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Symptom
dx.
Clinical Reference
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Clinical calculators
Practical Skills
ECG
Interpretation guide
POCUS
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Atrial Fibrillation (RVR)
Cardiovascular Presentations
Abdominal aortic aneurysm
Acute coronary syndrome (NSTEMI)
Acute coronary syndrome (STEMI)
Acute decompensated heart failure
Acute limb ischemia
Acute mesenteric ischemia
Aortic dissection
Aortic stenosis
Atrial fibrillation and flutter
Bradyarrhythmia and heart block
Cardiac arrest
Deep vein thrombosis
Myocarditis
Pericarditis
Pulmonary embolism
Stable angina
Superficial thrombophlebitis
Superior vena cava syndrome
Supraventricular tachycardia
Syncope (cardiogenic)
Unstable angina
Ventricular tachycardia
Respiratory Presentations
Acute bronchitis
Acute respiratory failure
Aspiration pneumonia
Asthma exacerbation
Bronchiolitis
Community-acquired pneumonia
COVID-19 pneumonia
COPD exacerbation
Croup
Croup (laryngotracheobronchitis)
Epiglottitis
Hemothorax
Hospital-acquired pneumonia
Pleural effusion
Pneumothorax (traumatic)
Pulmonary contusion
Spontaneous pneumothorax
Neurological Presentations
Bell's palsy
Benign paroxysmal positional vertigo
Brain abscess
Cauda equina syndrome
Cervical radiculopathy
Concussion (mild traumatic brain injury)
Encephalitis
Guillain-Barré syndrome
Hemorrhagic stroke (intracerebral)
Ischemic stroke
Lumbar radiculopathy
Malignant spinal cord compression
Migraine
Peripheral neuropathy (acute)
Retropharyngeal abscess
Schizophrenia (acute exacerbation)
Seizure (breakthrough:known epilepsy)
Seizure (first-time)
Spinal cord injury
Status epilepticus
Subarachnoid hemorrhage
Tension headache
Transient ischemic attack
Traumatic brain injury (moderate-severe)
Vestibular neuritis
Viral meningitis
Gastrointestinal Presentations
Acute appendicitis
Acute cholecystitis
Acute diverticulitis
Acute pancreatitis
Anal fissure
Choledocholithiasis and cholangitis
Clostridioides difficile colitis
Gastritis
Gastroenteritis (viral and bacterial)
Gastroesophageal reflux disease
Incarcerated or strangulated hernia
Inflammatory bowel disease flare
Large bowel obstruction
Lower GI hemorrhage
Peptic ulcer disease
Perforated viscus
Small bowel obstruction
Upper GI hemorrhage
Genitourinary and Reproductive Presentations
Acute prostatitis
Acute urinary retention
Ectopic pregnancy
Epididymitis
Orchitis
Ovarian torsion
Paraphimosis
Pelvic inflammatory disease
Priapism
Pyelonephritis
Renal laceration
Ruptured ovarian cyst
Testicular torsion
Tubo-ovarian abscess
Urinary tract infection (uncomplicated)
Urolithiasis (renal colic)
Vaginal bleeding (non-pregnant)
Infectious Disease Presentations
Acute sinusitis
Acute tonsillitis
Acute upper respiratory infection
Animal bite
Bacterial meningitis
Cellulitis
Conjunctivitis (bacterial)
Dental abscess
Endocarditis
Febrile neutropenia
Fournier gangrene
Hand-foot-mouth disease
Hepatitis (acute)
Herpes zoster
HIV-related illness
Human bite
Impetigo
Infected diabetic foot ulcer
Infectious mononucleosis
Influenza
Necrotizing fasciitis
Osteomyelitis
Otitis externa
Parasitic infection
Periorbital cellulitis
Peritonsillar abscess
Scabies
Sepsis
Septic arthritis
Spontaneous bacterial peritonitis
Tick-borne illness (Lyme disease)
Tinea infection
Tuberculosis
Viral exanthem
Wound infection
Trauma Presentations
Achilles tendon rupture
ACL and mceniscus tear
Ankle fracture
Ankle sprain
Burn
Calcaneus fracture
Cervical spine fracture
Clavicle fracture
Dental avulsion
Distal radius fracture
Drowning
Elbow fracture and dislocation
Electrical injury
Facial bone fracture
Facial laceration
Femur fracture
Fingertip amputation
Forearm fracture (radius and ulna)
Frostbite
Hand:finger laceration
Heat exhaustion
Heat stroke
Hip fracture
Humeral shaft fracture
Knee dislocation
Knee sprain
Lightning injury
Mandible fracture
Metacarpal fracture
Metatarsal fracture
Muscle strain
Nasal fracture
Non-accidental trauma
Orbital fracture
Patella fracture
Phalanx fracture (finger)
Proximal humerus fracture
Pulmonary contusion
Rib fracture
Rotator cuff tear (acute traumatic)
Scalp laceration
Scaphoid fracture
Shoulder dislocation
Skull fracture
Splenic laceration
Sternal fracture
Supracondylar pediatric fracture
Tendon laceration (hand:wrist)
Thoracic and lumbar spine fracture
Tibia:fibula fracture
Tibial plateau fracture
Toe fracture
Traumatic epistaxis
Traumatic hyphema
Toxicologic Presentations
Acetaminophen toxicity
Alcohol intoxication
Alcohol withdrawal
Anticholinergic toxicity
Anticoagulant overdose
Benzodiazepine overdose
Benzodiazepine:sedative overdose
Beta-blocker and calcium channel blocker toxicity
Carbon monoxide poisoning
Caustic ingestion
Digoxin toxicity
Drug eruption
Foreign body ingestion
Opioid intoxication
Opioid overdose
