MANAGEMENT OF ATRIAL FIBRILLATION IN ADULT PATIENTS A. VENTRICULAR RATE CONTROL RATE CONTROL
AF secondary to sympathetic stimulations (ie. Sepsis, post-op…)
Calcium antagonists: diltiazem, verapamil
USUAL SUGGESTED IV DOSES
Loading IV/PO: 10-15mcg/kg (lean body weight) in 3-4 divided doses during the 1st 24hrs Maintenance: 0.125-0.5mg per day (adjust dose per renal function, levels, heart rate)
Loading IV: 15-20mg (0.25mg/kg) over 2min, may repeat 20-25mg (0.35mg/kg) in 15min X 1 to control rate
Infusion: 5-15mg/h titrate to heart rate and BP (mix 100mg/100mL D5W)
IVP 2.5-5mg over 2 min initially, may repeat 5-10mg in 15-30min if needed (maximum 20mg) OR 5mg q15min to total dose of 30mg
IVP 5mg slow q5min up to 3 doses (maximum 15mg)
Infusion: 0.05-0.2mg/kg/min titrate to heart rate and BP (2.5gm/250mL NS)
B. PHARMACOLOGIC CARDIOVERSION AND MAINTENANCE OF SINUS RHYTHM: ANTI-ARRHYTHMIC AGENTS CARDIOVERSION OF HEMODYNAMICALLY STABLE AF MAINTENANCE OF SINUS RHYTHM WITHOUT WPW DURATION DURATION > 48 IMPAIRED HEART HEART FUNCTION
≤ 48 HOURS HOURS OR UNKOWN CHF or EF < 40% PRESERVED Delayed cardioversion: Early cardioversion: begin
* Note: only one of the above agents should be used at a time
♥ For patients who are hemodynamically unstable (ie. hypotensive), suggest DC cardioversion (start at 200 Joules).
♥ For patients with WPW, avoid adenosine, beta-blockers, calcium antagonists, digoxin and may use DC cardioversion,
amiodarone, procainamide, flecainide, propafenone, sotalol.
USUAL SUGGESTED DOSES
♥ Loading infusion: 150mg/100mL IV D5W over 10 min (15mg/min).
♥ Infusion: 1mg/min X 6hrs then 0.5mg/min (mix 900mg/500mL D5W). Max cumulative dose is 2.2g/day. ♥ Maintenance: 200mg qd PO
♥ Cardioversion: 200mg q4h (maximum 800mg)
♥ Maintenance: 100-300mg q12h Oral (SR product) (reduce doses in renal dysfunction)
♥ 500mcg q12h PO (adjust doses based on renal function and QT intervals) for conversion and maintenance
♥ Initiation of therapy requires hospitalization X 3 days ♥ MD must be certified to order, use standing order sheet for Dofetilide, follow Dofetilide guidelines
♥ Maintenance: 50-100mg bid up to 400-600mg/day (reduce doses in renal dysfunction)
♥ ≥ 60kg : 1mg IV over 10min, may repeat same dose in 10min X 1 (mix dose in 50mL D5W)
♥ < 60kg : 0.01mg/kg over 10min, may repeat same dose in 10min X 1 (mix dose in 50mL D5W)
♥ Loading infusion: 20mg/min (maximum total dose 17mg/kg). Loading infusion can /should be D/C when
1) arrhythmias are suppressed, 2) hypotension occurs, 3) QRS is prolonged by 50% of baseline, 4) QTc > 500msec
♥ Maintenance infusion: 1-3mg/min (mix 1g/250mL D5W or NS). ♥ Maintenance oral: 1-4gm/day (q4-6hr with immediate release products, q6-12h with SR products)
♥ Maintenance: 150-300mg q8h (adjust dose in hepatic dysfunction)
♥ Cardioversion: 200mg quinidine sulfate PO, followed 1-2 hours later by 400mg
♥ Maintenance: 324-468mg quinidine gluconate q8h, or quinidine sulfate 200-400mg qid PO
♥ Maintenance: 160-320mg per day in 2 divided doses (adjust doses in renal dysfunction)
♥ Initiation of therapy requires hospitalization
C. ANTICOAGULATIONS FOR STROKE PREVENTION: RISK STRATIFICATION DEFINITIONS RECOMMENDATIONS High-Risk Patients
Prior stroke/TIA or systemic embolus, h/o HTN, poor
♥ 1st choice: warfarin (INR 2-3, target 2.5)
LV systolic function, age > 75yrs, rheumatic mitral
♥ 2nd choice: ASA (if warfarin is contra-
indicated or poor candidate for warfarin)
Moderate-Risk Patients
Age 65-75 yrs, DM, CAD with preserved LV systolic
Low-Risk Patients
Age < 65 yrs lone AF (no cardiovascular disease)
Anticoagulation for elective cardioversion:
1. AF < 48hrs: Heparin during the peri-cardioversion period, even though the risk of embolism is low 2. AF ≥ 48hrs:
a) Preferred: Warfarin (INR= 2-3, target= 2.5) for 3 weeks before and at least 4 weeks after cardioversion b) Alternative: Heparin then TEE before cardioversion; if there is no thrombi, followed by warfarin until normal
sinus rhythm has been maintained for at least 4 weeks
Anticoagulation upon discharge:
1. Anticoagulation with Low-molecular-weight heparin can be considered in eligible patients for early discharge followed by oral anticoagulation.
REFERENCES:
1. A symposium: atrial fibrillation: advances for the new millennium. Am J of Cardiol 2000;85(10A): 1D-52D 2. Albers GW et al. Antithrombotic therapy in AF. Chest 2001;119(1): 194S-206S 3. Falk, R. Atrial fibrillation. N Engl J Med 2001;344(14):1067-1978 4. ILCOR Member Organizations. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care –
An international consensus on science. Circulation 2000;102(suppl I):I-1−I-11
5. Prystowsky EN et al. Management of patients with AF. Circulation 1996;93:1262-1277
Jennifer Bui, Pharm. D., Critical Care John Zimmerman, MD, Chief EPS
AF guidelines(3/25/01,4/17/01,4/30/01,5/8/01,5/11/01,5/22/01,6/8/01)
Field testing of a fish bioconcentration model proposed for risk assessment of human pharmaceutical residues in aquatic environments Jeffrey N. Brown†, Nicklas Paxéus*, Lars Förlin‡ and D.G. Joakim Larsson† † Institute for Neuroscience and Physiology, the Sahlgrenska Academy at Göteborg University, Sweden. * Environmental Chemistry, Gryaa
Simultaneous Analysis of Antifungals in Plasma by SPE with Agilent Bond Elut Plexa and an Agilent 1260 Infinity LC/MS/MS Abstract Multicompound analysis of six systemic antifungal drugs in human plasma iseffectively achieved using an Agilent LC/MS/MS system composed of an AgilentBond Elut Plexa polymeric sorbent, an Agilent Pursuit XRsUltra 2.8 Diphenyl column,and an Agilent 1260 Infinity