See<unk> with RVR for emergent treatment
Rhythm control (i.e. synchronized cardioversion)
Consider in the emergency department for:
Unstable (due to rhythm)
Younger patients (<65 years old) with new or paroxysmal episode (<48 hours)
Procedural anticoagulation status
If <48 hours of symptoms, do not need to anticoagulate prior to rhythm control (may perform in ED)
If >48 hours of symptoms, need have rhythm control as out patient referral (if stable)
Method: Procedural sedation and analgesia (e.g. fentanyl and propofol). Apply pads in anterior to posterior position. Synchronized electrical cardioversion starting at 150 to 200 J.
Rate control for all others or cardioversion failure
General principal - IV medications for immediate rate control followed by PO medications for sustained rate control
Beta-blocker
Metoprolol 5 mg IV q 5 min (max 3 doses) followed by 25-100 mg PO
Calcium channel blocker
Diltiazem 0.25 mg/kg to 0.35 mg/kg IV (20 mg typical starting dose), can follow with 25 mg IV as second dose if needed
Followed by PO dose 60-120 mg
If unable to get sustained response with IV push, consider diltiazem gtt
Digoxin
Indicated if patient hypotensive and cannot get AV nodal blockade or if patient has advanced heart failure
Typical digitizing dose 500 mcg then 250 mcg q4hx 2 for total dose of 1000 mcg
Requires renal dosing if patient has impaired renal function
Amiodarone
Indicated if patient has hypotension or advanced heart failure, usually second line after digoxin
Typical dosing 150 mg IV x 10 min then 1 mg/min x 6 hours then 0.5 mg/minx 18 hours
Amiodarone can convert patient to sinus rhythm.  Consider simultaneously starting empiric anticoagulation if high thromboembolism risk, see below
Procainamide
Indicated: Hemodynamically stable with systolic Blood Pressure >100 mmHg, less than 48 hrs onset, Normal Serum Potassium and Serum Magnesium
Ottawa protocol Method: Procainamide 1 g IV over 60 minutes. Monitor with frequent Blood Pressures, and hold Procainamide if systolic Blood Pressure <100 mmHg. Monitor telemetry for Arrhythmia, QTc Prolongation, QRS Widening and for successful cardioversion.
Consider in the emergency department for:
Unstable (due to rhythm)
Younger patients (<65 years old) with new or paroxysmal episode (<48 hours)
Procedural anticoagulation status
If <48 hours of symptoms, do not need to anticoagulate prior to rhythm control (may perform in ED)
If >48 hours of symptoms, need have rhythm control as out patient referral (if stable)
Method: Procedural sedation and analgesia (e.g. fentanyl and propofol). Apply pads in anterior to posterior position. Synchronized electrical cardioversion starting at 150 to 200 J.
Unstable (due to rhythm)
Younger patients (<65 years old) with new or paroxysmal episode (<48 hours)
If <48 hours of symptoms, do not need to anticoagulate prior to rhythm control (may perform in ED)
If >48 hours of symptoms, need have rhythm control as out patient referral (if stable)
General principal - IV medications for immediate rate control followed by PO medications for sustained rate control
Beta-blocker
Metoprolol 5 mg IV q 5 min (max 3 doses) followed by 25-100 mg PO
Calcium channel blocker
Diltiazem 0.25 mg/kg to 0.35 mg/kg IV (20 mg typical starting dose), can follow with 25 mg IV as second dose if needed
Followed by PO dose 60-120 mg
If unable to get sustained response with IV push, consider diltiazem gtt
Digoxin
Indicated if patient hypotensive and cannot get AV nodal blockade or if patient has advanced heart failure
Typical digitizing dose 500 mcg then 250 mcg q4hx 2 for total dose of 1000 mcg
Requires renal dosing if patient has impaired renal function
Amiodarone
Indicated if patient has hypotension or advanced heart failure, usually second line after digoxin
Typical dosing 150 mg IV x 10 min then 1 mg/min x 6 hours then 0.5 mg/minx 18 hours
Amiodarone can convert patient to sinus rhythm.  Consider simultaneously starting empiric anticoagulation if high thromboembolism risk, see below
Procainamide
Indicated: Hemodynamically stable with systolic Blood Pressure >100 mmHg, less than 48 hrs onset, Normal Serum Potassium and Serum Magnesium
Ottawa protocol Method: Procainamide 1 g IV over 60 minutes. Monitor with frequent Blood Pressures, and hold Procainamide if systolic Blood Pressure <100 mmHg. Monitor telemetry for Arrhythmia, QTc Prolongation, QRS Widening and for successful cardioversion.
