Atrial Fibrillation with Rapid Ventricular Rate admission

Patients may come to ER with c/o palpitations or stroke or dizziness etc. Some of them may have new onset Afib and some of them already diagnosed before.


Cardioversion if unstable for tachyarrhythmia i.e. low BP or altered mental status. This is very rare in ER.

Routine labs, CXR, Cardiac enzymes


IV fluids help if patient is dehydrated which can cause AFib.


Cardizem 5-20mg iv bolus [or Metoprolol 5mg IV], a repeat dose may be needed in 15min and if not converted to sinus–>Cardizem iv drip starting with 5mg/hr [or Amiodarone bolus f/b drip if BP is low.] If HR is controlled or if rhythm gets converted to NSR, scheduled Metoprolol or Cardizem or other rate limiting drug can be restarted if patient was on it before.


Telemetry observation, may qualify for inpatient if patient has positive troponins indicating ischemia.

Continue Cardizem drip/Amiodarone drip if already started in ER, change to Cardizem PO or Beta blocker PO.

Continue IV Fluids if needed


Lipid panel


Cardiology evaluation-may do Cardioversion if AFib is less than 48hrs old and if not converting to NSR with medications and patient is low risk for stroke. But if more than 48hrs old and high risk for stroke, TEE can be done rule out LA/LV thrombus. If no LA thrombus is present, cardiology may do Cardioversion/CV.

All cases do not need CV as long as rate is well controlled. Only a few selected symptomatic and persistent tachy patients need CV.

If patient is on Amiodarone, watch for Liver, thyroid dysfunction. Pulmonary toxicity can also occur. They don’t show up immediately but need to be monitored for after discharge.

If patient is started on Sotalol, patient’s QT should be monitored for 48hrs before discharging the patient. This will qualify for inpatient status.

AV nodal ablation or permanent pacemaker is placed for some with Tachy-Brady syndrome.  

Full dose anticoagulation  if CHADS2 score =/>2(Heparin plus coumadin, or SQ lovenox plus coumadin or Eliquis.

ASA 81 or 325mg PO daily if score is 0 or 1, Anticoagulation for Score of 2 or more.

Some Theory:

CHADSVASc Score   Annual Stroke Risk

0              1.9%

1             2.8%

2            4.0%

3            5.9%

4            8.5%

5            12.5%

6            18.2%

CHADSVASc Score: For Anticoagulation in AFib. 



2-A2-Age >75 yrs

1-D-Diabetes Mellitus

2-S2-Stroke or TIA

1-V-Vascular Disease(Peripheral Arterial Disease, Previous MI, Aortic atheroma)

1-A-Age 65-74 yrs

1-Sc-Sec Category(Female)

Calculate HAS-BLED score to look for chances of bleeding prior to starting anticoagulation.

Earn CME from UpToDate: Overview of atrial fibrillation