Like I have eluded to before, I prefer mnemonics that auto-indicate their purpose, like ‘SHOCKED’ for causes of Hypotension/Shock or ‘A-COPD’ for Acute-COPD exacerbation management. I however make an exception to using ABCDEF as a medical mnemonic for recalling interventions for Atrial Fibrillation with Rapid Ventricular Response (or A-Fib with RVR ), because ABCDEF gives me the exact sequence of interventions I use to fix the problem in my hospitalized patients ( same treatments apply to A-Flutter with RVR ) . So here goes:
A – Air trapping & bearing down (Valsalva Maneuver) if possible. (Not practical in all patients especially frail, intubated, hypoxic, weak, obtunded, etc) . ‘A‘ should remind you to NOT use Adenosine for A-Fib/A-flutter (will cover this in another post)
B – Beta blockers: If BP is ok, I try 5mg IV Metoprolol once, repeat another dose after 5 minutes if no reponse (again if BP is fine) . If slowing response seen, then add oral dose BID and IV PRN
C – Calcium channel Blocker (CCBs): Diltiazem bolus with drip is the drug of choice to add if ‘B’ not enough
D – Digoxin : If Blood pressure is low or if using higer doses of Beta-blockers and/or CCBs is limited by hypotension, then add IV Digoxin, even if just a temporary loading dose.
E – Electrical Manipulation !! Either via anti-arrhythmic drugs (IV Amiadrone drip) or ElectroCardioversion (usually get a cardiologist opinion prior)
F – Fluids If not in heart failure / fluid overload while using the above treatments. I try a small 500 cc IV NS bolus too during above treatments . Be cautious of overdoing since AFib-RVR can throw a heart into CHF
F – Find & Fix the AFib /tachycardia triggers – PE, Infection, alcohol etc ( Thankfully newer studies like this, this and this show that coffee ☕ consumption likely does not increase A-Fib risk 😎 )
F – Fry the nerve Fibers ! (RadioFrequency ablation via Electrophysiologist consult)
💡 Summarizing ABCDEF medical mnemonic sequence to treat AFib and A-Flutter w/RVR :
A – Air-Trapping & Bear down (Valsalva if possible), NO Adenosine for Afib/Aflutter
B – Beta-Blockers if A fails or not enough
C – Calcium Channel Blockers if C fails or not enough
D – Digoxin load & maintain short term if C & B are limited by low BP
E – Electrical manipultations f all above fail : Chemical (IV Amiodarone) or Physical (Electrocardioversion)
F – Fluids IV if not in Heart failure
F – Find & Fix the triggers always
F – Fry the nerve Fibers (RadioFrequency ablation) if above fails (EP consult)
