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13.09.2014

How to treat acute atrial fibrillation, any treatment for herpes - Test Out

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Intravenous amiodarone versus verapamil for acute conversion of paroxysmal atrial fibrillation to sinus rhythm.
Emergency management of atrial fibrillation and flutter: intravenous diltiazem versus intravenous digoxin. Ventricular rate control in chronic atrial fibrillation during daily activity and programmed exercise: a crossover open-label study of five drug regimens. Efficacy of agents for pharmacologic conversion of atrial fibrillation and subsequent maintenance of sinus rhythm: a meta-analysis of clinical trials.
Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. Managing chronic atrial fibrillation: a Markov decision analysis comparing warfarin, quinidine, and low-dose amiodarone.
Risk for clinical thromboembolism associated with conversion to sinus rhythm in patients with atrial fibrillation lasting less than 48 hours. Left atrial chamber and appendage function after internal atrial defibrillation: a prospective and serial transesophageal echocardiographic study. Cost-effectiveness of transesophageal echocardiographic-guided cardioversion: a decision analytic model for patients admitted to the hospital with atrial fibrillation. Time of occurrence, duration, and ventricular rate of paroxysmal atrial fibrillation: the effect of digoxin.
Comparison of intravenous ibutilide versus procainamide for the rapid termination of atrial fibrillation or flutter. Efficacy and proarrhythmic hazards of pharmacologic conversion of atrial fibrillation: prospective comparison of sotalol versus quinidine. Effectiveness of loading oral flecainide for converting recent-onset atrial fibrillation to sinus rhythm in patients without organic heart disease or with only systemic hypertension. Conversion of recent-onset atrial fibrillation by a single oral loading dose of propafenone or flecainide.
Oral propafenone to convert recent-onset atrial fibrillation in patients with and without underlying heart disease. A comparison of cardioversion of atrial fibrillation using oral amiodarone, intravenous amiodarone and DC cardioversion.
Intravenous amiodarone in treatment of recent-onset atrial fibrillation: results of a randomized, controlled study. Efficacy, safety, and determinants of conversion of atrial fibrillation and flutter with oral amiodarone. Effectiveness of amiodarone and electrical cardioversion for chronic rheumatic atrial fibrillation after mitral valve surgery. Comparison of sotalol with digoxin-quinidine for conversion of acute atrial fibrillation to sinus rhythm (the Sotalol-Digoxin-Quinidine Trial). Sotalol versus quinidine for the maintenance of sinus rhythm after direct current conversion of atrial fibrillation. Acute treatment of recent-onset atrial fibrillation and flutter with a tailored dosing regimen of intravenous amiodarone. Efficacy of intravenous ibutilide for rapid termination of atrial fibrillation and atrial flutter: a dose-response study. Although many patients with atrial fibrillation experience relief of symptoms with control of the heart rate, some patients require restoration of sinus rhythm.


Initial treatment is directed at controlling the ventricular rate, most often with a calcium channel blocker, a beta blocker, or digoxin. Noncardiac conditions that can predispose patients to develop atrial fibrillation include hyperthyroidism, hypoxia, alcohol intoxication, and surgery.4The ECG is the mainstay for diagnosis of atrial fibrillation (Figure 1).
External direct current (DC) cardioversion is the most effective means of converting atrial fibrillation to sinus rhythm. Digoxin, which is perhaps the oldest form of therapy for atrial fibrillation, has an onset of action between 30 minutes and two hours, with peak effect in two to six hours. Medical or electrical cardioversion to restore sinus rhythm is the next step in patients who remain in atrial fibrillation.
Processes that increase atrial size, such as valvular heart disease, ischemic heart disease and dilated cardiomyopathy, provide a greater surface area for the development of multiple reentrant wavelets. Several advances have been made in antiarrhythmic medications, including the development of ibutilide, a class III antiarrhythmic drug indicated for acute cardioversion of atrial fibrillation.
Oral agents may be used in ambulatory patients, provided that symptoms do not warrant prompt rate control.If atrial fibrillation has been present for less than 48 hours, it is not necessary for the patient to undergo anticoagulation before cardioversion.
The tracing demonstrates the absence of P waves (long arrow), as well as the presence of the fine f waves of atrial fibrillation (short arrows).
In addition, the effectiveness of digoxin varies with the individual patient's autonomic tone.Digoxin is not effective in converting atrial fibrillation to sinus rhythm. Until the results of several large-scale randomized clinical trials are available, the decision to choose cardioversion or maintenance of sinus rhythm must be individualized, based on relief of symptoms and reduction of the morbidity and mortality associated with atrial fibrillation.Atrial fibrillation is the most common sustained arrhythmia encountered in primary care practice.
This may account for the mixed efficacy of our current antiarrhythmic medications.Increased sympathetic activity and increased vagal tone decrease the atrial refractory period, as does thyrotoxicosis.
If atrial fibrillation has been present for more than 48 hours or if the onset is unknown, an initial three- to six-week course of anticoagulation is recommended. According to the Framingham Heart Study,1 atrial fibrillation has a prevalence of 4 percent in the adult population.
Patients with chronic atrial fibrillation (including paroxysmal fibrillation) and at least one risk factor for thromboembolism should be considered for chronic anticoagulation.Three large, prospective, randomized trials currently under way address the question of rate control versus rhythm control. Likewise, atrial fibrillation may be terminated by increasing the conduction velocity or increasing the refractory period of the atrial tissue.
Until the results of these trials are available, the decision for patients to undergo cardioversion for atrial fibrillation and to attempt to maintain sinus rhythm should be based on the patient's symptoms and risk for thromboembolism. Antiarrhythmic medications may be of benefit by prolonging the refractory period of atrial tissue, thus preventing propagation of multiple reentry wavelets in the atria.
Food and Drug Administration for use in hypertension, angina pectoris and acute myocardial infarction, it is commonly used for rate control in atrial fibrillation.Rate control is necessary in all patients. In addition, when the ventricular response to atrial fibrillation is very rapid (more than 200 beats per minute), variability of the R-R interval can frequently be seen more easily using calipers on a paper tracing.Atrial flutter is included in the spectrum of supraventricular arrhythmia. Although many patients with atrial fibrillation are symptomatic, some patients remain asymptomatic. Unfortunately, antiarrhythmic medications also decrease conduction velocity, therefore favoring atrial fibrillation, which may account for the mixed efficacy of antiarrhythmic medications in maintaining sinus rhythm.If the decision is made for a patient to undergo cardioversion, the procedure should be performed as close to the onset of arrhythmia as possible. This rhythm disturbance is usually distinguishable by its more prominent saw-tooth wave configuration and slower atrial rates (Figure 2).
Thus, it is often difficult to estimate the onset, duration or severity of atrial fibrillation by the history alone.


