DC cardioversion is the best treatment for Atrial Fibrillation patients who are hemodynamically unstable !
A 76-year-old woman is evaluated in the emergency department for dizziness, shortness of breath, and palpitations that began acutely one hour ago. She has a history of hypertension and heart failure with preserved ejection fraction. Medications are hydrochlorothiazide, lisinopril, and aspirin.
On physical examination, she is afebrile, blood pressure is 80/60 mm Hg, pulse rate is 165/min, and respiration rate is 30/min. Oxygen saturation is 80% with 40% oxygen by face mask. Cardiac auscultation reveals an irregularly irregular rhythm, tachycardia, and some variability in S1 intensity. Crackles are heard bilaterally one-third up in the lower lung fields.
Q: Which of the following is the most appropriate acute treatment?
Amiodarone can convert atrial fibrillation to normal sinus rhythm as well as provide rate control, but immediate treatment is needed and amiodarone may take several hours to work. Oral amiodarone may be a reasonable option for long-term atrial fibrillation prevention in this patient given the severity of her symptoms, especially if she has significant left ventricular hypertrophy.
Metoprolol or diltiazem would slow her heart rate; however, in patients who are hypotensive and these medications could make their blood pressure lower. In addition, in patients who are in active heart failure, and metoprolol or diltiazem could worsen the pulmonary edema.