ARR-01 · Part 2 of 2

Mechanism &
treatment strategy.

The rhythm converted. Now explain why the drug fits, what could make it harmful, and what the next team needs to watch.

Scope & review details

Review2026-10-08

ScopeExisting ARR-01 + shared atlas

Release0.11.0

Contents

How the treatment logic changed

Choose one story. Answer the opening question before reading, then make the decision for the changed patient.

CAST: a quieter monitor was not a safer patient

Before reading: Why might suppressing PVCs after an MI fail to prevent sudden death?

Read the clinical story

The idea was appealing: post-MI ventricular ectopy marked risk, so suppressing the ectopy might reduce sudden death. CAST tested that leap in patients with asymptomatic or mildly symptomatic ventricular arrhythmias after MI—not in everyone with AF or every kind of coronary disease. CAST-1989

The monitor improved. The outcome did not. In the preliminary encainide/flecainide comparison, total mortality was 7.7% versus 3.0% with placebo over an average ten months; the reported relative risk was 2.5 (95% CI 1.6–4.5). Those arms stopped early. PVC suppression had failed as a surrogate for survival. CAST-1989

The pharmacology helps explain the concern: slowing conduction in a diseased substrate can favor re-entry. That is a mechanistic interpretation, not a mechanism CAST itself proved. Today, US AF guidance excludes flecainide/propafenone with prior MI or significant structural disease, including scar/fibrosis and HFrEF. Use the current eligibility criteria—not a claim that CAST studied every CAD phenotype. EHRA-AAD-2025 ACC-AF-2023

Apply it

Synthetic case: a patient with AF, a prior anterior MI and EF 30% asks for flecainide because a friend uses it successfully.

What do you recommend, and how do you explain the refusal without saying “all rhythm control is dangerous”?

Compare the recommendation

I would not use flecainide here: the prior MI and reduced EF place this patient outside Class Ic candidacy. I would clarify the rhythm-control goal with cardiology and select a strategy compatible with the substrate. CAST does not prohibit every antiarrhythmic, and a successful ECG conversion does not establish long-term safety.

Boundary: This is a selection decision, not a complete HFrEF/AF treatment plan. A different patient without prior MI or significant structural disease still needs conduction, interaction and monitored-initiation checks.

AFFIRM to EAST-AFNET 4: the question changed

Before reading: Does “no survival advantage for rhythm control” mean sinus rhythm can never improve outcomes?

Read the clinical story

AFFIRM randomized 4,060 higher-risk patients with AF to rate- or rhythm-control strategies. Rhythm control offered no significant survival advantage: the mortality hazard ratio was 1.15 (95% CI 0.99–1.34), with more hospitalization and adverse drug effects. This was a comparison of the strategies delivered then, not a referendum on the value of sinus rhythm in every patient. AFFIRM-2002

EAST-AFNET 4 asked about timing. It enrolled 2,789 patients with AF diagnosed within a year plus cardiovascular conditions. Early rhythm control—drugs or ablation—reduced the composite of cardiovascular death, stroke, or hospitalization for worsening HF/acute coronary syndrome versus usual care: HR 0.79 (96% CI 0.66–0.94). The trial stopped early for efficacy. Serious rhythm-therapy-related adverse events were also more frequent (4.9% versus 1.4%). EAST-AFNET4-2020

So the useful update is not “AFFIRM was wrong.” Populations, timing and treatment strategies differ. Early rhythm control deserves consideration in eligible patients; EAST does not name one drug as the mortality winner or make every ED cardioversion prognostically beneficial. Stroke prevention remains a separate decision based on thromboembolic risk—not the satisfaction of seeing sinus rhythm on discharge. ACC-AF-2023 EAST-AFNET4-2020

Apply it

Synthetic case: a patient with hypertension has newly diagnosed AF, now rate-controlled and comfortable. A colleague says there is nothing more to discuss because AFFIRM settled rate versus rhythm.

How do you reopen the conversation without promising that a particular antiarrhythmic will prolong life?

Compare the recommendation

I would discuss early rhythm control as a strategy worth evaluating, alongside symptoms, cardiovascular risk, substrate, preferences and procedural options. EAST supports a strategy in an eligible early-AF population; it does not establish a mortality benefit for whichever drug we choose today. I would assess stroke prevention independently and arrange an explicit follow-up decision.

Boundary: Do not turn this into immediate cardioversion of uncertain-duration AF. Pericardioversion anticoagulation/imaging requirements and causal instability still determine the acute branch.

The rhythm converted. The risk changed with it.

Before reading: Why can slowing the rate expose a new hazard during sotalol or dofetilide therapy?

Read the clinical story

Sotalol and dofetilide can prolong repolarization more at slow rates and after pauses. Conversion removes the fast rhythm, but may reveal a longer QT and an early-afterdepolarization trigger. The victory lap is short: look at the post-conversion ECG, not only the pre-dose tracing. EHRA-AAD-2025

Now add an interaction. Trimethoprim inhibits dofetilide's renal cationic secretion; the combination is contraindicated, not fixed by separating administration times. Hydrochlorothiazide is also contraindicated, but its excess QT effect involves increased exposure and potassium reduction—not one identical mechanism for every listed interaction. Dofetilide label

Different drugs leave different footprints. Amiodarone's tissue persistence means adverse effects and interactions can continue after it is stopped. A shorter half-life is not automatically permission to stop monitoring either: kidney function, metabolites, rate and the rest of the regimen all matter. These are drug-specific behaviors, not universal Class III rules. Amiodarone label EHRA-AAD-2025

Apply it

Synthetic case: a patient taking dofetilide converts to sinus rhythm at 48/min, develops AKI, and receives a new TMP-SMX order. Telemetry now shows pauses.

What would you intercept, and what would make this an immediate resuscitation problem?

Compare the recommendation

Intercept TMP-SMX and promptly reassess dofetilide eligibility, renal dosing and QT against the label's algorithm with the treating team. Keep continuous monitoring, check electrolytes and look for recurrent polymorphic VT. Sustained polymorphic VT requires an immediate unsynchronized shock; do not wait for magnesium to work. This is not a routine outpatient interaction-management problem.

Boundary: A QT-associated risk pattern is not itself proof of torsades. The actual rhythm, perfusion and labeled stop criteria govern action; congenital and acquired long-QT management are not interchangeable.

On a later visit, answer one of these cases without reopening the story. Change the EF, kidney function, or timing of AF and explain whether your original recommendation still holds. Rehearsal is self-directed; these responses are not scored or recorded.

Drug atlas preview

Antiarrhythmic pharmacology

Mechanism, kinetics, interactions, and monitoring for 19 agents are in the antiarrhythmic drug atlas.

Open the antiarrhythmic drug atlas

Open the pharmacology workbenchFour safety sketches · EHRA compendium close read

A1 receptor

Adenosine

The AV node’s circuit breaker—not a universal reset button. It fits AV-node-dependent regular SVT and may expose atrial activity. Irregular, polymorphic, or pre-excited rhythms are a different electrical panel.

Half-life measured in seconds · give with a continuous rhythm strip and a defibrillator at hand · expect transient AF or brief proarrhythmia at conversion · caffeine/theophylline oppose · dipyridamole potentiates

Fast Na⁺ + NAPA IKr

Procainamide

It slows conduction and lengthens refractoriness. Useful in selected stable monomorphic VT or pre-excited AF; pressure, HF, QRS/QT, kidney function, and cumulative dose decide whether the runway is long enough.

Parent + active metabolite · renal accumulation · explicit stop rules

Multi-channel + β effects

Amiodarone

The electrophysiology Swiss Army knife—with a storage-unit lease. Broad utility does not erase IV hypotension, conversion risk, tissue persistence, interactions, or chronic organ toxicity.

