arrrythmia - kuku

[ArchivalUser]

Treatment

Medications

If atrial fibrillation persists for > 1 week


“ Spontaneous conversion is unlikely


“ Management consists of rate control and anticoagulation with warfarin (goal INR of 2“3)



Rate control is defined as ventricular rate of 50“100 bpm with usual daily activities and not exceeding 120 bpm except with moderate to strenuous activity


Conventional rate-control agents used singly or, in younger adults, often in combination, include


“ -Blockers


“ Digoxin


“ Calcium channel blockers (Table 40)



In patients with heart failure, coronary artery disease, or ongoing ischemia, -blockers or digoxin are preferred


Amiodarone (among other antiarrhythmic drugs) is useful


“ When rate control with other agents is incomplete or contraindicated


“ When cardioversion is anticipated



Do not use digoxin, verapamil, or -blockers if atrial fibrillation is associated with a known or suspected accessory pathway


Table 40. Antiarrhythmic Drugs.

Therapeutic Procedures

Urgent electrical cardioversion is recommended in patients who are hemodynamically unstable even if atrial fibrillation has been present for > 48 h


Elective electrical or pharmacologic cardioversion is recommended in patients


“ With an initial episode of recent onset when there is an identifiable precipitating factor


“ Who remain symptomatic despite aggressive efforts at rate control



If cardioversion is planned and the duration of atrial fibrillation is unknown


“ Perform a transesophageal echocardiography to exclude an atrial thrombus


“ Attempt electrical cardioversion while the patient remains sedated



If thrombus is present, delay cardioversion until therapeutic warfarin anticoagulation has been achieved for 4 weeks (goal INR of 2“3)


Use heparin while awaiting therapeutic warfarin anticoagulation in atrial fibrillation with mitral stenosis, a history of embolic events, or demonstrated thrombus on transesophageal echocardiography


After cardioversion, maintain therapeutic anticoagulation for at least 1“6 mo


Patients with atrial fibrillation who fail to convert should receive anticoagulation therapy indefinitely


However, indefinite anticoagulation therapy is not indicated for those with "lone atrial fibrillation," defined as


“ Age < 65


“ No associated heart disease, hypertension, atherosclerotic vascular disease, or diabetes mellitus



For drug refractory, symptomatic atrial fibrillation, consider radiofrequency catheter ablation or radiofrequency atrioventricular node ablation and permanent pacing

[ArchivalUser]

thnx triple helix

[ArchivalUser]

drog of choice 4 wpw?

[ArchivalUser]

Treatment

Some patients have a delta wave found incidentally on ECG. In the absence of palpitations, light-headedness, or syncope, these patients do not require specific therapy. They should be advised to report the onset of any of these symptoms. Patients found incidentally to have delta waves who have jobs that could potentially put others at risk (ie, pilot, bus driver, etc) may need to undergo electrophysiologic testing and prophylactic catheter ablation to ensure that they are not at risk for sudden death.

Radiofrequency Ablation

As with AVNRT, radiofrequency ablation has become the procedure of choice in patients with accessory pathways and recurrent symptoms. Patients with preexcitation syndromes who have episodes of atrial fibrillation or flutter should be tested by induction of atrial fibrillation in the electrophysiologic laboratory, noting duration of the RR cycle; if it is less than 220 ms, a short refractory period is present. These individuals are at highest risk for sudden death, and prophylactic ablation is indicated. Success rates for ablation of accessory pathways with radiofrequency catheters exceed 90% in appropriate patients.

Pharmacologic Therapy

Narrow-complex reentry rhythms involving a bypass tract can be managed as discussed for AVNRT. Atrial fibrillation and flutter must be managed differently, since agents such as digoxin, calcium channel blockers, and even -blockers may decrease the refractoriness of the accessory pathway or increase that of the AV node, leading to sometimes faster ventricular rates. Therefore, these agents should be avoided. The class Ia, class Ic, and class III antiarrhythmic agents will increase the refractoriness of the bypass tract and are the drugs of choice for wide-complex tachycardias. If hemodynamic compromise is present, electrical cardioversion is warranted.

Long-term therapy often involves a combination of agents that increases refractoriness in the bypass tract (class Ia or Ic agents) and in the AV node (verapamil, digoxin, and -blockers), provided that atrial fibrillation or flutter with short RR cycle lengths is not present (see above). The class III agents sotalol and amiodarone are effective in refractory cases. Patients who are difficult to manage should undergo electrophysiologic evaluation.

CMDT

[ArchivalUser]

Procainamide?

[ArchivalUser]

acording 2 kaplan drug of choice 4 wpw syndrom 4 stable pt is PROCAINAMIDE...

[ArchivalUser]

as given by triple helix and also coinfirmed by UW -- Class I a -- procain..