Opioid withdrawal
Organophosphate
Salicylate toxicity
Serotonin syndrome
Stimulant intoxication (cocaine, methamphetamine)
Tricyclic antidepressant overdose
Psychiatric Presentations
Acute anxiety
Acute psychosis
Agitation:behavioral emergency
Bipolar disorder
Conversion disorder
Major depressive episode
Neuroleptic malignant syndrome
Suicidal ideation and attempt
Musculoskeletal and Rheumatologic Presentations
Acute low back pain (mechanical)
Bursitis
Cervical radiculopathy
Costochondritis
Gout (acute)
Lumbar radiculopathy
Pseudogout
Tendinitis
Dermatology Presentations
Acute eczema (Eczema acute flare)
Allergic contact dermatitis
Erythema multiforme
Henoch-Schönlein purpura
Pressure injury
Psoriasis (acute flare)
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Urticaria (acute)
Environmental and Exposure Presentations
Envenomation (snake, spider, insect)
High-altitude illness
Hypothermia
Hematologic and Oncologic Presentations
Acute chest syndrome
Coagulopathy
Hyperviscosity syndrome
Sickle cell crisis (vaso-occlusive)
Symptomatic anemia
Thrombocytopenia (severe)
Tumor lysis syndrome
Pediatric-Specific Presentations
Bronchiolitis
Croup
Emergency delivery
Febrile seizure
Kawasaki disease
Neonatal jaundice
Neonatal sepsis
Nursemaid's elbow
Pediatric fever 0 to 28 days
Pediatric fever 29 to 60 days
Pediatric fever 61 to 90 days
Pyloric stenosis
Slipped capital femoral epiphysis
Intussusception
Endocrine and Metabolic Presentations
Adrenal crisis
Diabetic ketoacidosis
Hypercalcemia
Hyperosmolar hyperglycemic state
Hypertensive emergency
Hypertensive urgency
Hypoglycemia
Myasthenia gravis crisis
Myxedema coma
Severe hyperkalemia
Severe hyponatremia
Thyroid storm
ENT and Maxillofacial Presentations
Acute laryngitis
Acute otitis media
Acute pharyngitis
Cerumen impaction
Epistaxis (anterior)
Nasal foreign body
Otitis externa
Tympanic membrane perforation
Ophthalmologic Presentations
Acute angle-closure glaucoma
Central retinal artery occlusion
Chemical eye injury
Corneal abrasion
Corneal ulcer
Globe rupture
Ocular foreign body
Orbital cellulitis
Retinal detachment
Obstetric Presentations
Hyperemesis gravidarum
Painful vaginal bleeding in pregnancy
Placenta previa
Placental abruption
Preeclampsia:eclampsia
Preterm labor
Threatened:inevitable:incomplete abortion
Systemic and Miscellaneous Presentations
Anaphylaxis
Angioedema
Cannabis-induced hyperemesis
Atrial Fibrillation (RVR)
POCUS
Procedures
Calculators
Resuscitation
ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Hemodynamic instability branch
Immediate instability assessment
▶
Hypotension SBP <90 mmHg
▶
Altered mental status
Signs of end-organ hypoperfusion
Acute pulmonary edema
▶
Severe dyspnea and hypoxia
Crackles and elevated JVP
If hemodynamically unstable, immediate synchronized cardioversion
▶
Biphasic 120-200 J initial energy
Class I recommendation, AHA 2025
Do not delay for anticoagulation status
Pre-excited AF recognition
WPW danger pattern
▶
Wide-complex irregular tachycardia
▶
Rate often >200 bpm
Delta waves if sinus rhythm available
If pre-excited AF suspected, avoid AV nodal blockers
▶
Diltiazem, verapamil, beta-blockers, digoxin, IV amiodarone contraindicated
Risk of VF with AV nodal blockade
Procainamide or immediate cardioversion as preferred interventions
▶
Procainamide 15-17 mg/kg IV over 30-60 minutes
Expert consensus recommendation
Monitoring and stabilization
Monitoring bundle
▶
Continuous cardiac monitoring
▶
12-lead ECG immediately
Rhythm strip throughout
Continuous pulse oximetry
▶
SpO2 target >94%
Supplemental oxygen if hypoxic
IV access and blood pressure monitoring
▶
At least one large-bore IV
Non-invasive BP every 5-15 minutes
Immediate consult triggers
Escalation and consultation
▶
Cardiology for new-onset AF with reduced EF
▶
Refractory rate control
Rhythm control candidacy
Electrophysiology for suspected WPW
▶
Ablation candidacy assessment
Critical care for cardiogenic shock
▶
Vasopressor requirement
Invasive monitoring need
History
Onset and temporal features
Duration and timing
▶
Onset time precisely established
▶
Duration <48 hours critical for cardioversion and anticoagulation strategy
Duration >48 hours or unknown requires thrombus exclusion before cardioversion
New-onset vs recurrent paroxysmal episode
▶
Prior cardioversions
Known AF subtype: paroxysmal, persistent, long-standing persistent, permanent
Spontaneous termination pattern in prior episodes
▶
Average episode duration
Triggers for termination
Symptoms
Cardinal symptoms
▶
Palpitations prevalence 27-70% in AF
▶
Irregular vs rapid quality
Onset sudden or gradual
Dyspnea prevalence 28-76%
▶
Exertional vs rest
Orthopnea or PND suggesting HF
Fatigue prevalence 26-75%
▶
Exercise tolerance change
Baseline functional status
Chest pain prevalence 12-30%
▶
Ischemic quality vs pleuritic
Associated diaphoresis or radiation
