Today on the wee, we discuss why a pre and post-ecg may not be enough of a cardiac work-up for new onset atrial fibrillation, especially in younger patients…
Our Guests
Haval Chweich
(pronounced Schweish)
Pulm and Crit care physician and director of cardiac ICU at Tufts with passion for cardiogenic shock
Christopher Rago
Graduated Northeastern 2022 as an acute care NP, have been working in Cardiac ICU at Tufts since
Previously ICU RN of 10 years
Write-up by Chris Rago
Literature/Guidelines
- When you look at ACC guidelines for acute rate control in afib with RVR with hemodynamic stability it recommends against BB or non-dihydropyridine CCBs if concern for decompensated HF
- While simple in concept, it is sometimes hard to recognized decompensated HF and early stages of CS (Stage A or B)
- May present with only subtle signs (slight bump ALT, Cr, knee mottling, cool exam, mild pulm edema)
- In the Framingham cohort, among patients with new AF, a third of them had HF. Conversely patients with new HF, over half of them had AF
- Patients in decompensated HF may need a higher rate to compensate, and rate control alone may lead to a shock state
- This can be synergistic with negative chronotropy if CCB or BB given
Recommendations
- First question is “why are they in afib”
- Especially if young patient (<60 y/o) with no risk factors, they should not have a-fib
- Some possible etiologies:
- Peripartum CM
- Viral myocarditis
- ETOH cardiomyopathy
- New valvular Dz
- Some possible etiologies:
- Check POCUS/TTE in patients with new Dx of afib
- Color doppler over MV and AV as well as biV function
- AKI, LFT abnormalities, or lactate should raise suspicion of early stages of CS and give pause
- In a Finnish study by Jantti et all even modest early increases in ALT were associated with excess mortality in CS
- We see this retrospectively in many of these similar cases on chart review
- Cardiology consult, consider amiodarone (caution with Rx CV), digoxin, TEE/cardioversion, may need inotropic support +/- MCS
- Recognize this is a very small subset of patients with Afib, not encouraging to stop using BB or CCB as these are guideline recommendations for stable Afib with RVR. Just encouraging to maintain vigilance for new HFrEF and normotensive shock
Therapeutic momentum of rate control in these cases often continues onto the medical wards, so considering on presentation can be life saving
References:
- https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.115.018614
- https://www.jacc.org/doi/epdf/10.1016/j.jacc.2023.08.017
- https://scai.org/sites/default/files/2023-04/SCAI%20SHOCK%20Bedside%20Checklist%202022.pdf
- https://www.jscai.org/article/S2772-9303(21)00008-9/fulltext
- Jäntti, T., Tarvasmäki, T., Harjola, V. P., Parissis, J., Pulkki, K., Sionis, A., Silva-Cardoso, J., Køber, L., Banaszewski, M., Spinar, J., Fuhrmann, V., Tolonen, J., Carubelli, V., diSomma, S., Mebazaa, A., Lassus, J., & CardShock investigators (2017). Frequency and Prognostic Significance of Abnormal Liver Function Tests in Patients With Cardiogenic Shock. The American journal of cardiology, 120(7), 1090–1097. https://doi.org/10.1016/j.amjcard.2017.06.049
![](https://i0.wp.com/emcrit.org/wp-content/uploads/2024/07/Emcrit-Afib.jpg?resize=577%2C416&ssl=1)
Additional New Information
More on EMCrit
- The Case of the Irregular Irregularity(Opens in a new browser tab)
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- EM Nerd-The Case of the Irregular Irregularity Continues(Opens in a new browser tab)
- Atrial Fibrillation (AF) & Flutter complicating critical illness
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