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
Additional New Information
More on EMCrit
- The Case of the Irregular Irregularity(Opens in a new browser tab)
- EMCrit 20 – The Crashing Atrial Fibrillation Patient(Opens in a new browser tab)
- EM Nerd-The Case of the Irregular Irregularity Continues(Opens in a new browser tab)
- Atrial Fibrillation (AF) & Flutter complicating critical illness
You Need an EMCrit Membership to see this content. Login here if you already have one.
Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Latest posts by Scott Weingart, MD FCCM (see all)
- EMCrit 396 – Some Philosophy of Surgical Airways (Crics) and What to Do When the Doom is Lower Down (Central Airway Obstruction) - March 7, 2025
- EMCrit 395 – Stellate Ganglion Block – Not Whether, but When? - February 23, 2025
- EMCrit 394 – CV-EMCrit – Inotrope Basics Part 2 – Specific Scenarios - February 7, 2025
If starting amio how worried do we need to be about thromboembolic events/ stroke? For patients with borderline blood pressures (90-100 systolic or MAP in the low 60s) and a normal lactate or lactate in the 2-3 range. i tend to lean towards digoxin and magnesium and optimizing volume status/electrolytes until a TEE can be done. Usually this would be for a patient with rate fluctuating between 120-150 and may have pulmonary congestion or possible infection/sepsis. in cases where there is obvious shock or instability it’s easier to justify the cardio version (chemical or electrical) without the TEE.
I love this one.
I see this scenario at least once a year, a pt who ends up in the ICU after someone attempted rate control without knowing about the cardiac function.
It’s hard to justify not doing a bedside echo first before giving any negative inotrope.
This is a bugbear of mine in an Australian context. The deteriorating patient early warning systems prioritise scoring tachycardia with the goal of safely detecting shock. AF RVR scores points in these systems and places excessive attention on reducing the heart rate as a treatment priority particularly for trainee doctors. Simplistically, if we accept that 20% of SV comes from atrial priming then a normal HR of 80/ min needs to be 96 to maintain CO. In patients prone to AF – those with preexisting LV diastolic dysfunction and significantly more dependence on atrial priming then the PR required to… Read more »