Dizziness and presyncope prevalence 19-44%
▶
Syncope prevalence 3-4%
Neurologic deficit screen
Alarm features
Cannot-miss presentations
▶
Focal neurologic deficit
▶
Stroke or TIA as presenting event
Aphasia, facial droop, limb weakness
Hemodynamic compromise
▶
Syncope at onset
Near-syncope with exertion
Acute HF exacerbation
▶
Acute pulmonary edema symptoms
Rapid weight gain
Triggers and precipitants
Acute precipitants of RVR
▶
Sepsis or acute infection
▶
Fever and chills
Localizing infection symptoms
Pulmonary embolism
▶
Pleuritic chest pain
Hemoptysis
Alcohol binge
▶
Holiday heart phenomenon
Dose-dependent AF risk factor
Thyroid dysfunction
▶
Heat intolerance and weight loss
Tremor and hyperreflexia
Medication non-compliance
▶
Missed rate-control doses
Missed anticoagulation doses
Recent surgery
▶
Cardiothoracic surgery highest risk
Any major surgery risk
Risk factors
Modifiable cardiovascular risk factors
▶
Hypertension most common modifiable risk
▶
Medication compliance
Home blood pressure monitoring
Obesity
▶
BMI threshold association with AF burden
Weight loss >10% reduces AF recurrence
Obstructive sleep apnea
▶
Snoring and witnessed apneas
CPAP compliance
Excessive alcohol use
▶
Abstinence reduces recurrence
Caffeine not shown to increase AF risk
Non-modifiable risk factors
▶
Older age
▶
Prevalence increases markedly after age 65
Male sex association
Family history
▶
Heritable component established
Family history of AF, cardiomyopathy, sudden death
Past medical history
Cardiac history
▶
Heart failure subtype
▶
HFrEF vs HFpEF impacts drug selection
Prior LVEF measurements
Valvular disease
▶
Mitral stenosis impacts anticoagulant choice
Warfarin required for mechanical valves
Coronary artery disease
▶
Prior MI or revascularization
Antiplatelet agents already on board
Prior stroke or TIA
▶
Impacts CHA2DS2-VASc scoring
Urgency of anticoagulation initiation
Non-cardiac history
▶
Thyroid disease
▶
Hyperthyroidism as reversible cause
Prior treatment history
COPD or asthma
▶
Impacts beta-blocker use safety
Bronchospasm risk
Chronic kidney disease
▶
DOAC dosing adjustment threshold
Dialysis impacts anticoagulant choice
Bleeding history
▶
GI bleed or intracranial hemorrhage
HAS-BLED score inputs
Physical Exam
Vital signs
Hemodynamic profile
▶
Heart rate
▶
Typically 100-170 bpm in RVR
Rates >200 bpm suggest accessory pathway
Blood pressure
▶
SBP <90 mmHg triggers immediate action
Pulse pressure narrowing in low output state
Respiratory rate
▶
Tachypnea from HF or PE trigger
SpO2 room air value
Temperature
▶
Fever supports secondary AF trigger
Thyroid storm consideration if hyperpyrexia
Cardiac exam
Rhythm and auscultation
▶
Irregularly irregular rhythm
▶
Hallmark finding of AF
Pulse deficit: apical rate exceeds radial rate
Variable S1 intensity
▶
Due to varying ventricular filling time
Absence of S4 (atrial kick lost in AF)
Murmur assessment
▶
Mitral stenosis rumble at apex
Aortic stenosis systolic ejection murmur
Signs of heart failure
▶
Jugular venous pressure
▶
Elevated JVP in decompensated HF
Irregular venous pulsations
Absent a waves in AF
Peripheral edema
▶
Pitting edema severity grading
Sacral edema in bedridden patients
Pulmonary exam
Lung findings
▶
Crackles
▶
Bilateral basal crackles suggest pulmonary edema
Distinction from pneumonia consolidation
Wheeze
▶
COPD or asthma overlap affecting drug choice
Beta-blocker contraindication with severe wheeze
Thyroid and systemic exam
Thyroid assessment
▶
Goiter or nodule palpation
▶
Exophthalmos
Tremor and warm moist skin
Peripheral perfusion
▶
Cool mottled extremities in low output state
Capillary refill time
Neurologic screen
▶
Focal motor deficit
▶
Facial asymmetry
Grip strength asymmetry
Speech assessment
▶
Aphasia or dysarthria
New deficit mandates stroke pathway
PITFALLS
Common missed diagnoses
▶
Pre-excited AF misidentified as SVT or VT
▶
Wide irregular rhythm with rates >200 bpm is WPW until proven otherwise
AV nodal blockers can precipitate VF and death
Regular AF suggests AV block or junctional rhythm
▶
Digoxin toxicity consideration
Requires EP evaluation
ST changes misattributed to ACS
▶
Demand ischemia from tachycardia vs true ACS
Troponin trend essential
Differential Diagnosis
Life-threatening mimics
Cannot-miss diagnoses
▶
Pre-excited AF with WPW
▶
ICD-10 I45.6 pre-excitation syndrome
Wide irregular tachycardia >200 bpm
Ventricular tachycardia
▶
Wide complex regular or irregular rhythm
Hemodynamic compromise more common
Atrial flutter with variable block
▶
ICD-10 I48.3 typical atrial flutter
Sawtooth flutter waves 300 bpm
Ventricular rate often regularly irregular
Rhythm mimics
Irregular tachycardia differential
▶
Multifocal atrial tachycardia
▶
ICD-10 I47.1 supraventricular tachycardia
At least 3 distinct P-wave morphologies
Associated with COPD and hypoxia
Atrial tachycardia with variable block