IV and chronic pharmacology differ · CYP/P-gp interactions · very large Vd

Mg²⁺ · afterdepolarizations

Magnesium

Not seasoning for every ugly tracing. It may be considered for recurrent polymorphic VT with long QT; pair it with trigger removal and potassium correction, and keep the evidence limits visible.

2025 AHA Class 2b, C-LD · direct randomized torsades evidence is absent

Lead pharmacology source · corrected

Read antiarrhythmics as behavior—not a class list.

The 2025 EHRA practical compendium is the pharmacology spine for this deep dive. Its best move is connecting channel state, rate, tissue, substrate, PK, interactions, and proarrhythmia to what you monitor at the bedside.

Rate rises

Use dependence

Flecainide binds activated/inactivated sodium channels and dissociates slowly. Faster activation means accumulating block: useful against tachycardia, visible as rate-related QRS widening, and dangerous when substrate or conduction reserve is wrong.

Bedside tell → QRS behavior during loading or faster rates

Rate falls

Reverse use dependence

Sotalol and dofetilide prolong repolarization more at slower rates. Conversion can remove the tachycardia and reveal the hazard: pauses, longer QT, early afterdepolarizations, torsades.

Bedside tell → QT after conversion, pauses, K/Mg, renal function

Patient changes

PK becomes electrophysiology

Renal decline can turn yesterday’s tolerated exposure into today’s conduction or repolarization problem. Tissue storage and active metabolites can make the offset far slower than the infusion or prescription suggests.

Bedside tell → organ trajectory, cumulative dose, active metabolites

Regimen changes

Interactions become rhythm

CYP and P-gp inhibition can raise antiarrhythmic or companion-drug exposure; stacked AV-node block or QT activity can be intentional—or the mechanism of harm.

Bedside tell → full regimen, anticoagulants, rate agents, QT stack

The five-question drug read

What tissue and mechanism am I trying to alter?
What rate or channel state strengthens the drug?
What substrate makes that same effect unsafe?
How will this patient clear, store, or interact with it?
What ECG, hemodynamic, laboratory, and clinical stop rule will reveal failure first?

Closed-book check: explain the paradox

Retrieve first: Why can a sodium-channel blocker become more powerful during tachycardia while a potassium-channel blocker becomes more proarrhythmic after conversion?

Reveal expert response

Fast activation increases occupancy of activated/inactivated sodium channels when dissociation is slow—use dependence. Slower rates and pauses amplify repolarization prolongation from some IKr blockers—reverse use dependence. The monitoring target therefore changes with rate and with the moment of conversion.

Source-to-practice lab

Clinical studies

Read the enrolled population, absolute results, adverse events, and limits before applying a study to a case.

Open the literature labThree trial figures · 10 reading cards · 6 media resources

8 minutes

Rounds pass

Read the result and practice boundary on the tertiary, AHA, REVERT, and PROCAMIO cards.

20 minutes

Journal-club pass

Add methods, confidence intervals, and each teach-back before opening the full paper.

45 minutes

Full study review

Read every card, then transfer the evidence across ED, ICU, medicine, and physician decisions.

Figure lab 01 · original visualization

Three trials, three different questions.

Start with denominators. Then read the absolute effect, harm, and transfer boundary. A larger bar is not automatically a stronger or more transferable conclusion.

Intervention
Comparator
Worse outcome
Colour tracks the outcome, not the drug — the same agent can be the safer choice in one row and the harm in another.

REVERT · sinus rhythm at 1 minute

Technique changes the effect.

Standard Valsalva37 / 214

17%17%

Modified Valsalva93 / 214

43%43%

Absolute benefit: 26 percentage points
Approximate NNT: 4
Adjusted OR: 3.7 (95% CI 2.3–5.8)

PROCAMIO · tolerated WCT

Read benefit and harm together.

Major cardiac adverse events

Procainamide3 / 33

9%9%

Amiodarone12 / 29

41%41%

Tachycardia terminated by 40 minutes

Procainamide22 / 33

67%67%

Amiodarone11 / 29

38%38%

RAFF2 · selected stable acute AF

Near-equal totals can conceal different workflows.

Drug → shock196 / 204

96%96%

Shock only176 / 192

92%92%

Absolute difference: 4 points (95% CI 0–9)
Drug alone converted: 52%
Strategy p value: 0.07

Accessible data table for the three original trial visualizations and their confidence intervals.
Trial	Population	Endpoint	Comparison	Result
REVERT	Stable adult SVT	Sinus rhythm at 1 minute	Modified vs standard Valsalva	43% vs 17%
PROCAMIO	Tolerated regular WCT	Major cardiac adverse events	Procainamide vs amiodarone	9% vs 41%
PROCAMIO	Tolerated regular WCT	Termination by 40 minutes	Procainamide vs amiodarone	67% vs 38%
RAFF2	Selected stable acute AF	Conversion to sinus rhythm	Drug–shock vs shock-only	96% vs 92%

Commit an interpretation before revealing the debrief

REVERT: the clinically useful measure is the 26-point absolute benefit and NNT near 4—not a claim that every SVT is 3.7 times more likely to convert.

PROCAMIO: both the adverse-event and termination signals favor procainamide, but the sample is small and the transfer boundary excludes unstable, polymorphic, and pulseless rhythms.

RAFF2: both bundled strategies converted most eligible patients. A nonsignificant 4-point difference is not proof of equivalence; workflow, sedation, preference, and eligibility still matter.

verified excerpts · each 20 words or fewer

Key reading cards

0 reading cards marked complete.

01 Wide QRS Complex TachycardiaTertiary scaffold · Foundation

“Wide complex tachycardia is a dysrhythmia with a long list of potential causes”
Continuing Education Activity · 13 quoted words

What to retain

A wide-complex tachycardia has a long differential; treat it as VT until a safer explanation is proven.
Width and regularity are probability-changing features, not a final diagnosis.

Study / source frame

A broad, open-access clinical review that organizes the differential before the learner enters individual trials and guidelines.

Result signal

No comparative effect estimate; its job is orientation, vocabulary, and differential diagnosis.

What this supports

Start with patient stability, then treat width and regularity as probability-changing features rather than a final diagnosis.

What this does not prove

Tertiary reviews compress nuance and can age. Verify management-changing claims against the current guideline and direct evidence below.

Teach-back prompt

Retrieve first: Name four causes of wide-complex tachycardia that would change the medication plan.

Reveal expert response

Examples include ventricular tachycardia, pre-excited AF, sodium-channel blockade, hyperkalemia, SVT with aberrancy, pacing, and artifact. The point is to connect each cause to a different hazard or rescue pathway.

02 Sustained polymorphic ventricular tachycardiaCurrent guideline · ED + ICU

“Polymorphic ventricular tachycardia is always unstable and should be treated immediately with defibrillation”
Adult ALS: polymorphic VT discussion · 13 quoted words

What to retain

Sustained polymorphic VT is treated as unstable: immediate unsynchronized shock (Class 1, B-NR).
Magnesium for recurrent long-QT torsades is Class 2b, C-LD; the guideline notes randomized drug evidence is absent.
Beat-to-beat QRS variation defeats reliable synchronization.

Study / source frame

Current emergency guidance derived from systematic, scoping, and focused evidence reviews.

Result signal

Immediate unsynchronized shock for sustained polymorphic VT is Class 1, B-NR. Magnesium for recurrence with long QT is Class 2b, C-LD.

What this supports

Shock sustained polymorphic VT without waiting for synchronization, even when a pulse is present; address the substrate after energy.

What this does not prove

A recommendation is not a randomized comparison. The guideline notes that randomized evidence for drug management of polymorphic VT is absent.

Teach-back prompt

Retrieve first: Why is this an unsynchronized-shock pathway, and what additional action begins if the patient loses a pulse?

Reveal expert response

Beat-to-beat QRS variation makes reliable synchronization impractical. If pulse loss occurs, begin CPR and follow arrest rhythm analysis; defibrillate VF or pulseless VT.