Patients with paroxysmal atrial fibrillation do not require cardioversion by definition, although they may require medication to control heart rate and often require antiarrhythmic agents to maintain sinus rhythm.In patients with persistent atrial fibrillation, several intravenous and oral pharmacologic alternatives to DC cardioversion are available.
Atrial fibrillation should also be distinguished from atrial tachycardia with variable atrioventricular block, which usually presents with an atrial rate of approximately 150 beats per minute.
Furthermore, treatment strategies vary, depending on the patient's symptoms and clinical syndrome.Major goals of therapy include prevention of stroke and cardiomyopathy, reduction of symptoms and overall improvement in survival. Although this method is safe and effective, it requires the placement of transvenous shocking coils into the right ventricle and the right atrium. In this condition, the atrial rate is regular (unlike the irregular disorganized f waves of atrial fibrillation), but conduction to the ventricles is not regular.
Management includes heart rate control, rhythm control, anticoagulation therapy, or a combination of these strategies.Initial treatment also depends on the course of atrial fibrillation. However, the risk is very small in patients who have been in atrial fibrillation for less than 48 hours. Unlike amiodarone and sotalol, it is currently indicated for the acute termination of atrial fibrillation and flutter. Ibutilide prolongs repolarization of the atrial tissue by enhancing the slow inward depolarizing Na+ current in the plateau phase of repolarization. Paroxysmal atrial fibrillation is defined as recurrent episodes of spontaneously terminating atrial fibrillation. Ibutilide has little to no effect on the conduction velocity of the atrial tissue.33 The electrophysiologic actions of ibutilide make it difficult for the atrial tissue to support multiple wavelets of reentry. As initial treatment, 1 mg of propranolol is given intravenously over two minutes; this dose can be repeated every five minutes up to a maximum of 5 mg.
Persistent atrial fibrillation is defined by persistence of the arrhythmia until cardioversion is performed. A slower ventricular response rate also allows more filling time for the heart and, thus, improved cardiac output.14 However, the benefits of long-term treatment with calcium channel blockers or beta blockers should be carefully weighed against the negative inotropic effects.
Although class III agents are useful as adjuncts to electric cardioversion and are effective in maintaining sinus rhythm, only ibutilide is useful for acute cardioversion. Early successful cardioversion may also reduce the incidence of recurrent atrial fibrillation.3Medical cardioversion may be appropriate in certain situations, especially when adequate facilities and support for electrical cardioversion are not available or when patients have never been in atrial fibrillation before. If patients cannot be moved, the pads can be applied over the right sternal border and left lateral chest wall.3Patients with atrial fibrillation at a ventricular rate of less than 150 beats per minute who are hemodynamically stable can be initially treated with drugs for ventricular rate control and intravenously administered heparin for anticoagulation (see part II for more information).
In elderly patients with longstanding atrial fibrillation, repeated attempts at cardioversion may be counterproductive.
The chances of reverting to and maintaining sinus rhythm are lower with longer duration of atrial fibrillation and decrease to particularly low levels when atrial fibrillation has been present for more than one year. The success rate for electrical cardioversion is 90%.Medical cardioversion is a convenient and reasonable alternative in some patients, but it does not always terminate atrial fibrillation.



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