Please note: this guideline has exceeded its review date and is currently under review by specialists. Exercise caution in the use of the clinical guideline.
Requiring admission, or onset during admission for other problem e.g. post-surgery.
Options include:
Amiodarone IV 300mg infused over 1 hour then 900mg over 24 hours through a central line (preferable) or large peripheral line or
Flecainide IV 2mg/kg, up to 150mg, over 30 minutes if no structural or coronary heart disease.
Consult Cardiologist for advice. Options include beta-blocker, sotalol, flecainide and amiodarone depending upon circumstances and patient factors.
Amiodarone loading regime is amiodarone oral 200mg three times daily for 1 week then 200mg twice daily for 1 week then 200mg daily. Other oral regimens are sometimes used on the advice of a cardiologist.
N.B. Ideally, check baseline thyroid and liver function tests before starting. Interactions include digoxin and simvastatin (see BNF Appendix 1 for more details).
Start enoxaparin SC 1mg/kg twice daily unless active bleeding or high risk of bleeding – Consult senior before withholding. (For patients at extremes of body weight or eGFR <30ml/min/1.73m2 see guidelines on NHSGGC StaffNet, Clinical Guideline Electronic Resource Directory, search in 'Cardiovascular system'). |
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Haemodynamic compromise?
Adverse signs are: pallor, sweating, cold clammy extremities, impaired consciousness, systolic <90mmHg, pulmonary oedema, raised jugular venous pressure |
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If Yes – Select here for guidance. If No – Continue below. |
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Consult with senior |
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Chemical cardioversion |
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IV amiodarone / IV flecainide – for dosing guidance see start of guideline. |
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Chemical cardioversion failed? |
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Perform echo – Excludes mitral stenosis, gives structural and functional assessment of the heart (e.g. whether LV systolic dysfunction / hypertrophy) i.e. helps identify need for anticoagulant. N.B. Investigation should not delay treatment to slow the ventricular rate and reduce the risk of thromboembolism. See AF – Persistent guideline for guidance on anticoagulant. |
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Aim for rate control (apex <110bpm). Beta-blocker or calcium channel antagonist are first choice. Digoxin can be added or used as first-line if signs of heart failure. See AF – Persistent guideline. |
N.B. Deal with precipitants of AF: Infection, alcohol, hyperthyroidism, heart failure.