03 When atrial fibrillation is causing instabilityCurrent guideline · ED + physician

“In patients with hemodynamic instability attributable to AF, immediate electrical cardioversion should be performed to restore sinus rhythm”
Electrical cardioversion recommendations · 18 quoted words

What to retain

When AF is causing instability, immediate synchronized cardioversion (Class 1, C-LD).
The causal word matters: AF can be the driver, or a marker of sepsis, PE, or ACS.
Cardioversion does not replace simultaneous evaluation of the shock state.

Study / source frame

Multidisciplinary evidence synthesis for adults across the atrial-fibrillation continuum.

Result signal

Immediate synchronized cardioversion when instability is attributable to AF is Class 1, C-LD.

What this supports

The causal word matters: treat AF immediately when it is driving the instability.

What this does not prove

AF can also be a marker of sepsis, hemorrhage, PE, ACS, or another shock state. Cardioversion does not replace simultaneous causal evaluation.

Teach-back prompt

Retrieve first: A septic patient has AF at 160/min and hypotension. What observations would make AF more likely to be the driver rather than a compensatory response?

Reveal expert response

Look for temporal coupling, disproportionate rate, loss of atrial contribution in a preload-dependent patient, worsening with rhythm onset, and hemodynamic improvement with rate/rhythm intervention—while treating sepsis in parallel.

04 Flecainide and use dependenceExpert pharmacology synthesis · Pharmacology

“This use-dependent property enables flecainide to effectively block the activation front, contributing to the termination of atrial fibrillation”
Flecainide: use-dependent sodium-channel block · 18 quoted words

What to retain

Use dependence: sodium-channel block accumulates at fast rates because there is less diastolic time to dissociate.
It shows up as rate-related QRS widening during loading or exertion.
The same property is why flecainide is confined to structurally normal hearts.

Study / source frame

Expert consensus integrating ion-channel mechanisms, PK/PD, selection, monitoring, interactions, and proarrhythmia.

Result signal

This is a mechanistic statement, not a comparative clinical effect estimate.

What this supports

At faster activation rates, less time is available for flecainide to dissociate from sodium channels, strengthening blockade.

What this does not prove

The same mechanism can cause rate-related QRS widening and proarrhythmia. Mechanistic plausibility does not erase patient-selection restrictions.

Teach-back prompt

Retrieve first: What would exercise-related QRS widening reveal about flecainide’s channel-binding behavior?

Reveal expert response

It demonstrates use dependence: faster rates increase the fraction of blocked channels because there is less diastolic time for drug dissociation.

05 Sotalol and reverse use dependenceExpert pharmacology synthesis · Pharmacology + monitoring

“reverse use dependence describes the phenomenon where the effectiveness of a drug is greater at lower heart rates”
Proarrhythmia: reverse use dependence · 18 quoted words

What to retain

Reverse use dependence: IKr block prolongs the QT most at slow rates and pauses.
So torsades risk is highest just after conversion; watch post-conversion QT, K/Mg, and renal function.

Study / source frame

Expert consensus connecting antiarrhythmic mechanisms, rate, PK/PD, monitoring, interactions, and proarrhythmia.

Result signal

No comparative effect estimate; this is a mechanism and monitoring synthesis.

What this supports

After conversion or during bradycardia and pauses, some IKr blockers can prolong repolarization more strongly, shifting attention to post-conversion QT, electrolytes, and renal exposure.

What this does not prove

Not every potassium-channel effect behaves identically, and mechanism alone does not quantify an individual patient's torsades risk. Apply current labeling, guideline, and patient-specific monitoring requirements.

Teach-back prompt

Retrieve first: Why can successful conversion make an IKr-blocker safety problem more visible rather than less?

Reveal expert response

The slower rate and pauses after conversion can magnify repolarization prolongation through reverse use dependence. That can expose QT prolongation and early-afterdepolarization risk even though the tachyarrhythmia has ended.

06 REVERT: do the maneuver correctlyPrimary randomized trial · ED pharmacist

“We have shown that a simple, cost-free, well-tolerated postural modification to the standard Valsalva manoeuvre is highly effective”
Discussion · 18 quoted words

What to retain

Modified beat standard Valsalva: 43% vs 17% sinus rhythm at one minute.
Absolute benefit ~26 points, NNT ~4 for a free, repeatable maneuver before any drug.
Only for stable, regular, narrow SVT; it does not apply to AF, flutter, or wide-complex rhythms.

Study / source frame

Multicenter randomized, assessor-blinded trial in 10 UK EDs; 428 primary-analysis encounters with stable SVT.

Result signal

Sinus rhythm at one minute: 43% modified versus 17% standard; absolute difference 26 percentage points; approximate NNT 4; adjusted OR 3.7 (95% CI 2.3–5.8).

What this supports

A correctly performed modified Valsalva belongs before adenosine in an appropriate stable regular narrow-complex SVT pathway.

What this does not prove

The intervention was not blinded to clinicians or patients and does not apply to instability, AF/flutter, irregular rhythms, or undifferentiated WCT.

Teach-back prompt

Retrieve first: Calculate the absolute benefit and NNT, then name the rhythm and stability checks required before using the result.

Reveal expert response

The absolute benefit is about 26 percentage points and NNT is about 4. Confirm a stable patient with a compatible regular SVT; exclude rhythms and states in which a vagal-first pathway is inappropriate.

07 A newer, smaller Valsalva trialNew primary trial · Evidence critique

“Sinus rhythm was restored in 10 of 38 patients (26.3%) in the modified Valsalva group”
Abstract: Results · 15 quoted words

What to retain

A smaller 2026 trial: modified 26.3% vs standard 16.2%, same direction but far less precise.
The 95% CI spanned harm to large benefit, so it cannot overturn REVERT.
Not statistically significant is not the same as equivalent.

Study / source frame

Single-center, open-label, pragmatic randomized trial in 75 adults with stable PSVT in an Indian tertiary ED.

Result signal

Modified 26.3% versus standard 16.2%; 95% CI for the absolute difference −8.2% to 28.4%; not statistically significant.

What this supports

The direction of effect remained favorable, but the estimate was imprecise and smaller than REVERT’s.

What this does not prove

A small single-center trial with a confidence interval spanning harm and substantial benefit cannot establish equivalence or erase the larger trial.

Teach-back prompt

Retrieve first: Why does ‘not statistically significant’ fail to prove that the two maneuvers are equivalent?

Reveal expert response

Failure to reject no difference is not proof of equality. The wide confidence interval shows that the study cannot distinguish modest harm, no effect, or clinically important benefit.

08 PROCAMIO: comparative drug evidencePrimary randomized trial · ED + critical care

“Procainamide therapy was associated with less major cardiac adverse events and a higher proportion of tachycardia termination within 40 min”
Abstract: Conclusions · 20 quoted words

What to retain

In tolerated wide-QRS tachycardia, procainamide beat amiodarone on major cardiac adverse events: 9% vs 41%.
It also terminated more: 67% vs 38% by 40 minutes.
Small (n=62), open-label, with exclusions; do not extend to unstable, polymorphic, or pulseless VT, or to severe HF or long QT.

Study / source frame

Multicenter, randomized, open-label comparison; 74 enrolled and 62 analyzed with tolerated regular wide-QRS tachycardia, probably monomorphic VT.

Result signal

Major cardiac adverse events: 9% procainamide versus 41% amiodarone. Termination by 40 minutes: 67% versus 38%.

What this supports

For carefully selected tolerated monomorphic WCT, procainamide has stronger direct comparative evidence than amiodarone.

What this does not prove

Small, open-label, 12 exclusions from the principal analysis, and not powered for mortality. Do not extrapolate to unstable, polymorphic, or pulseless VT.

Teach-back prompt

Retrieve first: Would you transfer this result to LVEF 15%, SBP 92 mm Hg, CKD, and QTc 510 ms? Defend the plan.

