What are the recommended treatments for AFib

Summary
Introduction: In the emergency treatment of cardiac arrhythmias, different, sometimes life-saving therapy strategies must be adopted quickly. A distinction is made between the acute treatment of bradycardia with atropine or catecholamine administration and temporary pacemaker stimulation from the treatment of tachycardiac arrhythmias. Methods: The review article is based on the current therapy recommendations of the European Resuscitation Council from 2005, the guidelines published in 2003 by the American College of Cardiology, the American Heart Association and the European Society for Cardiology for the treatment of supraventricular arrhythmias, as well as a selective selection of the literature by the authors. Discussion: In tachycardiac arrhythmias, the question of hemodynamic stability is crucial. In the case of hemodynamically unstable tachycardias, an early termination usually has to be achieved by means of external defibrillation or cardioversion. The hemodynamically tolerated tachycardia is usually treated with medication, depending on the QRS width, either in the sense of ventricular tachycardia or supraventricular tachycardia.
Dtsch Arztebl 2007; 104 (17): A 1172-80.
Key words: cardiac arrhythmias, emergency therapy, antiarrhythmics, cardioversion


Summary
The emergency management of cardiac arrhythmia
Introduction: The treatment of acute arrhythmias requires quick and straight forward treatment. The treatment of bradyarrhythmias, using atropine, catecholamines or electrical stimulation of the heart by means of a pacemaker, must be distinguished from the treatment of tachyarrhythmias. Methods: Review based on the 2005 recommendations of the European Resuscitation Council, the 2003 Guideline of the American College of Cardiology, the American Heart Association and the European Society of Cardiology on the treatment of supraventricular arrhythmias, and a selective literature review. Discussion: Hemodynamic stability is the key determinant for the differential treatment of tachyarrhythmias. In a hemodynamically unstable patient, immediate cardioversion or defibrillation is indicated, whereas in the hemodynamically stable patient, drug treatment is the first line treatment in terminating supraventricular and ventricular tachycardia.
Dtsch Arztebl 2007; 104 (17): A 1172-80.
Key words: cardiac arrhythmias, acute treatment, antiarrhythmic drugs, cardioversion


The emergency treatment of cardiac arrhythmias places high demands on the therapist. In a short period of time, strategic decisions and concrete measures must be initiated and implemented in sometimes life-threatening situations. It is therefore important to have a basic understanding of the various causes of cardiac arrhythmias and the measures to be taken in an emergency.
Acute antiarrhythmic therapy differentiates between medicinal and electrotherapeutic measures. Electrotherapy includes:
- external defibrillation or R-wave synchronized cardioversion
- Antitachycardia stimulation, for example to terminate ventricular tachycardias or atrial flutter, as well
- Antibradycardiac stimulation, usually in the form of temporary transvenous or transcutaneous pacemaker therapy as part of acute therapy.
In the case of hemodynamically unstable tachycardias, the focus is not on differentiated ECG diagnostics and arrhythmia-specific therapy, but rather on the alignment of treatment measures according to criteria that are as simple as possible and that can be reliably identified under time pressure. The treatment of hemodynamically stable tachycardias is the domain of antiarrhythmic drug therapy (Table) (1).
In the following, practically relevant therapy algorithms such as the different treatment for bradycardia or tachycardia arrhythmias or for hemodynamically stable or unstable tachycardias are presented.
The therapy recommendations are based, on the one hand, on the authors' many years of clinical experience, on the other hand, are the current therapy recommendations of the European Resuscitation Council from 2005 and the guidelines published in 2003 by the American College of Cardiology, the American Heart Association and the European Society for Cardiology for the treatment of supraventricular arrhythmias considered. In contrast to the usual practice, in the emergency treatment of cardiac arrhythmias it is often not possible to state recognized levels of recommendation and evidence: the majority of the recommended measures are based on expert consensus and at most a few small, mostly non-prospective studies. Therefore, for example, the therapy recommendations of the European Resuscitation Council from 2005 completely dispense with the specification of the “level of evidence”, for example.
Since the present work is intended to be a summary of the existing recommendations and is not itself an official guideline, the authors have decided not to assign recommendation and evidence levels independently. Those therapy recommendations that are based on adequate data were provided with a corresponding note.
