IV metop first, then if that fails add PO metop, then if that fails add PO dilt 

Non heart failure patient with good blood pressure who is going fast: 
IV metop first, then if that fails IV dilt push, then if that fails IV dilt gtt, if that fails then amio. If at any point, the BP starts to fail to tolerate all the drugs, switch to amio earlier. 

Non heart failure patient with suboptimal blood pressure:
Fluid bolus first, if that fixes the BP then go with the above pathway, if that doesn't fix BP then go the below pathway. 

Non heart failure patient with crappy blood pressure: 
Fluid bolus then amio (IV load and gtt, or IV load and PO maintenance, depending on how fast they are and how urgently you need control). If that fails call MICU. 

Decompensated heart failure patient who isn't going really fast and has OK kidneys: 
Dig first, then if that fails, add amio. 

Decomp heart failure, who is going fast and/or has bad kidneys: 
Amio first, then if that fails, add dig (if kidneys are OK)  

Also call cards... most of us probably shouldn't be managing afib/flutter with rvr in patients with decompensated heart failure... 

About the options: 

- IV Metop. Given as pushes of 5mg each, up to 3 times with a 5 minute wait between each one. It's fast, but there's no drip metop; so if it only transiently works then you have to switch to an agent that has a drip. If you think there's high chance of success that a few IV pushes of beta-blockade will make them better (i.e. you know the patient, metop has worked in the past, etc) then this is fine. Otherwise start with dilt or esmolol. Of note, the patient will need to go home on PO metoprolol and may need to remain on it indefinitely.
- PO metop. If IV metop works, then start a PO metop regimen - in b-blocker naive, start at 12.5 q6; can titrate up to 50q6. In a stable person who is not-that-fast and chillin' comfortably you can even just start with PO metop and titrate up as needed.
- Esmolol gtt: great drug, works really well, but not an option for non-ICU patients - half life 9-12 minutes means you need constant titration means there is no way the floor nurses will let you do this. In fact, even saying the word esmolol will cause the charge nurse to suddenly appear, bearing down on you with an angry expression, ready to bash your skull in with their ever-present clipboards. Try it. It's like a magic trick. 
- IV dilt: Push 0.25mg/kg. Wait 15 minutes. If it didn't work, push 0.35 mg/kg. Wait 15 minutes. If that still doesn't work, start drip at 5-15mg/hr. Preferred drug for patients you don't know (may have atrial thrombus) and for people with tough to break a-fib who you think may need a drip.
- PO dilt: If you're gonna pick an agent to start, you're better off starting with PO beta-blockade than PO CCB esp in older people or people who you think might have suboptimal heart function (i.e. older, fat, HTN, DM, PAD, smoker, etc etc etc) -- CCB have more negative inotropy. If someone is already on dilt and it has worked for them you can keep pushing it up to 120q6. 
- Amio: 150mg IV push, then 60mg/hr for 6 hours, then 30/hr for 12-18 hours depending on where you are. This is a great drug-- it works fast, it works well, it doesn't drop the BP (well, actually it does, but to a way smaller extent than CCB or BB), it doesn't have negative inotropy. The dangerous thing a is that it's a class III antiarrhythmic, and you can inadvertently cardiovert, and if they have an atrial thrombus you may cause an embolic stroke. Although you can inadvertently cardiovert with metop as well... this drug also has tons of long term side effects so its' not as a great of a choice for the long term, but if you're just trying to stabilize someone who is going fast and has terrible BP until someone who knows more about hearts than you comes along, its a fantastic choice. 
- Dig: slow, but has positive inotropy. 1 hour onset time. At 6 hours, a significant number of people will still be tachycardic. Second line in heart failure patients who are unable to be rate controlled with amio. Don't use in people with renal failure!!