Reveal expert response

No automatic transfer. Hypotension, severe HF, renal accumulation, and prolonged QT narrow or remove the procainamide option; reassess stability and prepare electrical therapy with expert input.

09 RAFF2: two workable acute-AF strategiesPrimary randomized trial · ED pharmacist

“Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm”
Abstract: Interpretation · 16 quoted words

What to retain

Drug-shock 96% vs shock-only 92% conversion; both strategies work in selected recent-onset AF.
Procainamide alone converted ~52%, often sparing sedation and a shock.
The 4-point difference (CI 0-9, p=0.07) is not proof of equivalence; workflow and preference decide.

Study / source frame

Partial-factorial randomized trial at 11 Canadian academic EDs; 396 selected adults with stable acute AF.

Result signal

Conversion: 96% drug–shock versus 92% shock-only; absolute difference 4% (95% CI 0–9; p=0.07). Procainamide alone converted 52%.

What this supports

Either pathway can work for selected stable recent-onset AF; procainamide may avoid sedation and shock in about half.

What this does not prove

This compared bundled strategies, did not establish statistical equivalence, and excluded unstable or secondary-AF presentations.

Teach-back prompt

Retrieve first: How should prior response, sedation risk, ED resources, patient preference, and time-to-disposition alter the choice?

Reveal expert response

Use shared, context-specific selection. High sedation risk or limited procedural resources may favor a drug-first attempt; prior drug failure, patient preference, or a need for rapid predictable conversion may favor shock-first when eligible.

10 EAST-AFNET 4: rhythm control as prognosisPrimary randomized trial · Internal medicine

“Early rhythm-control therapy was associated with a lower risk of adverse cardiovascular outcomes than usual care”
Abstract: Conclusions · 16 quoted words

What to retain

Early rhythm control lowered cardiovascular events: HR 0.79 (3.9 vs 5.0 per 100 person-years).
Population was AF within ~1 year of diagnosis plus cardiovascular risk, a prognostic not acute-cardioversion message.
Rhythm-therapy serious adverse events were higher (4.9% vs 1.4%); it is a strategy, not one drug.

Study / source frame

International, randomized, open-label trial with blinded outcome assessment; 2,789 patients with AF diagnosed within one year plus cardiovascular conditions.

Result signal

Composite event rates: 3.9 versus 5.0 per 100 person-years; HR 0.79 (96% CI 0.66–0.94). Rhythm-therapy-related serious adverse events: 4.9% versus 1.4%.

What this supports

For selected early-AF patients, rhythm control can be a prognostic strategy rather than symptom rescue alone.

What this does not prove

Not an acute ED cardioversion trial. Therapy was heterogeneous, the trial was open-label and stopped early, and the composite cannot be assigned to one drug or ablation.

Teach-back prompt

Retrieve first: Which new AF patients leaving the ED merit an explicit early-rhythm-control referral instead of a rate-control-only plan?

Reveal expert response

Patients within a year of diagnosis who resemble the trial population and have cardiovascular risk or disease merit an intentional rhythm-control discussion, alongside anticoagulation and comorbidity management—not an automatic prescription for one intervention.

Watch · simulate · inspect

A curated media shelf, with a job for every click.

These are outbound resources, not endorsements of every statement they contain. Predict before opening; teach back afterward. Current guidance outranks an older demonstration when they differ.

Video · technique1:34

Modified Valsalva Maneuver

JAMA Network / JN Learning

Before opening: Predict the exact strain, repositioning, and leg-raise sequence before pressing play.
Afterward: Teach the maneuver back as an executable order, including patient selection and monitoring.

Access: Public player; an auto-generated transcript is available but may contain errors.

Boundary: Copyrighted AMA content. Link out only; do not copy, download, or embed.

Open resource

Link checked 2026-07-16

Video · procedureShort skills demonstration

Synchronised cardioversion

Resuscitation Council UK

Before opening: Name the four setup checks you expect before shock delivery.
Afterward: Identify the sync-marker, safety, sedation, and re-synchronization steps shown.

Access: Full transcript and contrast controls are available.

Boundary: The older 120-J example is a device/scenario demonstration, not a universal current energy recommendation; pair it with the 2025 AHA algorithm.

Open resource

Link checked 2026-07-16

Interactive simulatorSelf-paced

Manual External Defibrillation, Cardioversion, and Pacing

University of Florida Center for Safety, Simulation & Advanced Learning Technologies

Before opening: Write the device sequence for synchronized cardioversion from memory.
Afterward: Repeat locally using the text pathway: pads → rhythm → sync → energy → clear → shock → reassess → re-sync if needed.

Access: Free non-CME WebGL simulator; desktop-oriented and drag-heavy. The local text pathway is the keyboard alternative.

Boundary: Use for equipment logic, not as a substitute for device-specific training or current protocols.

Open resource

Link checked 2026-07-16

Visual learning unitsSelf-paced

Marion-Arnsdorf ECG Project

University of Chicago Medicine

Before opening: Choose one mechanism—automaticity, triggered activity, or re-entry—and sketch it first.
Afterward: Explain how that mechanism predicts onset, regularity, response to AV-nodal blockade, and recurrence.

Access: JavaScript is required. Learning units combine electrophysiology diagrams with rhythm examples.

Boundary: No reuse license was visible; link to the original rather than copying its images.

Open resource

Link checked 2026-07-16

Image-based quiz10 cases

Arrhythmia Quiz

University of Utah ECG Learning Center

Before opening: Use the same sequence every time: rate → regularity → P–QRS relation → width → patient context.
Afterward: Record one morphology clue you over-weighted and one clinical clue you under-weighted.

Access: Image-based questions include AVNRT, AF, flutter, VT, and a ladder diagram.

Boundary: Licensed CC BY-ND-NC; link-only avoids creating an unauthorized derivative.

Open resource

Link checked 2026-07-16

Visual algorithmOne-page reference

2025 Electrical Cardioversion Algorithm

American Heart Association

Before opening: Predict the starting-energy rows and the point at which synchronization no longer applies.
Afterward: Turn the algorithm into a bedside preparation checklist rather than memorizing one number.

Access: Graphic PDF plus a linked long-description companion.

Boundary: Confirm the specific defibrillator’s recommended energy and local protocol.

Open resource Accessible text companion

Link checked 2026-07-16

Evidence register

The sources behind the calls.

How these are weighed—three visible layers, study design versus recommendation authority, and the questions that decide usefulness—lives on one shared page: how we weigh evidence. Here is the arrhythmias register itself, each record traceable.

Open the full evidence record21 verified source records

seed records · verified links and identifiers

Scope: initial guideline spine and practice-shaping studies. This is a documented scoping set, not yet a completed systematic review.

1 Part 9: Adult Advanced Life Support — 2025 AHA Guidelines for CPR and ECCGuideline · current emergency algorithm · Recommendation-specific

Acute tachyarrhythmia, bradycardia, cardioversion, polymorphic VT, and arrest pathways.

Citation: Wigginton JG, et al. Circulation. 2025;152(suppl 2):S538–S577.
DOI / identifier: 10.1161/CIR.0000000000001376
Access / review due: 2026-10-08 / 2027-04-08. Official AHA full web guidance reviewed: WCT, polymorphic VT, regular narrow-complex tachycardia, AF/flutter and bradycardia; accessible tachyarrhythmia algorithm stopping criteria checked.

Open primary record

Accessible primary text used in this pass

2 Part 10: Adult and Pediatric Special Circumstances of Resuscitation — 2025 AHA GuidelinesGuideline · toxicology/special circumstances · Recommendation-specific

Hyperkalemia, pregnancy, pulmonary embolism, and arrhythmogenic drug/toxin emergencies.