Emergency treatment of bradycardiac arrhythmias
One speaks of a bradycardiac arrhythmia when there is an effective ventricular rate of < 60/min.="" für="" die="" notfallbehandlung="" der="" bradykarden="" herzrhythmusstörungen="" werden="" üblicherweise="" frequenzen="" von="">< 40/min="" relevant.="" die="" akuität="" und="" das="" ausmaß="" der="" therapie="" bradykarder="" arrhythmien="" richtet="" sich="" in="" erster="" linie="" nach="" den="" hämodynamischen="" auswirkungen="" der="" bradykardie="" und="" der="" begleitenden="" symptomatik.="" eine="" erkennbare="" ursache="" muss,="" soweit="" in="" der="" akutsituation="" möglich,="" behoben="" werden,="" zum="" beispiel="" eine="" elektrolytentgleisung,="" ein="" starker="" vagusreiz,="" eine="" perikardtamponade="" oder="" eine="" myokardischämie.="" bei="" ausgeprägter="" bradykardie="" oder="" asystolie="" mit="" bewusstseinsverlust="" sind="" unverzüglich="" reanimationsmaßnahmen="" einzuleiten="" (2,="" 3).="" bis="" eine="" passagere="" schrittmacherstimulation="" zur="" verfügung="" steht,="" sollten="" möglichst="" zeitgleich="" zu="" beginn="" der="" reanimationsmaßnahmen="" atropin="" oder="" katecholamine="" verabreicht="">
In severe, symptomatic but hemodynamically compensated bradycardias, atropine is the primary treatment. However, a prerequisite is the exclusion of an infra-secondary AV block. An infra-hemisphere AV block is the localization of the conduction disorder below the bundle of His bundle. The distinguishing feature is the substitute rhythm with broad complexes or lack of PQ lengthening before failure of the nodal conduction in the case of AV block II. Secondary, catecholamines should be used in severe symptomatic but hemodynamically compensated bradycardias. If bradycardia persists, temporary pacemaker therapy must be used (Figure 1) (4, 5).
Atropine - The indications for the administration of the parasympatholytic atropine are vagally mediated sinus bradycardia and asystole as well as suprahisar AV block. Atropine can be administered at a dose of 0.5 to 1.0 mg every 2 to 5 minutes up to a maximum dose of 0.04 mg / kg. This corresponds to a dose of around 3 mg for a 70 kg patient. If there is no venous access, endotracheal administration via a tube is also possible (2 to 3 times the IV dose in 10 to 20 mL physiological saline solution). If there are indications of an infra-strict conduction block in the ECG (AV block II degree, Mobitz type, or AV block III degree with an alternate rhythm with a widened QRS complex), paradoxical bradycardization with atropine can occur, so that primarily catecholamines should be used here or, better, rapid anti-bradycardia stimulation should be initiated.
Catecholamines: orciprenaline and adrenaline - The primary use of catecholamines, such as orciprenaline or adrenaline, is recommended if there is no or insufficient increase in frequency after atropine administration or if asystole initially requires resuscitation (2).
The temporary pacemaker therapy is the first choice for bradycardic arrhythmias that require catecholamine and should be carried out promptly. Bolus doses are mainly used in acute therapy for bradycardic arrhythmias requiring catecholamine: Orciprenaline i.v. 0.25 to 0.5 mg or / and IV adrenaline 0.02 to 0.1 mg (with endotracheal application: 2 to 3 times the IV dose in 10 to 20 mL physiological saline solution).
The box shows a selection of the indications for temporary pacemaker therapy - according to the guidelines of the German Society for Cardiology (5).
Emergency treatment for tachycardiac arrhythmias
Heart rates> 100 / min are referred to as tachycardia, and a symptomatically or hemodynamically relevant emergency situation can generally only be assumed from frequencies of 150 / min. The distinction between hemodynamically stable and unstable tachycardias is crucial for the approach in acute situations (Figure 2). In the case of hemodynamically unstable tachycardias that are associated with shock symptoms, impaired consciousness or congested lung, rapid cardioversion and / or defibrillation must be carried out. Hemodynamically unstable tachycardias with a narrow QRS complex, for example on the basis of atrial fibrillation or atrial flutter, usually respond to low defibrillation energies of 50 or 100 joules. Polymorphic ventricular tachycardias or ventricular fibrillation, on the other hand, should primarily be defibrillated with at least 200 to 300 joules. In the event of inefficiency, further defibrillations are carried out with maximum energy (360 joules). The non-terminable ventricular fibrillation or ventricular flutter is treated in addition to the usual resuscitation measures with intravenous amiodarone administration (150 to 300 mg IV) ([6] recommendation is backed up by data from a prospective randomized study). If defibrillation or cardioversion is necessary in patients with unstable hemodynamics and who are still conscious due to the clinical symptoms, sedative (e.g. midazolam) or analgesic premedication (e.g. morphine derivatives) should be used. However, analgesic sedation measures can only be taken if they are available quickly. Their intensity must be adapted to the hemodynamic and respiratory status of the patient. If the patient is still conscious, external cardioversion can be preceded by a brief attempt at intravenous administration of a specific antiarrhythmic such as amiodarone (7).
