Fibrillation auriculaire

Approche générale contemporaine pour la FA

Stiell IG, de Wit K, Scheuermeyer FX, Vadeboncoeur A, Angaran P, Eagles D, Graham ID, Atzema CL, Archambault PM, Tebbenham T, McRae AD, Cheung WJ, Parkash R, Deyell MW, Baril G, Mann R, Sahsi R, Upadhye S, Brown E, Brinkhurst J, Chabot C, Skanes A. https://pubmed.ncbi.nlm.nih.gov/34383280/2021 CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist. CJEM. 2021 Sep;23(5):604-610. doi: 10.1007/s43678-021-00167-y. Epub 2021 Aug 12. PMID: 34383280; PMCID: PMC8423652. 

Contrôler la fréquence cardiaque

• Calcium channel- and beta-blockers considered first line:

  • If patient already taking oral calcium channel- or beta- blocker, choose same drug group first

  • If difficulty achieving adequate rate control, consider using the other first-line agent, IV digoxin, or cardiology consultation

• Calcium channel blocker:

  • Avoid if acute heart failure or known LV dysfunction (POCUS may be helpful)

  • Diltiazem 0.25 mg/kg IV over 10 min; repeat q15-20 min at 0.35 mg/kg up to 3 doses

    1. Start 30–60 mg PO within 30 min of effective IV rate control

    2. Discharge on 30-60 mg QID or Extended Release 120–240 mg once daily

• Beta blocker:

  • Metoprolol 2.5–5 mg IV over 2 min, repeat q15–20 min up to 3 doses

    1. Start 25–50 mg PO within 30 min of effective IV rate control

    2. Discharge on 25–50 mg BID

• Digoxin is second line, as slow onset:

  • 0.25–0.5 mg loading dose, then 0.25 mg IV q4–6 h to a max of 1.5 mg over 24 h; caution in renal failure

  • Consider first line if hypotension or acute HF

• Heart rate target: < 100 bpm at rest, < 110 walking

Prévention des événements thromboemboliques

• If CHADS-65 positive (any of age ≥ 65, diabetes, hypertension, heart failure, stroke/TIA) initiate OAC prior to discharge; consider shared decision making to include patients’ preferences with regards to risks and benefits:

  • DOACs preferred over warfarin

  • Use warfarin (DOACs contraindicated) if mechanical valve, moderate-severe mitral stenosis, 

  • Opinion spécialisée si severe renal impairment (CrCl < 30 ml/min)

  • If stable CAD, discontinue ASA

  • If CAD with other anti-platelets or recent PCI < 12 months, consult cardiology

• If CHADS-65 negative, OAC might be considered for a 4-week period after careful consideration of risks and benefits and a shared decision-making process with the patient; ensure patient is aware anticoagulation will be discontinued after 4 weeks

• CHADS-65 negative and stable coronary, aortic, or peripheral vascular disease, ensure patient is on ASA 81 mg daily

• If TEE-guided CV, must initiate DOAC immediately × 4 weeks

  • If novo warfarin, need LMW heparin bridging

• Patients who convert spontaneously before ED treatment should generally be prescribed OAC according to the CHADS-65 criteria