Citation: Cao D, et al. Circulation. 2025;152(suppl 2):S578–S672.
DOI / identifier: 10.1161/CIR.0000000000001380

Open primary record

3 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial FibrillationGuideline · multidisciplinary synthesis · Recommendation-specific

US framework for AF staging, stroke prevention, rate/rhythm control, acute illness, and ablation.

Citation: Joglar JA, et al. Circulation. 2024;149:e1–e156.
DOI / identifier: 10.1161/CIR.0000000000001193
Correction / erratum: Correction DOI 10.1161/CIR.0000000000001207; PMID 38153996.
Access / review due: 2026-10-08 / 2027-04-08. Accessible primary author manuscript: sections 6.2, 7.2.1, 8.2, 8.3.1, 8.3.2, 8.3.3 and WPW/pre-excitation guidance checked for this pass.

Open primary record

Accessible primary text used in this pass

4 2024 ESC Guidelines for the management of atrial fibrillationGuideline · international synthesis · Recommendation-specific

AF-CARE framework and an explicit international comparison to US recommendations.

Citation: Van Gelder IC, et al. Eur Heart J. 2024;45:3314–3414.
DOI / identifier: 10.1093/eurheartj/ehae176
Correction / erratum: Later correction indexed as PMID 40622753.

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5 2018 ACC/AHA/HRS Bradycardia and Cardiac Conduction Delay Guideline — Executive SummaryGuideline · bradycardia/conduction · Recommendation-specific

Sinus node disease, AV block, pacing decisions, and reversible causes.

Citation: Kusumoto FM, et al. Circulation. 2019;140:e333–e381.
DOI / identifier: 10.1161/CIR.0000000000000627

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6 2015 ACC/AHA/HRS Guideline for Adult Supraventricular TachycardiaGuideline · supraventricular tachycardia · Recommendation-specific

AVNRT/AVRT, focal atrial tachycardia, pre-excitation, acute therapy, and ablation.

Citation: Page RL, et al. Circulation. 2016;133:e506–e574.
DOI / identifier: 10.1161/CIR.0000000000000311

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7 2019 ESC Guidelines for Supraventricular TachycardiaGuideline · international comparison · Recommendation-specific

Updated SVT diagnosis, acute treatment, ablation, pregnancy, and special contexts.

Citation: Brugada J, et al. Eur Heart J. 2020;41:655–720.
DOI / identifier: 10.1093/eurheartj/ehz467

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8 2022 ESC Guidelines for Ventricular Arrhythmias and Prevention of Sudden Cardiac DeathGuideline · ventricular arrhythmias · Recommendation-specific

Ventricular arrhythmias, electrical storm, structural disease, genetic evaluation, devices, and ablation.

Citation: Zeppenfeld K, et al. Eur Heart J. 2022;43:3997–4126.
DOI / identifier: 10.1093/eurheartj/ehac262

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9 REVERT: modified versus standard Valsalva for supraventricular tachycardiaRandomized controlled trial · Moderate · direct for stable SVT

Shows why the postural modification belongs before medication in a stable regular narrow-complex pathway.

Citation: Appelboam A, et al. Lancet. 2015;386:1747–1753.
DOI / identifier: 10.1016/S0140-6736(15)61485-4

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10 PROCAMIO: procainamide versus amiodarone for tolerated wide-QRS tachycardiaRandomized controlled trial · Low–moderate · small open-label trial

Practice-shaping comparative evidence, taught with its small sample and setting limitations visible.

Citation: Ortiz M, et al. Eur Heart J. 2017;38:1329–1335.
DOI / identifier: 10.1093/eurheartj/ehw230

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11 RAFF2: electrical versus drug–shock cardioversion for acute atrial fibrillationRandomized controlled trial · Moderate · ED acute AF population

ED rhythm-control strategy, procainamide, and electrical cardioversion in selected recent-onset AF.

Citation: Stiell IG, et al. Lancet. 2020;395:339–349.
DOI / identifier: 10.1016/S0140-6736(19)32994-0

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12 EAST-AFNET 4: early rhythm-control therapy in atrial fibrillationRandomized controlled trial · High for enrolled early-AF population

Changes the longitudinal frame from symptom rescue alone to selected early rhythm control.

Citation: Kirchhof P, et al. N Engl J Med. 2020;383:1305–1316.
DOI / identifier: 10.1056/NEJMoa2019422
Population: 2,789 patients with AF diagnosed ≤1 year earlier and cardiovascular conditions; median diagnosis-to-enrollment 36 days.
Methods: Open-label randomized strategy trial with blinded outcome assessment; early rhythm control (drugs/ablation) versus usual care; median follow-up 5.1 years, stopped early for efficacy.
Effect estimate: First primary cardiovascular composite: 249 versus 316 events, 3.9 versus 5.0 per 100 person-years; HR 0.79, 96% CI 0.66–0.94. Serious rhythm-therapy-related adverse events: 4.9% versus 1.4%.
Limits: An early-AF strategy result, not the mortality effect of an individual drug or an acute ED cardioversion. Open treatment allocation and early stopping matter.
Access / review due: 2026-10-08 / 2027-04-08. Primary PubMed abstract rechecked; existing study-card details retained without claiming a new complete full-text appraisal.

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13 EHRA Practical Compendium of Antiarrhythmic DrugsExpert consensus · pharmacology compendium · Consensus plus drug-specific evidence

Owner-selected lead pharmacology source for ARR: drug mechanism, rate/state dependence, selection, PK/PD, interactions, safety, and monitoring; always paired with the correction record.

Citation: Merino JL, et al. Europace. 2025;27:euaf076; corrected March 2026.
DOI / identifier: 10.1093/europace/euaf076
Correction / erratum: March 17, 2026 correction DOI 10.1093/europace/euag041: mexiletine dosing/formulation row, amiodarone oral-maintenance footnote, and Table 17 lactation wording.
Access / review due: 2026-10-08 / 2027-04-08. Open primary consensus compendium: kinetics, substrate, interactions and proarrhythmia sections; March 17, 2026 correction checked alongside parent.

Open primary record

14 Correction to the EHRA Practical Compendium of Antiarrhythmic DrugsPost-publication correction · Definitive for the corrected article text

Mandatory dependency for any mexiletine dosing/formulation table, amiodarone oral-maintenance table, or Table 17 pregnancy/lactation interpretation derived from the 2025 compendium.

Citation: Europace. 2026;28:euag041. Published March 17, 2026.
DOI / identifier: 10.1093/europace/euag041

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15 Ten key messages from the EHRA Practical Compendium of Antiarrhythmic DrugsExpert consensus · companion summary · Consensus summary; refer to full compendium for detail

Retrieval scaffold for the full compendium; never a substitute for corrected drug-specific detail.

Citation: European Heart Journal. 2026;47:ehaf805.
DOI / identifier: 10.1093/eurheartj/ehaf805

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16 FDA approval of intranasal etripamil (Cardamyst) for adult PSVT self-treatmentRegulatory review + randomized trials · Approved indication; post-guideline

A living-evidence example: contemporary approved therapy that is not integrated into the older US/ESC SVT guidelines.

Citation: US Food and Drug Administration. Drug Trials Snapshot: Cardamyst. December 2025.
DOI / identifier: FDA approval record; RAPID trial DOI 10.1016/S0140-6736(23)00776-6

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17 Effectiveness of the Valsalva manoeuvre for reversion of SVTSystematic review · Limited by heterogeneous, older studies

Evidence-synthesis layer used alongside, not as a substitute for, the later REVERT trial.

Citation: Smith GD, et al. Cochrane Database Syst Rev. 2015;CD009502.
DOI / identifier: 10.1002/14651858.CD009502.pub3

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18 Wide QRS Complex TachycardiaTertiary clinical review · Orientation layer · verify management claims

Open-access scaffold for WCT definitions, mechanisms, differential diagnosis, and initial evaluation.

