Therapeutic Handbook - GGC Prescribing

Algorithm for Cardioversion of AFStart enoxaparin SC 1 mg/kg twice daily unless active bleeding or high risk of bleeding -consult senior before withholding (for patients at extremes of body weight or eGFR< 30 ml/minute/1.73m 2 see guidelines on StaffNet, Clinical Guideline Electronic ResourceDirectory, search in 'Cardiovascular system'.Haemodynamic compromise?Adverse signs are pallor, sweating, cold clammy extremities, impaired consciousness,systolic < 90 mmHg, pulmonary oedema, raised jugular venous pressure.YESConsultseniorNOCardiovascular SystemOxygen and monitoring astachyarrhythmia (page 22)DCcardioversionMaintenance of sinus rhythmwith amiodaroneDeal with precipitants:• Infection• Alcohol• Hyperthyroidism• Heart FailurePerform Echo – Excludesmitral stenosis, givesstructural and functionalassessment of heart (e.g.whether LV systolicdysfunction /hypertrophy) i.e. helpsidentify need foranticoagulant.N.B. Investigation shouldnot delay treatment toslow the ventricular rateand reduce the risk ofthromboembolism.See AF guidelinepage 107 for guidance onanticoagulant.Consult seniorChemicalcardioversionIV amiodarone(see dose guidelinepage 111)Chemicalcardioversionfailed?Onset> 48hoursOnset< 48hoursAim for rate control (apex < 110 bpm)Digoxin for rapid control (if required)otherwiseBeta-blocker (bisoprolol) orCalcium channel antagonist (verapamil)See persistent AF guideline (next page)Consult senior atonce re urgentDC cardioversionPage 106