AFib with Rapid Ventricular Rate (RVR) – Rate >110

Primary AFib – Patients symptoms or their hemodynamic instability is due to the AFib itself. Treatment is by rate or rhythm control.

Secondary AFib – Patients AFib rate or their hemodynamic instability is due to an underlying secondary process (eg thyrotoxicosis, PE, sepsis, drugs, etc). Treatment is by treating the underlying process.

Unstable Primary AFib – The presence of hypotension, altered mental status, or pulmonary edema. Treatment is immediate cardioversion, second line agents include digoxin or amiodarone.

Stable Primary AFib (<48 hours duration ) – Treatment is by cardioversion in the ED

Stable Primary AFib ( >48hours or unknown duration) – Treatment is by rate control by CCB (diltiazem or verapimil), or by BB (metoprolol or esmolol)

Anticoagulation – Calculate CHADS2VASC and HASBLED score. Weigh risk of stroke versus risk of major bleeding prior to starting anticoagulation

Further Reading:

Atrial Fibrillation (EMCrit)

Atrial Fibrillation (ACEP Guidelines)

CHADS2VASC Score (MD Calc)

HASBLED Score (MD Calc)