The therapy of hemodynamically stable tachycardia is the domain of drug treatment. Generally, however, a 12-lead ECG should be recorded in hemodynamically stable patients. The information obtained from this ECG leads to the tachycardia classification (Figure 3), which is the basis for differential therapy, which is mostly drug-based. The QRS width is used as a decision criterion for a presumed supraventricular or ventricular tachycardial jump: In tachycardias with a narrow QRS complex, it is assumed that a QRS width < 120="" ms="" aufgrund="" der="" physiologischen="" antegraden="" nutzung="" des="" his-purkinje-systems="" entsteht="" und="" damit="" beweisend="" für="" einen="" oberhalb="" des="" his-bündels="" gelegenen="" supraventrikulären="" ursprung="" der="" tachykardie="">
All tachycardias in which there is supraventricular tachycardia or antegrade use of the His-Purkinje system due to a fascicle block or an antegrade conduction via the accessory pathway in Wolff-Parkinson-White syndrome (WPW syndrome) are excluded from this rule a broad QRS complex is created.
In the case of tachycardias with a broad QRS complex, with the following exceptions, tachycardia development at the ventricular level can be assumed:
- In acute therapy of atrial fibrillation / atrial flutter (QRS width < 120="" ms;="" unregelmäßiger="" rr-abstand)="" unterscheidet="" man="" die="" frequenzkontrolle="" mit="" av-nodal="" leitungsverzögernden="" substanzen,="" wie="" verapamil,="" digitalisglykosiden="" oder="" b-blocker="" von="" der="" kardioversion="" (grafik="" 3="" und="" 4).="" die="" akute="" kardioversion="" sollte="" nur="" dann="" durchgeführt="" werden,="" wenn="" das="" vorhofflimmern="" entweder="" mit="" sicherheit="" kürzer="" als="" 48="" h="" vorlag="" oder="" aber="" eine="" intraatriale="" thrombusbildung="" mihilfe="" einer="" transösophagealen="" echokardiographie="" ausgeschlossen="" wurde.="" in="" allen="" anderen="" fällen="" ist="" eine="" frequenznormalisierung="" anzustreben,="" um="" eine="" elektive="" kardioversion="" zu="">
- "Narrow complex" regular tachycardias (QRS < 120="" ms)="" werden="" primär="" einem="" vagalen="" manöver="" (wie="" carotismassage="" oder="" valsalva-pressversuch)="" unterzogen="" (8).="" bei="" ausbleibender="" terminierung="" der="" tachykardie="" erfolgt="" die="" rasche="" bolusapplikation="" von="" adenosin="" (initial="" 6="" mg,="" bis="" auf="" 12="" oder="" 18="" mg="" bolusgaben="" steigerbar="" [9]).="" bei="" einer="" dosis="" von="" 12="" bis="" 18="" mg="" adenosin="" kann="" in="" 90="" bis="" 95="" %="" der="" fälle="" eine="" terminierung="" erzielt="" werden,="" sofern="" es="" sich="" nicht="" um="" vorhofflimmern="" oder="" vorhofflattern="" handelt.="" alternativ="" oder="" bei="" ineffizienz="" des="" adenosin="" kommen="" calciumantagonisten="" oder="" betablocker="" zur="" anwendung="" (verapamil="" i.v.:="" unter="" blutdruckkontrolle="" werden="" langsam="" 2,5="" bis="" 5="" mg="" i.v.="" appliziert;="" mit="" einer="" zweiten="" applikation="" von="" 5="" bis="" 10="" mg="" sollten="" insgesamt="" 20="" mg="" verapamil="" nicht="" überschritten="" werden).="" falls="" trotz="" dieser="" maßnahmen="" keine="" terminierung="" eintreten="" sollte,="" ist="" bei="" stabilen="" hämodynamischen="" und="" respiratorischen="" verhältnissen="" der="" versuch="" einer="" spezifischen="" antiarrhythmikagabe="" angezeigt,="" zum="" beispiel="" flecainid="" i.v.,="" propafenon="" i.v.,="" ajmalin="" i.v.="" oder="" disopyramid="">
It should be noted that the use of ajmaline corresponds to the clinical experience of the authors, the data available from smaller prospective studies and common practice in Germany and is not part of the recommendations of the European Resuscitation Council. Another reason for this may be that most IV formulations of class IC antiarrhythmics are not approved in the USA. If this is unsuccessful, an electrical cardioversion must be used under analgesic sedation.
