CCS Case: Atrial Fibrillation with RVR

Case: Atrial Fibrillation with RVR

Clinical Setup

• Presentation: 71-year-old male with palpitations, dyspnea on exertion, irregularly irregular pulse, HR 158, BP 128/78, mild crackles, no chest pain.
• Location: Emergency Department.

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Pulse oximetry, continuous cardiac monitoring, BP q15min.
   • IV access, Normal saline 0.9% IV @ 75 mL/hr.
   • 12-lead ECG stat (confirm AFib, assess ischemia).
2. Focused Exam (Minute 1–2):
   • Cardiac exam (murmurs, JVD), lung exam (edema/fluid overload), thyroid exam, neuro screen (focal deficits).
3. Diagnostics (Minute 2–5):
   • CBC, BMP (K, Mg — replete both), TSH, troponin, BNP, PT/INR, PTT.
   • CXR portable; transthoracic echo (EF, atrial size, valve disease, thrombus assessment).
4. Therapeutics (Minute 5–15):
   • Rate control FIRST (stable patient): IV Metoprolol or Diltiazem (use Diltiazem cautiously if HFrEF — prefer beta-blocker or digoxin/amiodarone in reduced EF).
   • Assess stroke risk (CHA2DS2-VASc) and start anticoagulation if indicated: heparin bridge or direct oral anticoagulant per protocol.
   • If unstable (hypotension, chest pain, altered): synchronized cardioversion under sedation stat.
   • Rhythm control/elective cardioversion only after TEE or 3+ weeks anticoagulation if AFib > 48 hours or duration unknown.
   • Cardiology consult; advance clock and recheck rate/rhythm.
5. Disposition (Minute 15–20):
   • Admit to telemetry/stepdown for rate control and anticoagulation initiation.
   • Evaluate and treat triggers: ischemia, thyrotoxicosis, alcohol, sepsis, PE.
6. Final 2 Minutes:
   • Counsel on anticoagulant adherence, bleeding precautions, alcohol/caffeine limits, pulse self-checks.
   • Schedule cardiology and primary care follow-up; arrange outpatient Holter/echo if pending.