▶
Identifiable P waves before QRS
Regular P-P intervals
Sinus tachycardia with frequent PACs
▶
P waves present and upright in II
Gradual rate fluctuation
Secondary AF triggers in differential
Underlying cause driving RVR
▶
Sepsis
▶
ICD-10 A41.9 sepsis unspecified
Fever, leukocytosis, lactate elevation
Pulmonary embolism
▶
ICD-10 I26.99 pulmonary embolism
Hypoxia disproportionate to infiltrate
Thyroid storm
▶
ICD-10 E05.90 hyperthyroidism
Burch-Wartofsky score >45 suggests storm
Acute heart failure exacerbation
▶
ICD-10 I50.9 heart failure unspecified
Elevated BNP, volume overload signs
Primary AF classification
AF subtypes by ICD-10
▶
Paroxysmal AF
▶
ICD-10 I48.0 paroxysmal atrial fibrillation
Terminates spontaneously within 7 days
Persistent AF
▶
ICD-10 I48.11 longstanding persistent AF
Duration >7 days
Permanent AF
▶
ICD-10 I48.21 permanent AF
Rhythm control no longer pursued
Laboratory Tests
Essential initial labs
Electrolytes and metabolic panel
▶
Potassium
▶
Hypokalemia promotes AF and proarrhythmia
Target K+ >4.0 mmol/l before antiarrhythmic use
Magnesium
▶
Hypomagnesemia synergistic with hypokalemia
IV magnesium 2 g is reasonable rate-control adjunct
Renal function
▶
eGFR impacts DOAC selection and dosing
Creatinine baseline for drug monitoring
Glucose
▶
Hypoglycemia as tachycardia trigger
Hyperglycemia in thyroid storm or sepsis
Thyroid and secondary cause screening
TSH
▶
Hyperthyroidism as reversible AF cause
▶
Free T4 if TSH suppressed
Thyroid storm scoring if clinical suspicion high
Recommended by 2023 ACC/AHA/ACCP/HRS guideline for all new AF
▶
Class I recommendation
Treatment of thyrotoxicosis may convert AF
Cardiac biomarkers
Troponin
▶
Demand ischemia from sustained tachycardia common
▶
Troponin rise without obstructive CAD
True ACS requires ECG correlation and trend
Reasonable in new AF to risk-stratify
▶
Not required in known paroxysmal AF at baseline
Elevated troponin supports admission
BNP or NT-proBNP
▶
Heart failure complication assessment
▶
Elevated BNP >500 pg/mL supports HF decompensation
Guides admission decision
Prognostic value in AF-associated HF
▶
Serial measurement in admitted patients
Hematologic and coagulation labs
Complete blood count
▶
Anemia
▶
Exacerbates tachycardia and ischemia
Impacts anticoagulation risk-benefit
Leukocytosis
▶
Infection as secondary trigger
Elevated WBC with fever supports sepsis workup
Coagulation studies
▶
INR if on warfarin
▶
Subtherapeutic INR and thromboembolic risk
Supratherapeutic INR and bleeding risk
Not routinely required before DOAC initiation
▶
Renal function sufficient for DOAC dosing decisions
Liver function and additional labs
Hepatic panel
▶
Liver function impacts anticoagulant metabolism
▶
Rivaroxaban and apixaban hepatic metabolism
Child-Pugh C cirrhosis limits DOAC use
Alcohol-related hepatopathy in binge-drinking patients
▶
AST:ALT ratio >2 supports alcoholic etiology
Diagnostic Tests
Scoring Systems
CHA2DS2-VASc stroke risk score
▶
Scoring components
▶
Congestive heart failure: 1 point
Hypertension: 1 point
Age >=75 years: 2 points
Diabetes mellitus: 1 point
Stroke or TIA prior: 2 points
Vascular disease: 1 point
Age 65-74 years: 1 point
Sex category female: 1 point
Anticoagulation thresholds
▶
Score >=2 in men: OAC recommended
Score >=3 in women: OAC recommended
Class I recommendation, 2023 ACC/AHA guideline
HAS-BLED bleeding risk score
▶
Bleeding risk components
▶
Hypertension uncontrolled SBP >160 mmHg: 1 point
Renal or liver dysfunction: 1-2 points
Stroke history: 1 point
Bleeding history or predisposition: 1 point
Labile INR if on warfarin: 1 point
Elderly age >65 years: 1 point
Drug or alcohol use: 1-2 points
Clinical use
▶
Score >=3 indicates high bleeding risk
High score prompts risk factor modification, not OAC withholding
ED disposition scoring tools
▶
RED-AF score
▶
Identifies low-risk ED AF patients for discharge
Variables include heart rate, comorbidities, prior AF
AFFORD and AFTER scores
▶
Validated tools for ED-to-discharge decisions
Should supplement, not replace, clinical judgment
ACEP Level C recommendation for score-assisted disposition
MRI
Cardiac MRI role in AF
▶
Limited acute utility for RVR management
▶
Availability and patient stability constraints
Time requirement incompatible with acute RVR
Elective indications
▶
Left atrial fibrosis quantification for ablation candidacy
Cardiomyopathy characterization when echo inconclusive
LA scar imaging to predict recurrence post-ablation
Contraindications
▶
Hemodynamically unstable patient
Non-MRI-compatible pacemakers or devices
Severe claustrophobia
CT
CT in AF with RVR workup
▶
CT pulmonary angiography
▶
When PE is suspected as secondary trigger
Wells score or clinical gestalt to guide decision
Sensitivity 83%, specificity 96% for PE
CT head
▶
New focal neurologic deficit requiring stroke pathway
