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					                         Tachycardia: Atrial Fibrillation and Flutter (Control of Rate and Rhythm) Table

                                                Control Rate                                         Control Rhythm

       Atrial                 Heart Function                    Impaired Heart            Duration <           Duration > 48°
fibrillation/flutter            Preserved                      EF <40% or CHF                48°                or Unknown

                                                                                                           Avoid nonemergent
                                                                                                           cardioversion unless
                                                                                                           anticoagulation or slot
                                                                                                           precautions are taken
                                                                                                           (see Note 3)

                                                                                         Consider:         Note 3:
                                                                                         DC                Conversion of AF to
                                                                                         cardioversion     NSR with drugs or
                                                                                                           shock may cause
                                                                                                           embolization of atrial
                       Note 1:
                                                                                                           thromi unless patient
                       If AF >48° duration, use
                                                                                         Use only 1 of     has adequate
                       agents with potential to
                                                                                         the following     anticoagualtion.
                       convert rhythm with extreme
                                                                                         agents (see       Use antiarrhythmic
                       caution in patients not
                                                                                         Note 2):          agents with extreme
                       receiving adequate
                                                                                         Amiodarone        caution if (AF >48°
                       anticoagulation because of
                                                                                         (IIa)             duration (see Note 3).
                       possible embolic
Normal Cardiac                                                                           Ibutilide (IIa)   or
                       complications.                  (Does not apply)
   Function                                                                              Flecainide        Delayed
                                                                                         (IIa)             cardioversion
                       Use only 1 of the following
                                                                                         Propafenone       Antiocagulation x 3
                       agents (see Note 2):
                                                                                         (IIa)             weeks at proper levels
                       Calcium channel blockers (I)
                                                                                         Procainamide      Cardioversion, then
                       ß-Blockers (I)
                                                                                         (IIa)             Anticoagulation x 4
                       For additional drugs that are
                                                                                         For additional    weeks more
                       IIb recommendations, see
                                                                                         drugs that are    or
                       Guidelines or ACLS text
                                                                                         Class IIb         Early cardioversion
                                                                                         recommendati      Begin IV heparin at
                                                                                         ons, see          once
                                                                                         Guidelines or     TEE to exclude atrial
                                                                                         ACLS text         clot
                                                                                                           Cardioversion within
                                                                                                           Antocoagulation x 4
                                                                                                           more weeks

                                                       Note 1:                           Consider          Avoid nonemergent
                                                       If AF >48° duration, use                            cardioversion unless
                                                       agents with potential to          DC                anticagulation or clot
 Impaired Heart
                       (Does not apply)                convert rhythm with extreme       cardioversion     precautions are taken
(EV <40% or CHF)
                                                       caution in patients not                             (see Note 3)
                                                       receiving adequate                or
                                                       anticoagulation because of                          Anticagulation as
                                                       possible embolic                 Amiodarone       described above,
                                                       complications.                   (IIb)            followed by
                                                       Use only 1 of the following
                                                       agents (see Note 2):                              DC cardioversion
                                                       Digoxin (IIb)
                                                       Diltiazem (IIb)
                                                       Amiodarone (IIb)

                                                                                        ic agents
                      Note 1:                                                           Use only 1 of
                      If AF >48° duration, use                                          the following
                      agents with potential to                                          agents (see
                      convert rhythm with extreme                                       Note 2):
                      caution in patients not                                           Amiodarone
                      receiving adequate                                                (IIa)
                      anticoagulation because of                                        Flecainide
                      possible embolic                 Note 1:                          (IIa)
                      complications.                   If AF >48° duration, use         Propafenone      Avoid nonemergent
                      or                               agents with potential to         (IIa)            cardioversion unless
                      Primary antiarrhythmic agents    convert rhythm with extreme      Procainamide     anticagulation or clot
                      Use only 1 of the following      caution in patients not          (IIa)            precautions are taken
                      agents (see Note 2):             receiving adequate               Solotol (IIb)    (see Note 3)
                      Amiodarone (IIb)                 anticoagulation because of
                      Flecainide (IIb)                 possible embolic                                  Antocoagulation as
                      Procainamide (IIb)               complications.                   Class III (can   described above,
                      Propafenone (IIb)                ~ DC cardioversion               be harmful)      followed by
                      Sotalol (IIb)                    or                               ~ Adenosine      DC cardioversion
                                                       ~ Amiodarone (IIb)               ~ ß-Blockers
                                                                                        ~ Calcium
                      Class III (can be harmful)                                        ~ Digoxin
                      ~ Adenosine
                      ~ ß-Blockers
                      ~ Calcium blockers                                                Impaired
                      ~ Digoxin                                                         heart (EF
                                                                                        <40% or
                                                                                        ~ DC
                                                                                        ~ Amiodarone

   WPW indicates Wolff-Parkinson-White syndrome; AF, atrial fibrillation; NSR, normal sinus rhythm; TEE transesophageal
                                      echocardiogram; and EF, ejection fraction.

    Note 2: Occasionally 2 of the named antiarrhythmic agents may be used, but use of these agents in combination may have
proarrhythmic potential. The classes listed represent the Class of Recommendation rather than the Vaughn-Williams classification
                                                         of antiarrhythmics.

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