Metoprolol 5 mg IV q 5 min (max 3 doses) followed by 25-100 mg PO
Diltiazem 0.25 mg/kg to 0.35 mg/kg IV (20 mg typical starting dose), can follow with 25 mg IV as second dose if needed
Followed by PO dose 60-120 mg
If unable to get sustained response with IV push, consider diltiazem gtt
Indicated if patient hypotensive and cannot get AV nodal blockade or if patient has advanced heart failure
Typical digitizing dose 500 mcg then 250 mcg q4hx 2 for total dose of 1000 mcg
Requires renal dosing if patient has impaired renal function
Indicated if patient has hypotension or advanced heart failure, usually second line after digoxin
Typical dosing 150 mg IV x 10 min then 1 mg/min x 6 hours then 0.5 mg/minx 18 hours
Amiodarone can convert patient to sinus rhythm.  Consider simultaneously starting empiric anticoagulation if high thromboembolism risk, see below
Indicated: Hemodynamically stable with systolic Blood Pressure >100 mmHg, less than 48 hrs onset, Normal Serum Potassium and Serum Magnesium
Ottawa protocol Method: Procainamide 1 g IV over 60 minutes. Monitor with frequent Blood Pressures, and hold Procainamide if systolic Blood Pressure <100 mmHg. Monitor telemetry for Arrhythmia, QTc Prolongation, QRS Widening and for successful cardioversion.
ACCP Recommendations
In patients with AF, including those with paroxysmal AF, with only one of the risk factors listed immediately above, we recommend long-term antithrombotic therapy (Grade 1A), either as anticoagulation with an oral VKA, such as warfarin (Grade 1A), or as aspirin, at a dose of 75-325 mg/d (Grade 1B)
In patients with AF, including those with paroxysmal AF, who have two or more of the risk factors we recommend long-term anticoagulation with an oral VKA (Grade 1A).
In patients with AF, including those with paroxysmal AF, with only one of the risk factors listed immediately above, we recommend long-term antithrombotic therapy (Grade 1A), either as anticoagulation with an oral VKA, such as warfarin (Grade 1A), or as aspirin, at a dose of 75-325 mg/d (Grade 1B)
In patients with AF, including those with paroxysmal AF, who have two or more of the risk factors we recommend long-term anticoagulation with an oral VKA (Grade 1A).
CCS Recommendations
Oral anticoagulants are recommended for all AF patients aged 65 or older or who have any one of the traditional CHADS2 risk factors of stroke, hypertension, heart failure, or diabetes (remember as CHADS-65).  Otherwise, patients with a history of coronary artery disease or arterial vascular disease should be prescribed ASA. CCS recommends that the first choice for oral anticoagulation should be the novel direct-acting oral anticoagulants (i.e. NOACs, for non-valvular AF). The big paradigm change is that ED physicians should prescribe OACs to at-risk AF patients before they leave the ED.
Oral anticoagulants are recommended for all AF patients aged 65 or older or who have any one of the traditional CHADS2 risk factors of stroke, hypertension, heart failure, or diabetes (remember as CHADS-65).  Otherwise, patients with a history of coronary artery disease or arterial vascular disease should be prescribed ASA. CCS recommends that the first choice for oral anticoagulation should be the novel direct-acting oral anticoagulants (i.e. NOACs, for non-valvular AF). The big paradigm change is that ED physicians should prescribe OACs to at-risk AF patients before they leave the ED.
Score 0: consider no treatment or ASA
Score 1: consider warfarin or ASA
Score 2-6: consider warfarin (INR goal = 2-3)
All patients with significant valvular disease should be on anticoagulation
Used to assess 1 yr risk of bleeding on OAC medications
Score 1: 1.0 bleeds per 100 patient-years
Score 2: 1.9 bleeds per 100 patient-years
Score 3: 3.7 bleeds per 100 patient-years
Score 4: 8.7 bleeds per 100 patient-years
Score 5-9: Insufficient Data
Atrial fibrillation 
Regular
Atrial flutter
AV Node Independent
Torsades de pointes
Sinus tachycardia
Atrial tachycardia
Atrial tachycardia 