Intracranial hemorrhage exclusion before thrombolytics
CT chest
▶
Not routinely indicated for AF evaluation
Pulmonary disease workup if indicated by clinical context
Contrast considerations
▶
Renal function before contrast administration
Allergy history and premedication planning
Ultrasound
Echocardiography
▶
Transthoracic echocardiography
▶
Recommended for all new-onset AF
LV and RV function assessment
Valvular disease identification
Left atrial size and pulmonary pressures
Class I recommendation, 2023 ACC/AHA guideline
Transesophageal echocardiography
▶
Thrombus exclusion before cardioversion
Indicated if AF duration >48 hours or unknown and not anticoagulated
Left atrial appendage thrombus exclusion
Sensitivity 95-100% for LAA thrombus
Point-of-care ultrasound
▶
Cardiac POCUS
▶
LV function gross estimate in acute setting
Pericardial effusion exclusion
RV strain pattern suggesting PE
IVC assessment
▶
Volume status estimation
IVC collapsibility limited by tachycardia and irregular rhythm
ACEP Level B recommendation for POCUS in undifferentiated tachycardia
Disposition
Admission indications
Inpatient admission criteria
▶
Hemodynamic instability requiring cardioversion
▶
SBP <90 mmHg despite rate control
Ongoing shock physiology
Refractory RVR despite adequate IV therapy
▶
Heart rate >110 bpm after two agents trialed
Ongoing IV infusion requirement
New-onset AF with significant comorbidity
▶
New AF with reduced EF (<40%)
ACS concurrent diagnosis
New stroke or TIA
Significant underlying trigger requiring inpatient management
▶
Sepsis or bacteremia
Pulmonary embolism requiring anticoagulation
Thyroid storm treatment
ICU level care
ICU indications
▶
Hemodynamic compromise requiring vasopressors
▶
Cardiogenic shock
Norepinephrine or dobutamine requirement
Rapid deterioration despite initial management
▶
Rising lactate
Worsening mental status
WPW with cardioversion requirement
▶
Continuous monitoring need
Arrhythmia recurrence risk
Observation unit
Observation criteria
▶
Rate-controlled AF awaiting echocardiography
▶
New AF stable but incomplete workup
Elective cardioversion planning
Conversion after ED intervention with monitoring needed
▶
Post-pharmacologic or electrical cardioversion observation
Minimum 4-hour monitoring post-cardioversion
Discharge criteria
Copy
Safe discharge requirements
▶
Heart rate controlled
▶
HR <110 bpm at rest
Hemodynamically stable
Oral medications tolerated
▶
Rate-control agent initiated and tolerated
Anticoagulation addressed and prescribed
Outpatient workup arranged
▶
TTE if not obtained in ED
Cardiology follow-up within 1-2 weeks
Known paroxysmal AF similar to prior episodes
▶
Reliable follow-up confirmed
Patient education completed
Disposition scoring tools as adjunct
▶
RED-AF, AFFORD, AFTER score support
ACEP Level C recommendation
Treatment
Hemodynamically unstable
Immediate cardioversion
▶
Synchronized DC cardioversion
▶
Biphasic energy 120-200 J initial
▶
Increase energy stepwise if first attempt fails
Up to 360 J monophasic equivalent
Sedation before cardioversion in conscious patient
▶
Propofol 0.5-1.5 mg/kg IV or midazolam 1-2 mg IV
Ketamine 1-2 mg/kg IV if hemodynamically compromised
Do not delay for anticoagulation status
▶
Class I recommendation AHA 2025
Thromboembolic risk from cardioversion acceptable vs hemodynamic compromise
Rate control — hemodynamically stable with preserved EF
Calcium channel blockers
▶
Diltiazem IV
▶
Bolus 0.25 mg/kg IV over 2 minutes
▶
Repeat bolus 0.35 mg/kg if inadequate response at 15 minutes
Infusion 5-10 mg/h maintenance
Contraindicated in EF <=40% or decompensated HF
▶
Class 3 Harm recommendation
Avoid in hypotension
Verapamil IV
▶
2.5-5 mg IV over 2 minutes
▶
Repeat doses up to 20 mg total
Avoid in HF with reduced EF or hypotension
Beta-blockers IV
▶
Metoprolol IV
▶
2.5-5 mg IV over 2 minutes
▶
Up to 3 doses at 5-minute intervals
Maximum 15 mg total
Avoid in decompensated HF and severe asthma
▶
Selective beta-1 blockade still has risks in severe reactive airway disease
Esmolol IV
▶
500 mcg/kg bolus over 1 minute
▶
Maintenance infusion 50-300 mcg/kg/min
Titrate by 25-50 mcg/kg/min every 5-15 minutes
Extremely short half-life 9 minutes
▶
Advantage for rapid dose adjustment
Avoid in decompensated HF
Rate control — reduced EF or decompensated HF
Amiodarone IV
▶
Dosing for rate control in HFrEF
▶
300 mg IV over 1 hour loading
▶
Maintenance 10-50 mg/h over 24 hours
Oral transition when rate controlled
Effective for both rate and rhythm control
▶
Use when other agents contraindicated
QT prolongation monitoring required
Digoxin IV
▶
Dosing
▶
0.25 mg IV, maximum 1.5 mg per 24 hours
▶
Slow onset 1-4 hours limits acute utility
Most useful as adjunct to other agents
Caution in renal impairment
▶
Dose reduction required eGFR <30 mL/min
Narrow therapeutic index
IV magnesium adjunct
▶
Magnesium sulfate 2 g IV over 10-20 minutes