- The broad complex (QRS) 120 ms) tachycardia is either of ventricular origin, which applies to about 80% of acute tachycardias with a broad QRS complex, or it is based on a supraventricular tachycardia with aberrant conduction. It is rarely the result of atrial fibrillation, atrial flutter or atrial tachycardia with accessory conduction in Wolff-Parkinson-White syndrome.
The authors' experience shows that most errors are made in the treatment of initially hemodynamically tolerated tachycardia with broad QRS complexes. An overinterpretation of the ECG, such as the assumption of a functional bundle branch block with actual ventricular tachycardia or the wrong formula of “stable hemodynamics with low symptoms and broad QRS tachycardia = supraventricular tachycardia with bundle branch block” are usually the starting point. Rather, any broad complex tachycardia should be viewed as ventricular tachycardia until proven otherwise. Nevertheless, in individual cases with stable hemodynamics and suspicion of a supraventricular origin, an initial IV adenosine bolus application can be carried out for diagnostic reasons, even with broad QRS tachycardia (8).
The therapy recommended by the authors for hemodynamically tolerated regular tachycardia with a broad QRS complex is shown in Figure 3. In monomorphic regular ventricular tachyardy, in addition to amiodarone i.v. alternatively also ajmaline i.v. can be used (7, 10). It should be noted that the use of ajmaline corresponds to the authors' own clinical experience, the data available from smaller prospective studies and standard practice in Germany. Here, too, the application is not part of the recommendations of the European Resuscitation Council. The reason for this may also be that most IV formulations of class IC antiarrhythmics are not approved in the USA.
One of the advantages of Ajmaline administration in broadly complex tachycardia with an unspecified tachycardia mechanism is that, in most cases, ajmaline can be used to terminate the tachycardia or at least reduce the frequency significantly, even in supraventricular tachycardias with bundle branch block. In addition, ajmaline is an alternative for atrial fibrillation with rapid accessory conduction in Wolff-Parkinson-White syndrome ([11] recommendation confirmed by smaller, but prospective, randomized studies; not part of the guidelines). It should be noted that IV administration of adenosine, verapamil and digitalis is contraindicated. The reason for this is, among other things, an acceleration of the accessory atrioventricular conduction by shortening the antegrade refractory period of the accessory fiber with a simultaneous inhibition of the AV-nodal conduction capacity.
If there is an acute infarction or if an ischemic tachycardia is suspected, in addition to amiodarone - based on the authors' clinical experience - the administration of lidocaine (100–150 mg IV) is also possible. Other specific antiarrhythmics such as sotalol, flecainide or propafenone only play a subordinate role in the acute treatment of ventricular tachycardia, for example as reserve substances in intensive therapy.
In the case of polymorphic ventricular tachycardias, the detection of "torsades de pointes" - tachycardias in the context of a congenital or acquired QT prolongation is of great importance (3). This form of polymorphic ventricular tachycardia is not based on a stable circular excitation phenomenon, but is an expression of multiple focal discharges, which lead to clearly changing frequencies and the typical picture of "peak reverse tachycardia" or "torsades de pointes". In
In this case, repolarization-prolonging antiarrhythmics such as sotalol or ajmaline are prohibited. Rather, the therapy is based on a high dose of magnesium (1 to 2 g IV) and the use of beta blockers or catecholamines, lidocaine and electrotherapeutic measures (overstimulation).
In the case of polymorphic ventricular tachycardias, which are not the result of prolonged repolarization but occur, for example, in the context of ischemic or dilated heart disease, intravenous administration of amiodarone (150-300 mg iv) is an effective treatment option. the treatment of cardiac ischemia and the exclusion of a drug-toxic effect.
As with monomorphic ventricular tachycardia, administration of intravenous lidocaine is also advisable for polymorphic ventricular tachycardias that are not the result of prolongation of repolarization. as well as beta blockers possible.
