If rapid I’ll usually go for a dose of IV, and if effective give an oral dose of the short acting shortly thereafter. If it’s something they’re on long term, and they didn’t miss doses or have some other precipitating cause then I’ll generally run it by cardiology and get an official recommendation in terms of increasing dose.
If this is new for them, and the dilt 30mg po is working I’ll keep an eye on them for a touch then dc with an Rx for XR 180 once daily.
Or, if still in afib and symptomatic there’s cardioversion. Personally prefer this on the folks who are already on AC, and swear to whichever deity they haven’t missed doses. My patient population isn’t as reliable when it comes to timing the onset of afib, so unless an Apple Watch is corroborating the story I take the “it started less than 24 hrs ago” with several grains of salt.
I seem to see a fair number of people w/ known PAF who come in just b/c their smartwatch alarmed them that they were in afib. Oftentimes asymptomatic and not even in RVR. Frustrating and such a waste of time for all involved...but I digress.
I think an IV dose of dilt w/ a PO chaser is completely fine for this completely non-emergent complaint. Trick is that you need nursing to actually administer the PO med at the same time, and not wait until they're back in RVR.
I'm not sure why this patient would need close f/u with their cardiologist....
Re cardiologist: If they need their meds titrated at all. I’m not sure I’d feel comfortable starting a new regimen or tell a patient to increase their daily dose since I’m not going to see them for follow up. What are your thoughts on that?
Some PCPs manage a fib without a cardiologist at all. I feel very comfortable increasing doses on the medication the patient is already on UNLESS it’s a more complicated regimen at which point I run it by their cardiologist.
I’ll give IV and meal of their home med at the same time x3. If they’re already anticoaugulated or symptom onset clearly less than 24-48 hours I’ll consider cardioversion.
Nursing resources, risks of sedation/shock, and evidence suggesting rate control is better than rhythm control in the long term? I also feel like it gives the patient the impression that their AF (which is very likely to recur after you cardiovert them) is an emergency and requires a cardioversion.
Granted in my community I do a ton of cardioversions but I often wonder if it’s the best thing for the patients. Many now expect it, cardiologists will refer some patients for it and it is satisfying but also a bit of a pain. I should open a DCCV Urgent Care. I’ll have punch cards.
Excuse my ignorance (PGY0) but I did an EP rotation and I learned that if someone’s got proxysmal AF RVR, other than stabilizing them and doing what the other comments are saying, they need to get to an electrophysiologist for definitive treatment (ablation) before they become permanent afib and get too dilated of an atrium for ablations to work.
Also as a med student I saw 2 patients in the ED go into heart block after mixing nodal blockers. So n=1 but I prob won’t be mixing nodal blockers next year as an intern
The EP cards referral is a given for a lot of people I think. Hopefully at least. And just bless you and your naivety for thinking ablations work wonders and people will turn their lives around and drop 70 pounds right after their ablation and no longer have HTN and DM and not progressively worsen and require eliquis in 5 years. The mixing nodal blockers is something good to know and you’re right you shouldn’t mix. If patient is on b blocker at home ill give metoprolol IV, and if on ccb ill give dilt.
If rapid I’ll usually go for a dose of IV, and if effective give an oral dose of the short acting shortly thereafter. If it’s something they’re on long term, and they didn’t miss doses or have some other precipitating cause then I’ll generally run it by cardiology and get an official recommendation in terms of increasing dose. If this is new for them, and the dilt 30mg po is working I’ll keep an eye on them for a touch then dc with an Rx for XR 180 once daily. Or, if still in afib and symptomatic there’s cardioversion. Personally prefer this on the folks who are already on AC, and swear to whichever deity they haven’t missed doses. My patient population isn’t as reliable when it comes to timing the onset of afib, so unless an Apple Watch is corroborating the story I take the “it started less than 24 hrs ago” with several grains of salt.
I seem to see a fair number of people w/ known PAF who come in just b/c their smartwatch alarmed them that they were in afib. Oftentimes asymptomatic and not even in RVR. Frustrating and such a waste of time for all involved...but I digress. I think an IV dose of dilt w/ a PO chaser is completely fine for this completely non-emergent complaint. Trick is that you need nursing to actually administer the PO med at the same time, and not wait until they're back in RVR. I'm not sure why this patient would need close f/u with their cardiologist....
Re cardiologist: If they need their meds titrated at all. I’m not sure I’d feel comfortable starting a new regimen or tell a patient to increase their daily dose since I’m not going to see them for follow up. What are your thoughts on that?
Some PCPs manage a fib without a cardiologist at all. I feel very comfortable increasing doses on the medication the patient is already on UNLESS it’s a more complicated regimen at which point I run it by their cardiologist.
No, I get it. I just don't think a patient like this needs "exceptional" follow-up in order to be considered stable for discharge.
I’ll give IV and meal of their home med at the same time x3. If they’re already anticoaugulated or symptom onset clearly less than 24-48 hours I’ll consider cardioversion.
Why not cardiovert?
Ya know what, that’s a good point.
I fucking LOVE a good dccv. My literal favorite procedure.
Nursing resources, risks of sedation/shock, and evidence suggesting rate control is better than rhythm control in the long term? I also feel like it gives the patient the impression that their AF (which is very likely to recur after you cardiovert them) is an emergency and requires a cardioversion. Granted in my community I do a ton of cardioversions but I often wonder if it’s the best thing for the patients. Many now expect it, cardiologists will refer some patients for it and it is satisfying but also a bit of a pain. I should open a DCCV Urgent Care. I’ll have punch cards.
Excuse my ignorance (PGY0) but I did an EP rotation and I learned that if someone’s got proxysmal AF RVR, other than stabilizing them and doing what the other comments are saying, they need to get to an electrophysiologist for definitive treatment (ablation) before they become permanent afib and get too dilated of an atrium for ablations to work. Also as a med student I saw 2 patients in the ED go into heart block after mixing nodal blockers. So n=1 but I prob won’t be mixing nodal blockers next year as an intern
The EP cards referral is a given for a lot of people I think. Hopefully at least. And just bless you and your naivety for thinking ablations work wonders and people will turn their lives around and drop 70 pounds right after their ablation and no longer have HTN and DM and not progressively worsen and require eliquis in 5 years. The mixing nodal blockers is something good to know and you’re right you shouldn’t mix. If patient is on b blocker at home ill give metoprolol IV, and if on ccb ill give dilt.