MDM - Atrial Fibrillation - Rapid Ventricular Rate (RVR)

[##]-year-old [male/female] with complaint of [rapid heart rate/lightheadedness/palpitations] with history and exam consistent with atrial fibrillation with rapid ventricular response (RVR).

Initial consideration in this patient included atrial fibrillation, atrial tachycardia, atrial flutter, sinus tachycardia, paroxysmal supraventricular tachycardia (SVT) from atrioventricular (AV) nodal re-entry tachycardia, multifocal atrial tachycardia, ventricular tachycardia, acute coronary syndrome (ACS), and various drug and medication effects including caffeine, alcohol, cocaine and other drugs of abuse, and other medications including digoxin among others.

Patient presented with complaint of [lightheadedness/palpitations/chest pain] with initial EKG noted to show atrial fibrillation with evidence of heart rates ranging from [###/140-180] beats per minute consistent with RVR.  Patient reported onset of symptoms [### minutes/hours] prior to presentation in the ED.  Patient [reported/denied] prior similar episodes [with known paroxysmal/underlying atrial fibrillation].  Patient placed on cardiac monitors with pacing/defibrillation pads placed on the patient upon arrival in the ED.  Patient felt to be [stable/unstable] based on [absence of chest pain, hypotension, dyspnea, or altered mental status/presence of ischemic chest pain/systolic blood pressure less than 90 mmHg/acute pulmonary edema/altered mental status].  [Cardioversion felt to be contraindicated in patient with over 48 hours of symptoms suggestive of prolonged atrial fibrillation and increased risk for thrombus and potential stroke.  Atrial fibrillation with RVR managed with rate control using Diltiazem/Metoprolol in the ED.  We discussed plan for close outpatient follow up with Cardiology for anticoagulation and delayed cardioversion.]  Procedural sedation considered [inappropriate in patient with evidence of instability warranting emergent synchronized cardioversion at ### Joules/with risks, benefits and alternatives discussed with the patient who provided verbal and written consent prior to sedation as noted above.  Sedation achieved with Etomidate/Ketamine/Propofol without significant complications.].  [Anticoagulation considered in this patient and felt to not be indicated in the setting of clear onset of symptoms in reliable patient within ### hours of presentation to the ED/initiated with heparin/low molecular weight heparin (LMWH) prior to/immediately after cardioversion.]  Cardioversion achieved in the ED with [Amiodarone/Diltiazem/Procainamide/synchronized cardioversion at ### Joules] without significant complications.

Labs were obtained to include [a troponin, CBC, and BMP/other] and were [unremarkable as noted above/notable for abnormality].  We also obtained [a chest x-ray/other] in the evaluation of this patient [which was noted to be unremarkable/abnormality].  Prior to discharge we discussed initiation of anticoagulation, which was felt to [not be indicated/to be indicated based on CHA₂DS₂-VASc score of ### consistent with increased risk for stroke and an ATRIA score consistent with low risk for major bleeding/best be deferred to the patient’s primary care provider on close outpatient follow up].

Prior to discharge, we discussed return precautions, specifically for evidence of recurrent dysrhythmia or worsening cardiac symptoms, treatment [with rate control medication], and close follow up with primary care provider and Cardiology within the next [2-3 days/week] for further evaluation and management, and the patient demonstrated understanding and agreement.