▶
Reasonable adjunct to standard rate control
▶
Evidence from multiple small trials
May reduce ventricular rate when added to diltiazem or beta-blocker
Rhythm control — cardioversion
Timing and anticoagulation strategy
▶
AF duration <48 hours
▶
Cardioversion may proceed without TEE
▶
Anticoagulate before and continue 4 weeks post-conversion regardless of CHA2DS2-VASc
Heparin IV or LMWH bridge if DOAC not yet at therapeutic level
Electrical cardioversion success rate 92-96% for recent-onset AF
AF duration >48 hours or unknown
▶
TEE to exclude LAA thrombus before cardioversion
▶
Or therapeutic anticoagulation >=3 weeks before cardioversion
Followed by >=4 weeks anticoagulation post-conversion
Class I recommendation, ACC/AHA 2023 guideline
Pharmacologic cardioversion
▶
Flecainide or propafenone (pill-in-pocket strategy)
▶
Only if no structural heart disease
▶
Flecainide 200-300 mg PO single dose
Propafenone 450-600 mg PO single dose
Must have AV nodal blocking agent on board first
▶
Prevents 1:1 flutter conduction risk
IV ibutilide
▶
1 mg IV over 10 minutes
▶
Repeat if no conversion at 10 minutes
QT monitoring required for 4-6 hours post-dose
Torsades de pointes risk 1-4%
▶
Avoid if QTc >440 ms at baseline
Resuscitation equipment at bedside
Anticoagulation
DOAC initiation
▶
Apixaban
▶
5 mg PO twice daily standard dose
▶
Reduce to 2.5 mg twice daily if >=2: age >=80, weight <=60 kg, Cr >=133 umol/l
Class I recommendation for non-valvular AF
Rivaroxaban
▶
20 mg PO once daily with evening meal
▶
Reduce to 15 mg daily if CrCl 15-49 mL/min
Avoid if CrCl <15 mL/min
Dabigatran
▶
150 mg PO twice daily standard dose
▶
Reduce to 110 mg twice daily if age >=80 or high bleeding risk
Contraindicated if CrCl <30 mL/min
Edoxaban
▶
60 mg PO once daily
▶
Reduce to 30 mg if CrCl 15-50 mL/min, weight <=60 kg, or certain P-gp inhibitors
Warfarin indications
▶
Mechanical heart valves
▶
DOACs inferior to warfarin in this context
INR target 2.5-3.5 for most mechanical valves
Moderate-severe mitral stenosis
▶
Warfarin preferred over DOACs
INR target 2-3
Anticoagulation timing in ED
▶
Safe to initiate DOACs in ED
▶
Apixaban or rivaroxaban most commonly used
Evidence supports ED initiation is safe
Post-cardioversion anticoagulation minimum 4 weeks
▶
Regardless of CHA2DS2-VASc score
Stunning phenomenon risk despite sinus rhythm restoration
Rate control targets
Heart rate targets
▶
Lenient rate control target
▶
HR <110 bpm at rest acceptable per RACE II trial
▶
Non-inferior to strict control for most patients
Fewer medication side effects
Strict rate control target
▶
HR <80 bpm at rest if symptoms persist at 110 bpm
▶
HR <110 bpm during moderate exertion
Indicated when tachycardia-mediated cardiomyopathy suspected
Special Populations
Pregnancy
Pregnancy considerations in AF
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Physiologic changes affecting AF
▶
Increased plasma volume and cardiac output
▶
AF risk increased in structural heart disease
Peripartum cardiomyopathy associated AF
Hypercoagulable state of pregnancy
▶
Thromboembolism risk compounded by AF
Rate control options in pregnancy
▶
Metoprolol generally preferred beta-blocker
▶
Crosses placenta; IUGR monitoring recommended
Category C safety profile
Digoxin acceptable adjunct
▶
Crosses placenta; neonatal toxicity monitoring
Dose adjustment in third trimester
Diltiazem limited data; avoid in first trimester
▶
Use only when beta-blockers insufficient
Cardioversion in pregnancy
▶
Electrical cardioversion considered safe in all trimesters
▶
Fetal cardiac monitoring during procedure
Hemodynamic instability is absolute indication regardless of trimester
Anticoagulation in pregnancy
▶
DOACs contraindicated in pregnancy
▶
Fetal teratogenicity and bleeding risk
LMWH preferred for anticoagulation
▶
Enoxaparin 1 mg/kg SQ twice daily therapeutic dose
Anti-Xa monitoring for therapeutic range
Warfarin in second trimester acceptable in high-risk cases
▶
Warfarin embryopathy risk in first trimester
Avoid near delivery: switch to LMWH at 36 weeks
Geriatric
Older adult AF considerations
▶
Prevalence and disease burden
▶
AF prevalence approximately 10% in adults >80 years
▶
Leading cause of embolic stroke in elderly
Atypical presentation more common: fatigue, falls, confusion
Rate control cautions
▶
Beta-blockers
▶
Increased sensitivity to bradycardia
Orthostatic hypotension risk with all agents
Diltiazem
▶
Reduced hepatic clearance increases drug levels
Start at lower doses: 0.15-0.2 mg/kg
Digoxin toxicity risk increased
▶
Reduced renal clearance
Target serum level 0.5-0.9 ng/mL
Anticoagulation in elderly
▶
Benefits of anticoagulation exceed bleeding risk in most patients >=75
▶
Even with high HAS-BLED scores, net clinical benefit favors OAC
Falls risk alone should not preclude anticoagulation
Apixaban preferred DOAC in elderly
