AFIB-Ottawa Protocol

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Jonathan W. -

In item IV. Why not attempt rate control firtst?

Is there data to support that beta blockers are often unable to slow rate significantly, and

Beta blockers do not facilitate subsequent candioversion and may actually antagonize it.

These are my personal observation also, but not supported in Up To Date.

Jon Wasserberger MD

Elizabeth S. -

1. How did you arrive at the decision to use Procainamide instead of another anti-arrhythmic? It seems to have more side effects than some of the other options.

2. What about the "atrial stunning" that is talked about in some studies, leading to the use of Warfarin for 1 month after cardioversion?

3 If a patient is on an anti-arrhythmic, such as Tambecor, Rhythmol, etc. and has a break-through episode, would that exclude them from the use of Procainamide? Would you be more likely to use the agent they are already taking and just give them an extra dose or a dose early?

Mel H. -

Lots of great questions here - we will try and get Ian and Robert to talk about them. One quick thing, atrial stunning tends to last proportional to the duration of atrial fib. So in acute atrial fib you start pumping pretty fast - if you have had atrial fib for a LONG time - you don't contract again for days or more after conversion.

Philip D. -

I had a perfect patient to use the Ottawa A-fib protocol on a few days ago. I elected to contact the patient's cardiologist via phone to see if they were comfortable with me attempting cardioversion in the ED as this is not a standard practice in our ED, and I am a new residency graduate. The cardiologist strenuously objected to this for no particular reason and instead recommending rate control with Dig and metoprolol. Neither of these therapies worked and patient was subsequently admitted. It seems to me our cardiologists are resistant to us attempting cardioversion in the ED, which may ultimately be due to reimbursement. Any recommendations about what to do, or how to justify attempting cardioversion in the ED?

Mohammed A. -

I've seen cases with new onset A Fib and negative initial troponin, cardioverted, repeated troponin came back high positive.
How safe to discharge home a possible case of NSTEMI, isn't new A Fib a possible sign of ACS?

Duane A., D.O. -

since this lecture i have used this on 5 patients no one converted on procanamide 4 converted with electrial tx and were discharged w/o coumadin i followed up on all patients myself all have done well in my small very rural hospital game changer for my patients

Ruth R., M.D. -

What sedation is best for electrical comversion? Etomidate? Versed? Does it matter? If electrical conversion fails would you make a second attempt?

Douglas L. -

I'm not sure about the overall utility of all this, other than in select groups of patients. My practice has always been as follows:

1. A fib with RVR - admit
2. New Onset A fib - probably admit, primarily for the purpose of ruling out badness (AMI, infection, metabolic causes, PE), as well as to establish care with a cardiologist, to risk stratify for anticoagulation, patient education, and possibly for cardiac imaging.
3. A fib with unclear onset time. I have to say that a ton of patients often fall into this category. Fatigue, palpitations, SOB, etc may be difficult to characterize.

That leaves me with low risk patients with recurrent a fib with a clear point of symptom onset <48 hours, and ideally already on coumadin. I have cardioverted several patients in this group, but I feel that they are certainly the minority. Everyone else tends to go on Cardizem or Dig. Many of them, end up converting within a few hours.

Almaateeq H.A -

Still cardiologists are not familiar with blind electrical cardioversion in ED in low risk payients..

Mohammed A. -

i understand why the cardiologists would be nervous-if you don't know how long the pt has been in afib and you shock you can get a stroke, I have seen this in a pt and the consequences are devastating, why risk this trying to play the hero role, which I know many ER docs love to do.

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