Editing Post-op AF (section)

== '''Initial management''' ==

* '''Approach'''
** Rate-control strategy first, unless unstable and successful ventricular rate control cannot be achieved
** Avoid RVR and the possibility of ensuing cardiac ischaemia
** HR target of <120 is reasonable post-op
** Indications for rhythm control:
*** Symptomatic AF despite good rate control
*** Rate control difficult to achieve
*** Patients unlikely to have a recurrence of AF (younger, less comorbidities, small left atrium)
*** Consider when good reason to avoid anticoagulation
** >50% with new post-op AF will convert to sinus rhythm within 24 hours
*** If this occurs, no need for further management, but should have outpatient Holter and TTE
* '''For rate control'''
** Metoprolol 25mg PO BD (75mg max; can start with 12.5mg BD in a stable patient sometimes, particularly if there might be chronicity to AF and you’d like to start slowly) or 5mg IV (in increments up to 15mg - not good on ward) OR
** Amiodarone 300mg IV (up to 5mg/kg) OR
** Digoxin 0.25mg IV every two hours, to a total dose of 1.5mg, then 0.125-0.375mg IV daily
** Calcium channel blocker or a second agent at discretion of cardiology
* '''For rhythm control (unstable patient, or other indication for rhythm control)'''
** IV amiodarone 300mg (up to 5mg/kg) or diltiazem/flecainide)
** Synchronised DCR (requires peri-procedural anticoagulation and then for 4/52 afterwards)
* '''Specific situations'''
** Able to give PO, stable - PO metoprolol, with consideration of digoxin in CCF, or PO amiodarone if second agent is required
*** Generally worth trying PO metoprolol first, even if absorption is considered to be borderline or questionable, as long as the patient is stable
** Unable to give PO, stable on ward - IV digoxin
** Able to give PO, unstable - IV amiodarone and ICU
** Unable to give PO, unstable - IV amiodarone and ICU