AFib with RVR

  • Hx of a fib
  • Denies feeling of palpitations.
  • Denies chest pain
  • Denies shortness of breath
  • Denies any recent stimulants, caffeine, illicit medications.
  • States is admherent to rate control medications.
  • On anticoagulation
  • Suspect atrial fibrillation with RVR.
  • Stability:
    • Upon arrival in the emergency department, patient was evaluated for stability.
    • Patient is stable by virtue of:
    • Sufficient blood pressure,
    • Normal mentation/no encephalopathy
    • No chest pain thought to be secondary to ischemia
    • No shortness of breath
  • ED Course:
    • Upon arrival in the emergency department, an EKG was obtained emergently. EKG, as described above revealed atrial tachycardia with rapid ventricular response.
    • Given patient is stable with atrial fibrillation with tachycardia will elect for pharmacologic rate control.
  • Diagnostically:
    • CBC to evaluate for significant anemia
    • BMP to evaluate for electrolyte derangements
    • Magnesium and phosphorus
    • Chest x-ray
  • Therapeutically:
    • diltiazem 20 mg IV under my direct observation.
    • Subsequent to that patient had continued atrial tachycardia dose refractory to initial management.
    • dilatiazem 20mg IV (2nd dose)
    • To prevent recurrence of RVR, 
      • Diltiazem drip at 5 mg per hour initiated emergently with titration goals of heart rates to 110s with hold parameters for hypotension.
      • Diltiazem 60mg PO given. 
  • Evaluated for precipitant of atrial fibrillation with RVR:
    • Unlikely medication noncompliance given patient states he is compliant with his medications for rate control.
    • Unlikely electrolyte derangements given electrolytes evaluated which were nonremarkable.
    • Unlikely infectious precipitant given on review of systems and examination, there is no obvious infectious cause.
    • Unlikely ischemic event precipitant given history not typical for myocardial ischemia and negative troponin.

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