Citation: Obando MA, Marra EM. StatPearls [Internet]. Updated June 26, 2023.
DOI / identifier: Bookshelf ID NBK559054; PMID 32644480

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19 Modified versus standard Valsalva for PSVT in an Indian emergency departmentRandomized controlled trial · new evidence · Low–moderate · small single-center trial

A current, imprecise replication signal used to teach confidence intervals, external context, and why one small trial does not erase REVERT.

Citation: Arora S, et al. Indian Heart J. 2026. Online ahead of print.
DOI / identifier: 10.1016/j.ihj.2026.02.004

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20 CAST preliminary report: encainide/flecainide after MIPrimary randomized trial · Population-specific evidence

Historical explanation of the failure of PVC suppression as a survival surrogate; boundary for the Class Ic case and assessment.

Citation: Cardiac Arrhythmia Suppression Trial (CAST) Investigators. N Engl J Med. 1989;321:406–412.
DOI / identifier: 10.1056/NEJM198908103210629
Population: Post-MI patients with asymptomatic or mildly symptomatic ventricular ectopy; randomized after demonstrated drug suppression.
Methods: Randomized placebo-controlled arrhythmia-suppression trial; preliminary encainide/flecainide comparison stopped early.
Effect estimate: Total mortality 56/730 (7.7%) versus 22/725 (3.0%); RR 2.5, 95% CI 1.6–4.5; mean follow-up ten months.
Limits: Post-MI ectopy is not every AF/CAD phenotype; current guidelines supply broader prescribing restrictions. Early stopping and responder selection constrain interpretation.
Access / review due: 2026-10-08 / 2027-04-08. Accessible primary PubMed abstract; no claim of full-text appraisal.

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21 AFFIRM: rate versus rhythm-control strategyPrimary randomized trial · Population-specific evidence

Historical context for the AFFIRM-to-EAST narrative.

Citation: Wyse DG, Waldo AL, DiMarco JP, et al.; AFFIRM Investigators. N Engl J Med. 2002;347:1825–1833.
DOI / identifier: 10.1056/NEJMoa021328
Population: 4,060 patients with AF at high risk of stroke or death.
Methods: Randomized comparison of rate-control versus then-delivered rhythm-control strategies.
Effect estimate: Mortality HR 1.15, 95% CI 0.99–1.34 (P=0.08); no significant survival advantage for rhythm control.
Limits: Strategy and treatment era matter; not proof that sinus rhythm never helps, nor a comparison of every modern early rhythm-control strategy.
Access / review due: 2026-10-08 / 2027-04-08. Primary publisher indexed abstract; survival result also checked in the accessible 2023 AF guideline author manuscript. Publisher full text unavailable.

Open primary record

What was checked in this pass

Each new story and field-note claim is mapped to guidance, a primary report, or explicit synthesis. The existing atlas drills and assessment were also reconciled against their supporting sources. This is a scoped safety review, not an independent pharmacist sign-off or a completed systematic review of every monograph sentence.

Open claim-by-claim review

LADDER-SVT-REVERT · Initial choice, all four option rationales/conditional uses, execution and changed-patient rescue for SVT-REVERT

Guideline/label-based teaching with explicit expert synthesis · Reviewed 2026-10-08

Check: Reviewed the initial key, each option's mechanism/eligibility boundary, execution/monitoring and stop-rescue response against the named sources. Synthetic recommendations are not complete medication orders; unsafe options are not given fabricated appropriate uses.

Source / location: REVERT-2015, ACC-SVT-2015 · AHA 2025 §17; 2015 SVT guidance; REVERT trial record in existing source dossier

Applies to: Part 1 #case-SVT-REVERT (including changed case and provider rehearsal)

LADDER-VT-PROCAMIO · Initial choice, all four option rationales/conditional uses, execution and changed-patient rescue for VT-PROCAMIO

Guideline/label-based teaching with explicit expert synthesis · Reviewed 2026-10-08

Source / location: PROCAMIO-2017, AHA-ALS-2025 · AHA 2025 §15 and tachycardia algorithm; PROCAMIO primary trial in existing source dossier

Applies to: Part 1 #case-VT-PROCAMIO (including changed case and provider rehearsal)

LADDER-AF-RAFF2 · Initial choice, all four option rationales/conditional uses, execution and changed-patient rescue for AF-RAFF2

Guideline/label-based teaching with explicit expert synthesis · Reviewed 2026-10-08

Source / location: RAFF2-2020, ACC-AF-2023 · 2023 AF §8.2.1–8.2.3; RAFF2 primary trial in existing source dossier

Applies to: Part 1 #case-AF-RAFF2 (including changed case and provider rehearsal)

LADDER-PREEXCITED-AF · Initial choice, all four option rationales/conditional uses, execution and changed-patient rescue for PREEXCITED-AF

Guideline/label-based teaching with explicit expert synthesis · Reviewed 2026-10-08

Source / location: ACC-AF-2023, ACC-SVT-2015 · 2023 AF §10.6; AHA 2025 §18; 2015 SVT orthodromic AVRT guidance

Applies to: Part 1 #case-PREEXCITED-AF (including changed case and provider rehearsal)

LADDER-DIGOXIN-SAMPLING · Initial choice, all four option rationales/conditional uses, execution and changed-patient rescue for DIGOXIN-SAMPLING

Guideline/label-based teaching with explicit expert synthesis · Reviewed 2026-10-08

Source / location: LABEL-DIGOXIN · DailyMed digoxin §2.5, §5.3 and §12.3

Applies to: Part 1 #case-DIGOXIN-SAMPLING (including changed case and provider rehearsal)

LADDER-DOFETILIDE-INTERACTION · Initial choice, all four option rationales/conditional uses, execution and changed-patient rescue for DOFETILIDE-INTERACTION

Guideline/label-based teaching with explicit expert synthesis · Reviewed 2026-10-08

Source / location: LABEL-DOFETILIDE · DailyMed dofetilide boxed warning, contraindications, trimethoprim interaction, dosage

Applies to: Part 1 #case-DOFETILIDE-INTERACTION (including changed case and provider rehearsal)

LADDER-AMIODARONE-HANDOFF · Initial choice, all four option rationales/conditional uses, execution and changed-patient rescue for AMIODARONE-HANDOFF

Guideline/label-based teaching with explicit expert synthesis · Reviewed 2026-10-08

Source / location: LABEL-AMIODARONE, LABEL-DIGOXIN · DailyMed amiodarone §5.1 and §7; digoxin monitoring/renal impairment

Applies to: Part 1 #case-AMIODARONE-HANDOFF (including changed case and provider rehearsal)

LADDER-BRADY-PACING · Initial choice, all four option rationales/conditional uses, execution and changed-patient rescue for BRADY-PACING

Guideline/label-based teaching with explicit expert synthesis · Reviewed 2026-10-08

Source / location: AHA-ALS-2025, ACC-BRADY-2018 · AHA 2025 §19; 2018 bradycardia guideline

Applies to: Part 1 #case-BRADY-PACING (including changed case and provider rehearsal)

LADDER-UNSTABLE-WCT · Initial choice, all four option rationales/conditional uses, execution and changed-patient rescue for UNSTABLE-WCT

Guideline/label-based teaching with explicit expert synthesis · Reviewed 2026-10-08

Source / location: AHA-ALS-2025 · AHA 2025 §15 and §16

Applies to: Part 1 #case-UNSTABLE-WCT (including changed case and provider rehearsal)

LADDER-AF-DECOMP-HF · Initial choice, all four option rationales/conditional uses, execution and changed-patient rescue for AF-DECOMP-HF

Guideline/label-based teaching with explicit expert synthesis · Reviewed 2026-10-08

Source / location: ACC-AF-2023, AHA-ALS-2025, LABEL-ESMOLOL, LABEL-DIGOXIN · 2023 AF §7.2.1 and §8.2.2; AHA 2025 §18; DailyMed esmolol §4–5