▶
Lower major bleeding vs warfarin (ARISTOTLE trial)
Dose reduction criteria apply at age >=80
Cognitive and functional assessment
▶
Medication adherence capacity evaluation
▶
Blister packs or caregiver administration for complex regimens
Simplified once-daily regimens when possible
Pediatrics
Pediatric AF considerations
▶
Epidemiology
▶
AF rare in children without structural heart disease
▶
Congenital heart disease most common underlying cause
WPW as important substrate in pediatric AF
Rate control in children
▶
Metoprolol weight-based dosing
▶
0.1-0.2 mg/kg IV per dose maximum 5 mg
Oral metoprolol 1-6 mg/kg/day divided twice daily
Diltiazem weight-based
▶
0.25 mg/kg IV over 2 minutes
Oral 1.5-2 mg/kg/day divided three times daily
Digoxin in infants and young children
▶
Maintenance 8-12 mcg/kg/day divided twice daily
Serum level and renal monitoring required
Cardioversion in children
▶
Electrical cardioversion starting energy 0.5-1 J/kg
▶
Increase to 2 J/kg if ineffective
Sedation mandatory in children
Pediatric cardiology consultation required
▶
Electrophysiology evaluation for WPW or structural disease
Ablation may be definitive therapy in adolescents
Anticoagulation in pediatric AF
▶
Heparin IV standard anticoagulation acutely
▶
Weight-based dosing per institutional nomogram
DOAC data in children emerging but limited
▶
Off-label use only with specialist guidance
Warfarin remains most-used long-term OAC in pediatric AF
Background
Epidemiology
Global burden
▶
Prevalence
▶
Approximately 37 million people with AF globally
▶
US prevalence approximately 6-7 million
Projected to increase to 12-16 million in US by 2050
Age-adjusted prevalence 2-4% in general population
▶
Rises to approximately 10% above age 80
Incidence
▶
Lifetime risk of developing AF approximately 25-33%
▶
Higher in White Europeans compared to Black populations despite equal disease burden
Annual incidence approximately 600,000 new cases in US
Mortality and morbidity
▶
1.5-2x increased mortality risk compared to general population
▶
Annual stroke risk without anticoagulation 5% with average CHA2DS2-VASc
Annual stroke risk with therapeutic anticoagulation reduced by 60-70%
Tachycardia-mediated cardiomyopathy
▶
Persistent rates >110 bpm can cause reversible LV dysfunction
Normalization of LVEF expected with rate or rhythm control
Pathophysiology
Electrophysiologic mechanisms
▶
Focal trigger mechanisms
▶
Pulmonary vein firing is dominant trigger
▶
Basis for PVI ablation strategy
Automatic firing and triggered activity from PV sleeves
Other foci: superior vena cava, crista terminalis, ligament of Marshall
Substrate mechanisms
▶
Atrial structural remodeling
▶
Fibrosis and interstitial changes reduce conduction velocity
Progressive remodeling: AF begets AF
Electrical remodeling
▶
Shortened atrial effective refractory period
Increased dispersion of refractoriness
AV node role in RVR
▶
AV node acts as gatekeeper during AF
▶
Conducts variable fraction of atrial impulses
Concealed conduction limits maximum ventricular rate
Autonomic modulation of AV node
▶
Sympathetic activation increases conduction: explains RVR in sepsis, PE, thyrotoxicosis
Vagal activation slows rate: basis for vagal maneuvers utility limited in AF
Thrombus formation
▶
Left atrial appendage thrombus mechanism
▶
Loss of atrial mechanical function in AF
▶
Blood stasis in LAA due to absent coordinated contraction
Virchow triad fulfilled: stasis, endothelial injury, hypercoagulability
LAA thrombus accounts for 90% of cardiac thrombi in non-valvular AF
▶
Thrombus persists up to 10 days post-cardioversion in some patients
Basis for 4-week post-cardioversion anticoagulation requirement
Therapeutic Considerations
Rate vs rhythm control evidence
▶
Rate control equivalence
▶
AFFIRM trial: rate control non-inferior to rhythm control for mortality
▶
All-cause mortality similar at 5 years
Rate control simpler with fewer adverse events from antiarrhythmics
RACE trial confirmatory findings
▶
Lenient rate control (HR <110) non-inferior to strict (HR <80) per RACE II
Rhythm control benefits in selected patients
▶
EAST-AFNET 4 trial: early rhythm control reduces composite CV outcomes
▶
Benefit greatest when initiated within 1 year of AF diagnosis
Younger patients, HFpEF, and symptomatic AF benefit most
CASTLE-AF trial: AF ablation superior to medical therapy in HFrEF
▶
Reduced mortality and HF hospitalization
Catheter ablation improves LVEF in tachycardia-mediated cardiomyopathy
Anticoagulation evidence
▶
ARISTOTLE trial: apixaban vs warfarin
▶
Apixaban superior for stroke/SE prevention
▶
21% relative risk reduction in stroke
31% reduction in major bleeding
Survival benefit with apixaban
RE-LY trial: dabigatran vs warfarin
▶
Dabigatran 150 mg twice daily superior for stroke prevention
▶
Non-inferior for major bleeding
ROCKET-AF trial: rivaroxaban vs warfarin
