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Optimal practice review: recommendation reminders detail

Recommendation reminder 3: In patients with non-life-threatening haemodynamic instability following the onset of AF:

Guidance:Atrial fibrillation
Date issued:June 2006

Atrial fibrillation (AF) is a condition that affects the heart. It occurs when the electrical impulses controlling the heartbeat become disorganised, so that the heart beats irregularly and too fast. As a result, the heart is not able to efficiently pump blood around the body and the pulse is irregular. This may cause symptoms such as palpitations, chest pain or discomfort, shortness of breath, dizziness and fainting. If severe, these can be life threatening and require immediate treatment. However, many people with AF have no or only mild symptoms.

AF may increase the risk of blood clots because when the heart beats irregularly, the blood does not flow properly through the heart and the rest of the body. People with AF may need medication to reduce or prevent this risk.

Haemodynamic instability occurs when a problem with the heart means that sufficient blood flow and pressure cannot be maintained without medical help. Although most people with AF do not have haemodynamic instability, there is a small number who do require immediate hospitalisation and urgent treatment to prevent further deterioration.

A treatment called ‘cardioversion’ can be used to help the heart return to beating normally. Cardioversion uses either medicine (pharmacological cardioversion) or electric shock (electrical cardioversion), or sometimes both, to help the heart return to its normal (sinus) rhythm. Medicines used to help the heart return to a normal rhythm are called ‘antiarrhythmic drugs’. Examples of antiarrhytmic drugs used to prevent and treat abnormal fast rhythms of the heart (tachyarrhythmias) are amiodarone and flecainide.

Wolff–Parkinson–White syndrome is a condition that some people are born with that affects the heart rhythm. People with Wolff–Parkinson–White syndrome are particularly at risk following the onset of AF because it can cause very high heart rates (greater than 200 beats per minute).

The evidence reviewed by the NICE Guideline Development Group (GDG) indicated that antiarrhythmic drugs that work by blocking the action of a small bundle of specialised heart muscle fibres called the atrioventricular node could worsen this problem. Therefore it is recommended that atrioventricular node-blocking agents (for example, diltiazem, verapamil and digoxin) should not be used in people with Wolff–Parkinson–White syndrome.

This page was last updated: 09 September 2009

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.