Applies to: Part 1 #case-AF-DECOMP-HF (including changed case and provider rehearsal)

LADDER-ACQUIRED-TORSADES · Initial choice, all four option rationales/conditional uses, execution and changed-patient rescue for ACQUIRED-TORSADES

Guideline/label-based teaching with explicit expert synthesis · Reviewed 2026-10-08

Source / location: AHA-ALS-2025, LABEL-SOTALOL · AHA 2025 §16; DailyMed oral sotalol §2.5, §5.1 and §12.3

Applies to: Part 1 #case-ACQUIRED-TORSADES (including changed case and provider rehearsal)

LADDER-POLYMORPHIC-ISCHEMIA · Initial choice, all four option rationales/conditional uses, execution and changed-patient rescue for POLYMORPHIC-ISCHEMIA

Guideline/label-based teaching with explicit expert synthesis · Reviewed 2026-10-08

Source / location: AHA-ALS-2025 · AHA 2025 §16 recommendations 1–4 and supportive text

Applies to: Part 1 #case-POLYMORPHIC-ISCHEMIA (including changed case and provider rehearsal)

ATLAS-ED-SAFETY-011 · Six targeted ED summaries: torsades shock/recurrence separation, esmolol eligibility, mexiletine neurologic differential, selected isoproterenol use

Established guidance/regulatory label plus explicit synthesis · Reviewed 2026-10-08

Check: Sustained polymorphic VT requires immediate unsynchronized shock; magnesium and expert-selected rate support do not replace it. Short esmolol disposition does not negate decompensated-HF/shock exclusions. Mexiletine adverse effects do not exclude stroke. Isoproterenol is selected expert-guided support, not a routine ACLS bradycardia infusion.

Source / location: AHA-ALS-2025, LABEL-DOFETILIDE, LABEL-SOTALOL, LABEL-MEXILETINE, LABEL-ESMOLOL · AHA 2025 §16/19; esmolol §4/5; mexiletine adverse reactions

Applies to: Atlas #drug-dofetilide, #drug-sotalol, #drug-magnesium, #drug-isoproterenol, #drug-esmolol, #drug-mexiletine, Ladder AF-DECOMP-HF, ACQUIRED-TORSADES, POLYMORPHIC-ISCHEMIA

N-CAST-1 · CAST: a quieter monitor was not a safer patient

Primary trial evidence · Reviewed 2026-10-08

Check: Population restricted to post-MI ventricular ectopy; no extrapolation to all AF or all CAD.

Source / location: CAST-1989 · CAST preliminary abstract: Methods/Conclusions

Applies to: Part 2 narrative #cast

N-CAST-2 · CAST: a quieter monitor was not a safer patient

Primary trial evidence · Reviewed 2026-10-08

Check: Verified total-mortality percentages, average follow-up and RR/95% CI; kept separate from arrhythmic death/nonfatal arrest endpoint.

Source / location: CAST-1989 · CAST preliminary abstract: Results

Applies to: Part 2 narrative #cast

N-CAST-3 · CAST: a quieter monitor was not a safer patient

Explicit synthesis grounded in guidance · Reviewed 2026-10-08

Check: Re-entry explanation explicitly synthesis; current prior-MI/scar/HFrEF exclusion not misattributed as CAST's full population.

Source / location: EHRA-AAD-2025, ACC-AF-2023 · EHRA channel/substrate discussion; 2023 AF guideline 8.3.1

Applies to: Part 2 narrative #cast

N-CAST-4 · CAST: a quieter monitor was not a safer patient: patient recommendation

Explicit expert synthesis · Reviewed 2026-10-08

Check: This is a selection decision, not a complete HFrEF/AF treatment plan. A different patient without prior MI or significant structural disease still needs conduction, interaction and monitored-initiation checks.

Source / location: CAST-1989, EHRA-AAD-2025, ACC-AF-2023 · Same source sections as the narrative

Applies to: Part 2 synthetic transfer case #cast

N-AF-1 · AFFIRM to EAST-AFNET 4: the question changed

Primary trial evidence · Reviewed 2026-10-08

Check: Verified n=4,060, HR 1.15/95% CI 0.99–1.34 and nonsignificance. Strategy/era boundary retained; full publisher text inaccessible.

Source / location: AFFIRM-2002 · AFFIRM primary publisher indexed abstract; 2023 AF guideline 7.1

Applies to: Part 2 narrative #af-strategy

N-AF-2 · AFFIRM to EAST-AFNET 4: the question changed

Primary trial evidence · Reviewed 2026-10-08

Check: Verified n=2,789, early-AF criteria, composite endpoint, HR 0.79 with 96% (not 95%) CI and early stopping; included treatment-related serious adverse events.

Source / location: EAST-AFNET4-2020 · EAST-AFNET 4 primary PubMed abstract: Methods/Results

Applies to: Part 2 narrative #af-strategy

N-AF-3 · AFFIRM to EAST-AFNET 4: the question changed

Explicit synthesis grounded in guidance · Reviewed 2026-10-08

Check: Strategy comparison cannot identify one drug's mortality effect; independent risk-based stroke prevention preserved.

Source / location: ACC-AF-2023, EAST-AFNET4-2020 · 2023 AF guideline 6.2 and rhythm-control recommendations; EAST abstract

Applies to: Part 2 narrative #af-strategy

N-AF-4 · AFFIRM to EAST-AFNET 4: the question changed: patient recommendation

Explicit expert synthesis · Reviewed 2026-10-08

Check: Do not turn this into immediate cardioversion of uncertain-duration AF. Pericardioversion anticoagulation/imaging requirements and causal instability still determine the acute branch.

Source / location: AFFIRM-2002, EAST-AFNET4-2020, ACC-AF-2023 · Same source sections as the narrative

Applies to: Part 2 synthetic transfer case #af-strategy

N-QT-1 · The rhythm converted. The risk changed with it.

Established guidance / pharmacology · Reviewed 2026-10-08

Check: Reverse use dependence identified for sotalol/dofetilide, not every Class III drug; post-conversion risk framed as possible, not inevitable.

Source / location: EHRA-AAD-2025 · EHRA pharmacodynamic/channel kinetics and proarrhythmia sections

Applies to: Part 2 narrative #conversion-risk

N-QT-2 · The rhythm converted. The risk changed with it.

Established guidance / pharmacology · Reviewed 2026-10-08

Check: TMP renal cationic secretion verified; HCTZ has exposure plus potassium effect. Contraindicated combinations not cured by staggering doses.

Source / location: LABEL-DOFETILIDE · Dofetilide label Contraindications and Drug–Drug Interactions

Applies to: Part 2 narrative #conversion-risk

N-QT-3 · The rhythm converted. The risk changed with it.

Established guidance / pharmacology · Reviewed 2026-10-08

Check: Persistent toxicity/interactions after discontinuation verified; other drugs not assigned the same half-life or behavior.

Source / location: LABEL-AMIODARONE, EHRA-AAD-2025 · Oral amiodarone label 5.1 and interactions; EHRA PK sections

Applies to: Part 2 narrative #conversion-risk

N-QT-4 · The rhythm converted. The risk changed with it.: patient recommendation

Explicit expert synthesis · Reviewed 2026-10-08

Check: A QT-associated risk pattern is not itself proof of torsades. The actual rhythm, perfusion and labeled stop criteria govern action; congenital and acquired long-QT management are not interchangeable.

Source / location: EHRA-AAD-2025, LABEL-DOFETILIDE, LABEL-AMIODARONE · Same source sections as the narrative

Applies to: Part 2 synthetic transfer case #conversion-risk

F-1 · No pulse

Established guidance / labeled pharmacology · Reviewed 2026-10-08

Check: Shockable VF/pVT separated from nonshockable PEA/asystole.