▶
Non-inferior for stroke and SE prevention
▶
Once-daily dosing advantage
Catheter ablation
▶
Pulmonary vein isolation
▶
First-line option for symptomatic paroxysmal AF failing or intolerant of antiarrhythmics
▶
Class I recommendation in 2023 ACC/AHA guideline
Success rate 60-80% at 1 year for paroxysmal AF
Persistent AF ablation success rates lower
▶
Additional substrate modification often required
Multiple procedures may be needed
Patient Discharge Instructions
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Understanding your diagnosis
▶
Atrial fibrillation is an irregular heart rhythm where the upper chambers of the heart beat chaotically
▶
This can cause palpitations, shortness of breath, and fatigue
It also increases risk of stroke, which is why a blood thinner may be prescribed
Your heart rate was very fast (rapid ventricular response) and has been treated in the emergency department
▶
Medications have been given or prescribed to control your heart rate
Follow-up is essential to prevent recurrence
Your new medications
▶
Rate control medication instructions
▶
Take exactly as prescribed every day
Do not stop without speaking to your doctor, even if feeling better
Report dizziness, very slow heart rate, or new shortness of breath to your doctor
Blood thinner (anticoagulant) instructions
▶
Take at the same time each day with food if required for your medication
Do not skip doses; missed doses increase stroke risk
Report unusual bruising, blood in urine or stool, or prolonged bleeding
Lifestyle modifications
▶
Alcohol avoidance or strict limitation
▶
Even moderate alcohol can trigger AF recurrence
Complete abstinence significantly reduces recurrence risk
Weight management
▶
Weight loss of 10% or more reduces AF burden in overweight patients
Blood pressure control
▶
Home blood pressure monitoring encouraged
Target below 130/80 mmHg
Sleep apnea treatment
▶
If diagnosed with sleep apnea, use CPAP consistently
Untreated sleep apnea is a major AF trigger
Warning signs to return to the emergency room
▶
Sudden severe shortness of breath at rest
▶
Worse lying flat
Chest pain or pressure
▶
Especially with sweating or arm pain
Sudden weakness or numbness on one side of the body
▶
Drooping face or speech difficulty: call 911 immediately
Fainting or loss of consciousness
▶
Near-fainting episodes
Heart rate very fast again or palpitations severe and persistent
▶
New irregular pounding sensation
Signs of bleeding if on blood thinner
▶
Black or red stool
Pink or red urine
Vomiting blood
Severe headache unlike prior headaches
Follow-up plan
▶
Family doctor or cardiologist within 1-2 weeks
▶
Bring medication list to appointment
Echocardiogram (heart ultrasound) may be arranged if not done in ED
Additional tests that may be scheduled
▶
Holter monitor for rhythm monitoring
Thyroid function if not checked
Sleep study if sleep apnea not yet evaluated
References
Guidelines and key sources
Primary guidelines
▶
2023 ACC/AHA/ACCP/HRS Guideline for Diagnosis and Management of Atrial Fibrillation
▶
Joglar JA et al., Journal of the American College of Cardiology 2024
Comprehensive rate and rhythm control recommendations
AHA 2025 Adult Advanced Life Support Guidelines
▶
Wigginton JG et al., Circulation 2025
Cardioversion indications and pre-excited AF management
2014 AHA/ACC/HRS Guideline for Management of Atrial Fibrillation
▶
January CT et al., Circulation 2014
Anticoagulation and cardioversion protocols
Key clinical trials
▶
AFFIRM trial: rate vs rhythm control equivalence for mortality
▶
New England Journal of Medicine 2002
RACE II trial: lenient vs strict rate control non-inferior
▶
New England Journal of Medicine 2010
EAST-AFNET 4: early rhythm control reduces CV events
▶
New England Journal of Medicine 2020
CASTLE-AF: ablation superior to medical therapy in HFrEF with AF
▶
New England Journal of Medicine 2018
ARISTOTLE trial: apixaban vs warfarin
▶
New England Journal of Medicine 2011
Emergency medicine sources
▶
Long B, Brady WJ, Gottlieb M. Emergency Medicine Updates: AF with RVR
▶
American Journal of Emergency Medicine 2023
ED-specific rate control and disposition guidance
Chyou JY et al. AF During Acute Hospitalization, AHA Scientific Statement
▶
Circulation 2023
Secondary AF management principles
Ko D et al. Atrial Fibrillation: A Review
▶
JAMA 2025
Contemporary epidemiology and management overview
ICD-10 coding reference
▶
AF coding by subtype
▶
I48.0 paroxysmal atrial fibrillation
I48.11 longstanding persistent atrial fibrillation
I48.19 other persistent atrial fibrillation
I48.20 chronic atrial fibrillation unspecified
I48.21 permanent atrial fibrillation
I48.91 unspecified atrial fibrillation
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.
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Management Protocols
Atrial Fibrillation (RVR)