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We cardiovert quite a lot of the fast ones, but the well controlled ones we send to ambulatory care the next day and they book a planned cardioversion as an outpatient On 2016-11-04 09:39, Phil Moss wrote: > Suggest refer to the Cardiology consultant ( not the junior ) and make it their problem both clinically and operationally > If they breech it's their fault. > Cheers > Disgruntled of Tooting > > Sent from my iPhone > >> On 4 Nov 2016, at 09:12, Rowley Cottingham <[log in to unmask]> wrote: Hello all, I haven't seen much activity here of late so hope this list is still going. I'd like some thoughts, please. While we weren't looking, the management of AF has changed, and the emphasis from the cardiologists now seems to be on keeping people in sinus rhythm for as long as possible rather than rate control. If I had AF I would want this too, but it would appear to have caused a surge in attendances at our department with patients who know that they have gone back into AF and have been told by the cardiologists that they need to be cardioverted as soon as possible and to turn up with us. This of course wasn't agreed with the ED team... However, the effect is that people now turn up in AF or flutter with reasonable heart rates and blood pressures expecting cardioversion. They are usually already taking something for their rhythm control, most commonly bisoprolol in our area, but I have als o seen amiodarone, flecainide, verapamil and diltiazem. Even worse, they usually have a rescue treatment outlined by the cardiologist 'and only go to casualty if that doesn't work'. So I am presented with a patient who may be on one or more of these quite different agents who is now fretting that they only have 48 hours to be reverted, 24 of which have passed and I need to work out what to do. If you ring the cardiologists for advice you normally get an uninterested junior. If you try referral to the medics they often push back until you have tried 'something'. But it is very difficult to decide what to do because of the variety of potential treatments and the period of time I have available to treat once the patient has made their way through the processes to get to me. I usually try 2.5mg of bisoprolol which usually doesn't work, except to slow the heart rate and drop the blood pressure sufficiently that I don't want to give another 2.5mg if the patient has to leave in the next 30 minutes or risk a 4 hour breach. They also won't be safe for electrical cardioversion. I can't be the only person with the problem - has anyone got a foolproof solution? Kindest regards Rowley.