What is the management for an unstable patient with a Do Not Resuscitate (DNR) order who has not responded to cardioversion for unstable atrial fibrillation (AFib) with rapid ventricular response (RVR)?

From the Guidelines

In a patient with unstable atrial fibrillation with rapid ventricular response (AFib with RVR) who has a DNR order and has not responded to cardioversion, the priority is to control the ventricular rate while respecting the patient's advance directives. The management of such a patient involves careful consideration of the most appropriate rate-controlling strategy. According to the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1, for patients with AFib and RVR who are hemodynamically unstable, urgent cardioversion is recommended. However, since this patient has not responded to cardioversion and has a DNR order, the focus shifts to rate control.

Rate Control Strategies

• Intravenous beta blockers such as metoprolol (5 mg IV over 2-5 minutes, may repeat twice at 5-minute intervals) are recommended for rate control in patients with AFib and RVR, especially in the absence of pre-excitation and heart failure 1.
• Nondihydropyridine calcium channel antagonists like diltiazem (initial bolus of 0.25 mg/kg over 2 minutes, followed by continuous infusion at 5-15 mg/hour) can also be used for rate control, particularly in patients with heart failure or when beta blockers are contraindicated 1.
• Amiodarone may be considered for rate control in patients with AFib and RVR, especially if other medications are contraindicated or ineffective, and the patient has heart failure or hypotension (150 mg IV over 10 minutes, followed by 1 mg/min for 6 hours, then 0.5 mg/min) 1.

Supportive Care

• Oxygen supplementation should be provided as needed to maintain adequate oxygenation.
• Careful fluid management is crucial to avoid exacerbating heart failure or causing hypotension.
• Treatment of any precipitating factors such as infection or electrolyte abnormalities is essential.
• Continuous cardiac monitoring is necessary to assess the response to therapy and adjust the treatment plan as needed.

Consideration of DNR Order

The presence of a DNR order indicates that the patient does not want resuscitative efforts if cardiac arrest occurs. However, this does not preclude the use of appropriate medical management to control the arrhythmia and improve the patient's quality of life. The goal is to provide comfort and prevent further deterioration while respecting the patient's advance directives.

From the FDA Drug Label

Esmolol hydrochloride injection is indicated for the rapid control of ventricular rate in patients with atrial fibrillation or atrial flutter in perioperative, postoperative, or other emergent circumstances where short-term control of ventricular rate with a short-acting agent is desirable The management for an unstable patient with a Do Not Resuscitate (DNR) order who has not responded to cardioversion for unstable atrial fibrillation (AFib) with rapid ventricular response (RVR) is not directly addressed by the use of esmolol (IV) as the label does not provide guidance on management in the context of a DNR order.

• The esmolol label indicates its use for rapid control of ventricular rate in patients with atrial fibrillation.
• However, it does not provide information on how to manage a patient with a DNR order who is unstable and has not responded to cardioversion.
• Given the lack of direct information, the use of esmolol in this specific scenario would require careful consideration of the patient's overall clinical status and goals of care 2.

From the Research

Management of Unstable Patient with DNR Order and Unstable AFib with RVR

• The management of an unstable patient with a Do Not Resuscitate (DNR) order who has not responded to cardioversion for unstable atrial fibrillation (AFib) with rapid ventricular response (RVR) is complex and requires careful consideration of the patient's wishes and medical condition 3.
• According to the study by 4, emergent cardioversion is indicated in hemodynamically unstable patients, but in this case, the patient has not responded to cardioversion.
• An alternative approach may be to use antiarrhythmic medications such as amiodarone, which has been shown to be effective in converting AFib to sinus rhythm 5.
• The study by 6 compared the efficacy of amiodarone and metoprolol in patients with heart failure and persistent AFib with RVR, and found that amiodarone had a lower cardiovascular mortality and first hospitalization for heart failure.
• It is also important to consider the patient's DNR order and respect their autonomy, while also providing appropriate medical care 3.
• The use of anticoagulation therapy should also be considered, as it is an important component of management for patients with AFib 4.
• Ultimately, the management of this patient will require a multidisciplinary approach, involving cardiologists, emergency physicians, and other healthcare professionals to ensure that the patient receives appropriate care while respecting their wishes.

Considerations for DNR Order

• A DNR order does not necessarily mean that the patient will not receive any medical treatment, but rather that they do not want to receive resuscitative efforts in the event of a cardiac arrest 3.
• It is essential to communicate the patient's DNR order to all healthcare providers involved in their care to ensure that their wishes are respected.
• The study by 3 found that DNR orders were not always communicated to emergency medical services (EMS) providers, which can lead to resuscitative efforts being initiated despite the patient's wishes.

Pharmacological Management

• Amiodarone has been shown to be effective in converting AFib to sinus rhythm and may be considered as an alternative to cardioversion 5.
• The study by 6 found that amiodarone had a lower cardiovascular mortality and first hospitalization for heart failure compared to metoprolol in patients with heart failure and persistent AFib with RVR.
• Beta blockers such as metoprolol may also be used to control the ventricular rate in patients with AFib, but may not be as effective in converting AFib to sinus rhythm 6.