1. Daily Report John Feng, MD 07-08-2016

5. HPI: 60 YO M no pmhx 1 week of epigastric pain that is constant, worse with exertion, better with food, started after drinking 12 beers on 6/19 He developed SOB associated with the pain 3 days ago, it is described as "being unable to breathe when sleeping". No orthopnea, no LE swelling. He developed palpitations and dizziness on morning of admission and decided to come to the ER

6. History cont’d PMH: None NKDA Home Med: Aspirin Psx: none FH: DM SH: Lives with son. 4 beers week. 50 pack year smoking hx. No recreational drugs

7. Differential?

8. Objective VS on presentation: T 37.4 HR 172 RR 22 BP 163/100 SaO2 95%RA Exam notable for: JVP 7cm, bilateral crackles at lung bases heart sound irregularly irregular Mild TTP over epigastrum with some distension but no rebound or guarding. Negative murphy's sign. None to trace LE edema

9. Objective cont’d EKG

10. Objective cont’d Labs: Na 138 K 4.4 Cl 103 HCO3 24 BUN 18 Cr 0.98 Glc 173 Ca 9.1 Mg 2.0 WBC 9.9 Hgb 14.2 Hct 43.0 Plt 152 Trop 0.039 BNP 687.9 TSH 1.663 Utox neg U/A: trace ketones

12. Atrial Fibrillation

13. ER Course In the ER he was found to be in Afib RVR rates to 170s, given dilt 20mg IV x1 and bolused 1L NS. HR came down to 90s-110s with dilt IV, called out to medicine Night resident gave Lasix 20mg IV and hydral 25mg PO, Metoprolol 25mg PO 3 hours later, HR came back up to 160s  Metop 5mg IV pushed HR came down to 60s-90s Pt remained hypertensive throughout and continued to sat well on room air

14. Brief Hospital Course Cards consulted Coumadin 5mg PO daily started Pt was maximized on beta blockade, but despite this had runs of RVR to 150s Digoxin started on Hospital day 4, d/c’d hospital day 6 due to bradycardia TEE with cardioversion performed 7/7/16

15. Acute Management of Afib RVR First, assess pt’s stability– i. e. is pt hypotensive, mental status abnormal, severe CHF If unstable, rhythm control through cardioversion immediately Stable patients– how fast is RVR? Does it need rate control? Address underlying etiology 4 Classes of rate control agents: Beta blockers Calcium Channel blockers Digoxin Amiodarone

16. Pros and Cons of Acute Rate Control Agents Beta blockers–Pros: mortality benefit in long term for CAD, CHF (coreg/metop XL). Cons: may decrease cardiac output which will worsen CHF. Hypotension. Bronchospasm. Calcium channel blockers–Pros: highly effective in short term. Cons: no mortality benefit in CHF in long term, worsens CHF in short term, hypotension, significant effect on SA node Digoxin– Pros: increased contractility, reduced ventricular rate Cons: Not as effective as BB or CCB. Toxicity in renal pts, elderly. Amiodarone– Pros: Unlikely to cause hypotension. Cons: long-term side effects (pulm, thyroid, skin); may cardiovert pt and cause hypotension or embolic event

17. Antiarrhythmics Typically initiated in pts who fail rate control, young, or symptomatic despite rate control Antiarrhythmics for Afib are Class IC or III IC– Flecainide, propafenone III– amiodarone, dronedarone, sotalol, dofetilide Pitfalls: dofetilide, sotalol, flecainide, propafenone should be avoided in pt with LVH (>1.5cm) CAD– avoid flecainide Sotalol, propafenone, flecainide should be avoided in heart failure Amiodarone’s long term toxicity

18. Anticoagulation If patient needs to be cardioverted and no TEE available  3 weeks of anticoagulation After cardioversion, 4 weeks of anticoagulation Chronic anticoagulation  CHA 2 DS 2 -VASc >= 2 To bridge or not to bridge? Non-valvular afib, no hx of thromboembolic CVA = no bridge. Acute stroke = no bridge. No bridging for NOACs

19. NOACs vs Warfarin Warfarin– INR 2.0-3.0 NOACs Dabigatran (Pradaxa) 150mg BID. Direct thrombin inhibitor. Stomach upset. Edoxaban (Savaysa) 60mg daily. Direct thrombin inhibitor. Rash. Transaminitis. Apixaban (Eliquis) 5mg BID. Factor 10a inhibitor. Nausea. Can be used in renal failure Rivaroxaban (Xarelto) 20mg daily. Factor 10a inhibitor. Back pain. Nausea

20. http://www.uptodate.com/contents/control-of-ventricular-rate-in- atrial-fibrillation-pharmacologic-therapy http://www.uptodate.com/contents/control-of-ventricular-rate-in- atrial-fibrillation-pharmacologic-therapy http://www.uptodate.com/contents/antiarrhythmic-drugs-to- maintain-sinus-rhythm-in-patients-with-atrial-fibrillation- recommendations http://www.uptodate.com/contents/antiarrhythmic-drugs-to- maintain-sinus-rhythm-in-patients-with-atrial-fibrillation- recommendations http://www.uptodate.com/contents/atrial-fibrillation-anticoagulant- therapy-to-prevent-embolization http://www.uptodate.com/contents/atrial-fibrillation-anticoagulant- therapy-to-prevent-embolization http://www.uptodate.com/contents/management-of-new-onset- atrial-fibrillation

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