Acute onset rapid Afib - Should the cardiac ischemia medical directive be considered for symptoms of palpitation, chest pain and similar ischemic symptoms

Question#: 607

Question:

Considering some research suggesting that new onset rapid afib can be associated with new onset MI. Should the cardiac ischemia medical directive be considered for symptoms of palpitation, chest pain and similiar ischemic symptoms in acute onset rapid afib. Especially when st segment elevation is difficult with such fast heart rates.

Answer:

That is an excellent question, and one that has been discussed at length over the years. with varying philosophies

As you have mentioned, cardiac ischemia may cause atrial fibrillation, and, inversely, atrial fibrillation can lead to cardiac ischemia.

ASA is extremely valuable in cardiac ischemia and has a low risk profile when there are no contraindications.
Essentially, if in doubt about rate related versus ischemic pain, it is reasonable to proceed with ASA (which can be beneficial for either diagnosis), but nitroglycerin may be withheld. Nitrates are a symptom relief medication and are not integral in positive outcomes. For tachydysrhythmias, nitroglycerin can pose potential risks if the patient is pre-load dependent.

The bottom line is that we trust your judgment. Outlining your thought process on the ACR assists others to understand the care plan.

As always, the Base Hospital Physicians are available to consult for these complex cases.