Conclusion
The therapy algorithms presented make it possible to quickly adopt the right strategy in the emergency treatment of cardiac arrhythmias. The pioneering criteria are the hemodynamic stability under tachycardiac conditions and the QRS width as a marker of a presumed ventricular or supraventricular development.



Conflict of interest
The authors declare that there is no conflict of interest within the meaning of the guidelines of the International Committee of Medical Journal Editors.

Manuscript dates
Taken in: March 8, 2006, revised version accepted: January 29, 2007
Address for the authors
PD. Dr. med. Thorsten Lewalter
Medical Clinic and Polyclinic II
University Hospital Bonn
Sigmund-Freud-Strasse 25
53105 Bonn
Email: [email protected]





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Lewalter T, Lüderitz B: Drug therapy for cardiac arrhythmias. Internist 2000; 41: 22-33. MEDLINE
Hazinski MF, Cummins RO, Field JM: Handbook of emergency cardiovascular care for healthcare providers. Guidelines CPR, ECC. American Heart Association, 2005.
European Resuscitation Council Guidelines for Resuscitation 2005. Resuscitation 2005; 67: 39-86. MEDLINE
Lüderitz B: cardiac arrhythmias. 5th edition, Berlin, Heidelberg, New York: Springer 1998; 236-82.
Lemke B, Nowak B, Pfeiffer D: guidelines for pacemaker therapy. Indications, choice of system, follow-up care. Z Kardiol 2005; 94: 704-20. MEDLINE
Kudenchuk PJ, Cobb LA, Copass MK et al .: Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med 1999; 341: 871-8. MEDLINE
Jung W, Lüderitz B: Recommendations for preclinical emergency medicine. Internist 1998; 39: 142-51.
AHA / ACC / ESC Guidelines for the management of patients with supraventricular arrhythmias - Executive Summary. Circulation 2003; 108: 1871-1909.
Camm AJ, Garratt CJ: Adenosine and supraventricular tachycardia. N Engl J Med 1991; 325: 1621-9. MEDLINE
Manz M, Mletzko R, Jung W, Lüderitz B: Electrophysiological and hemodynamic effects of lidocaine and ajmaline in the management of sustained ventricular tachycardia. Eur Heart J 1992; 13: 1123-8. MEDLINE
Chen X, Borggrefe M, Martinez-Rubio A, Hief C, Haverkamp W, Hindricks G, Breithardt G: Efficacy of ajmaline and propafenone in patients with accessory pathways: a prospective randomized study. J Cardiovasc Pharmacol 1994; 24: 664-9. MEDLINE
1. Lewalter T, Lüderitz B: Drug therapy for cardiac arrhythmias. Internist 2000; 41: 22-33. MEDLINE
2. Hazinski MF, Cummins RO, Field JM: Handbook of emergency cardiovascular care for healthcare providers. Guidelines CPR, ECC. American Heart Association, 2005.
3. European Resuscitation Council Guidelines for Resuscitation 2005. Resuscitation 2005; 67: 39-86. MEDLINE
4. Lüderitz B: cardiac arrhythmias. 5th edition, Berlin, Heidelberg, New York: Springer 1998; 236-82.
5. Lemke B, Nowak B, Pfeiffer D: guidelines for pacemaker therapy. Indications, choice of system, follow-up care. Z Kardiol 2005; 94: 704-20. MEDLINE
6. Kudenchuk PJ, Cobb LA, Copass MK et al .: Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med 1999; 341: 871-8. MEDLINE
7. Jung W, Lüderitz B: Recommendations for preclinical emergency medicine. Internist 1998; 39: 142-51.
8. AHA / ACC / ESC Guidelines for the Management of Patients with Supraventricular Arrhythmias - Executive Summary. Circulation 2003; 108: 1871-1909.
9. Camm AJ, Garratt CJ: Adenosine and supraventricular tachycardia. N Engl J Med 1991; 325: 1621-9. MEDLINE
10. Manz M, Mletzko R, Jung W, Lüderitz B: Electrophysiological and hemodynamic effects of lidocaine and ajmaline in the management of sustained ventricular tachycardia. Eur Heart J 1992; 13: 1123-8. MEDLINE
11. Chen X, Borggrefe M, Martinez-Rubio A, Hief C, Haverkamp W, Hindricks G, Breithardt G: Efficacy of ajmaline and propafenone in patients with accessory pathways: a prospective randomized study. J Cardiovasc Pharmacol 1994; 24: 664-9. MEDLINE
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