This handout is for atrial flutter precipitating cardiogenic shock (afl with rvr + low-output state). Your care team identified this based on: atrial flutter on monitor + sbp <90 mmhg + signs of hypoperfusion (cool extremities, lactate ≥2, oliguria, ams) → scai b-c cardiogenic shock screen with emergent dccv indication (acc/aha 2024 class i pmid 38753446).
Other reasons your team may use this plan: new-onset afl with rvr + acute pulmonary edema in patient with pre-existing hfref or critical valvular disease — composite emergency requiring emergent dccv before pharmacologic rate control; known severe aortic stenosis or severe mitral stenosis with new afl + acute decompensation (atrial kick essential to maintain stroke volume across stenotic valve); syncope or pre-syncope in patient with afl rvr + sustained hypotension — signals critical low-output state requiring icu + dccv.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| synchronized_DCCV_100J_biphasic | 100 J synchronized biphasic; escalate to 200 J if unsuccessful; pre-treat with K ≥4 + Mg ≥2 | electrical | single shock; may repeat at higher energy | ACC/AHA 2024 Class I (PMID 38753446) — only intervention restoring atrial kick acutely; flutter cardioverts at lower energies than AF; do not delay for TEE if unstable — give heparin bolus then proceed |
| unfractionated_heparin | 60 U/kg IV bolus (max 5000 U) → 12 U/kg/h infusion (max 1000 U/h) titrate to PTT 1.5–2× control or anti-Xa 0.3–0.7 | IV | bolus + continuous | Bridge AC for emergent CV when prior AC absent — ACC/AHA 2024 (PMID 38753446); reversible; preferred over LMWH given titratability + reversal options in shock context |
| norepinephrine | 0.05–0.5 mcg/kg/min IV titrate to MAP ≥65 | IV | continuous | First-line vasopressor in cardiogenic shock per SCAI 2022 (PMID 35718438); preserves coronary perfusion + improves MAP without excessive tachycardia worsening RVR |
| dobutamine | 2.5–10 mcg/kg/min IV titrate to CI ≥2.2 L/min/m^2 | IV | continuous | β1-inotropic support for low CI; cautious in active arrhythmia substrate (may worsen tachycardia) — titrate to lowest effective dose; SCAI 2022 (PMID 35718438) |
| esmolol | 500 mcg/kg IV bolus → 25–100 mcg/kg/min infusion (start LOW given hypoperfusion); avoid if SBP <100 or worsening shock | IV | bolus + continuous | Ultra-short half-life (~9 min) allows rapid titration / discontinuation if hypotension worsens — preferred over metoprolol in shock context — ACC/AHA 2024 |
| diltiazem | REDUCED DOSE: 0.15 mg/kg IV (NOT full 0.25 mg/kg); avoid if EF <40 or SBP <100 — relatively contraindicated in HFrEF substrate | IV | cautious bolus only | AVOID in HFrEF (negative inotropy worsens shock); reduced dose only if EF preserved + BP recovered — ACC/AHA 2024 (PMID 38753446) |
| amiodarone | 150 mg IV over 10 min then 1 mg/min × 6 h then 0.5 mg/min × 18 h | IV | load + infusion | Acceptable in HFrEF + structural heart disease; minimal negative inotropy vs other AADs; pulm/thyroid/hepatic toxicity with chronic use — ACC/AHA 2024 (PMID 38753446) |
| ibutilide | 1 mg IV over 10 min (0.01 mg/kg if <60 kg); may repeat × 1; baseline QTc <440 + K ≥4 + Mg ≥2 mandatory | IV | single dose, may repeat once with QT monitoring | Highly effective for flutter (~60% conversion); ~3% torsades risk requires K + Mg repletion + 4 h QT monitoring — ACC/AHA 2024 (PMID 38753446) |
| apixaban | 5 mg BID (2.5 mg if 2 of: ≥80 yr, ≤60 kg, Cr ≥1.5) | PO | BID | Mandatory ≥4 weeks post-CV regardless of CHA2DS2-VASc; lifelong if AFL persistent or cardiomyopathy substrate; ARISTOTLE (PMID 21870978); ACC/AHA 2024 Class I (PMID 38753446) |
| rivaroxaban | 20 mg with food (15 mg if CrCl 15–50) | PO | once daily | ROCKET-AF (PMID 21830957); X-VeRT data extends to flutter; ACC/AHA 2024 |
| warfarin | 5 mg daily; INR target 2–3; bridge with UFH until therapeutic ×24h | PO | daily | Mechanical valve / severe MS / triple-positive APS only — ACC/AHA 2024 (PMID 38753446) |
Plan: AFL precipitating cardiogenic shock — emergent synchronized DCCV + inotrope/pressor support + cautious pharmacologic rate control + AC bridge to DOAC + long-term CTI ablation pathway — ACC/AHA 2024 (PMID 38753446) + SCAI 2022 (PMID 35718438) + DanGer Shock (PMID 38587234)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Cardiology + EP follow-up at week 1 + month 1; advanced HF follow-up if HFrEF; CTI ablation booked at 4–8 weeks if typical AFL + recurrent decompensation (Calkins 2007 PMID 17572388); valve replacement / repair if MS/AS substrate driving recurrence; cardiac rehab; lifelong AC per CHA2DS2-VASc + cardiomyopathy substrate
Guideline: 2024 ACC/AHA/ACCP/HRS AF + AFL Joint Guideline (Joglar PMID 38753446) + SCAI 2022 CS staging (Baran PMID 35718438) + DanGer Shock 2024 (Møller PMID 38587234)