Source / location: AHA-ALS-2025 · ALS arrest pathway / defibrillation

Applies to: Field note sheet 1

F-2 · Causative unstable tachyarrhythmia

Established guidance / labeled pharmacology · Reviewed 2026-10-08

Check: Causal instability, synchronization, nondelaying sedation and sustained polymorphic unsynchronized shock checked.

Source / location: AHA-ALS-2025 · WCT and polymorphic VT recommendations; tachyarrhythmia algorithm

Applies to: Field note sheet 1

F-3 · Stable regular narrow rhythm

Established guidance / labeled pharmacology · Reviewed 2026-10-08

Check: Re-entrant SVT distinguished from sinus response and flutter unmasking.

Source / location: AHA-ALS-2025 · Regular narrow-complex tachycardia recommendations

Applies to: Field note sheet 1

F-4 · Stable regular monomorphic WCT

Established guidance / labeled pharmacology · Reviewed 2026-10-08

Check: Adenosine restricted to stable regular monomorphic WCT; verapamil/diltiazem prohibited for undifferentiated WCT; rescue availability retained.

Source / location: AHA-ALS-2025 · WCT recommendations and accessible tachyarrhythmia algorithm

Applies to: Field note sheet 1

F-5 · Pre-excited AF

Established guidance / labeled pharmacology · Reviewed 2026-10-08

Check: Stable procainamide/ibutilide selection and unstable electrical therapy checked; AV-nodal blockers including IV amiodarone avoided. Not every irregular WCT equated with WPW.

Source / location: ACC-AF-2023 · 10.6 WPW / pre-excitation

Applies to: Field note sheet 1

F-6 · Poor-perfusion bradycardia

Established guidance / labeled pharmacology · Reviewed 2026-10-08

Check: Reversible causes, reasonable atropine, refractory pacing/epinephrine/dopamine bridge and mechanical capture checked; no universal isoproterenol or delay for repeated atropine.

Source / location: AHA-ALS-2025 · 19: Initial Management of Bradycardia

Applies to: Field note sheet 1

F-7 · AF before selecting therapy

Established guidance / labeled pharmacology · Reviewed 2026-10-08

Check: Moderate/severe LV dysfunction excludes IV nondihydropyridine CCBs even without decompensation; chemical and electrical conversion share thromboembolic planning.

Source / location: ACC-AF-2023, AHA-ALS-2025 · 7.2.1 Acute Rate Control; 8.2 cardioversion

Applies to: Field note sheet 1

F-8 · Procainamide stopping rules

Established guidance / labeled pharmacology · Reviewed 2026-10-08

Check: Hypotension, termination, >50% QRS increase and maximum load; HF/long-QT avoidance; renal NAPA handling. No numeric dose or energy inserted.

Source / location: AHA-ALS-2025, ACC-AF-2023, EHRA-AAD-2025 · Accessible 2025 tachyarrhythmia algorithm; EHRA procainamide PK

Applies to: Field note sheet 2

F-9 · Recurrent torsades versus sustained polymorphic VT

Established guidance / labeled pharmacology · Reviewed 2026-10-08

Check: Magnesium recommendation limited to recurrent long-QT polymorphic VT (2b, C-LD). Sustained rhythm needs immediate shock; pause-dependent acquired recurrence may need expert rate support; normal-QT branch differs.

Source / location: AHA-ALS-2025 · 16: Polymorphic Ventricular Tachycardia

Applies to: Field note sheet 2

F-10 · Class Ic candidacy / pill-in-the-pocket

Established guidance / labeled pharmacology · Reviewed 2026-10-08

Check: Prior monitored validation and nodal protection reduce risk, not guarantee safety; CAST trial population separated from current selection rules.

Source / location: ACC-AF-2023, EHRA-AAD-2025, CAST-1989 · 8.2.3; 8.3.1 and 8.3.2; CAST primary abstract

Applies to: Field note sheet 2

F-11 · Dofetilide/sotalol monitoring and interaction

Established guidance / labeled pharmacology · Reviewed 2026-10-08

Check: Dofetilide ≥3-day monitored initiation/re-initiation and TMP contraindication checked. Renal/ECG/electrolyte/rate review is drug-specific.

Source / location: LABEL-DOFETILIDE, EHRA-AAD-2025, LABEL-SOTALOL · Boxed warning; contraindications; drug interactions; EHRA kinetics

Applies to: Field note sheet 2

F-12 · Persistent amiodarone / digoxin handoff

Established guidance / labeled pharmacology · Reviewed 2026-10-08

Check: Amiodarone persistence and warfarin/digoxin exposure checked; digoxin level alone or an early sample not equated with toxicity.

Source / location: LABEL-AMIODARONE, LABEL-DIGOXIN · 5.1 and interactions; digoxin monitoring/toxicity sections

Applies to: Field note sheet 2

A-1 · Acute opening case and orientation

Guidance plus explicit bedside synthesis · Reviewed 2026-10-08

Check: Unstable organized WCT with a pulse requires synchronized cardioversion. Distinguish causative tachyarrhythmia from compensatory sinus tachycardia; prepare rescue despite current stability.

Source / location: AHA-ALS-2025 · WCT, regular narrow-complex and bradycardia sections

Applies to: Part 1 opening case, Part 1 acute orientation

D-af-hfref-rate · The rate agent that also drops the pump

Guidance applied to an original synthetic drill · Reviewed 2026-10-08

Check: Preserved-perfusion/HF context and CCB exclusion retained; esmolol offset not permission in shock.

Source / location: ACC-AF-2023, LABEL-ESMOLOL · AF guideline 7.2.1; esmolol warnings

Applies to: Atlas drill af-hfref-rate: stem, correct option, all four option feedback lines, explanation

D-stable-vt-mi · Tolerated monomorphic VT: choosing a pharmacologic attempt

Guidance applied to an original synthetic drill · Reviewed 2026-10-08

Check: Selected tolerated monomorphic WCT only; no universal procainamide superiority or substitution for shock.

Source / location: AHA-ALS-2025, PROCAMIO-2017 · AHA WCT recommendations; PROCAMIO Methods/Results

Applies to: Atlas drill stable-vt-mi: stem, correct option, all four option feedback lines, explanation

D-preexcited-af-wpw · The rhythm where blocking the node feeds the pathway

Guidance applied to an original synthetic drill · Reviewed 2026-10-08

Check: AV-nodal blockers including IV amiodarone unsafe; procainamide/ibutilide only suitable stable patient.

Source / location: ACC-AF-2023 · AF guideline 10.6

Applies to: Atlas drill preexcited-af-wpw: stem, correct option, all four option feedback lines, explanation

D-torsades-pause-dependent · The twisting rhythm you do not treat with a class III

Guidance applied to an original synthetic drill · Reviewed 2026-10-08

Check: Recurrent self-terminating acquired long-QT episodes separated from sustained electrical emergency; magnesium evidence limited and rate support specialist-directed.

Source / location: AHA-ALS-2025 · AHA polymorphic VT recommendations

Applies to: Atlas drill torsades-pause-dependent: stem, correct option, all four option feedback lines, explanation

D-thyrotoxic-sympathetic-rate · The beta-blocker you can take back in minutes

Guidance applied to an original synthetic drill · Reviewed 2026-10-08

Check: Stem now specifies preserved perfusion/EF and no HF; short half-life does not prevent collapse, and amiodarone not categorically prohibited.

Source / location: LABEL-ESMOLOL, EHRA-AAD-2025 · Esmolol indications/warnings; EHRA thyroid-related arrhythmia discussion

Applies to: Atlas drill thyrotoxic-sympathetic-rate: stem, correct option, all four option feedback lines, explanation

D-pip-flecainide-normal-heart · The single-dose cardioverter that needs a clean substrate first

Guidance applied to an original synthetic drill · Reviewed 2026-10-08

Check: Monitored prior validation and candidacy checks explicit; nodal protection reduces 1:1 risk, not absolute protection; historical trial boundary corrected.

Source / location: ACC-AF-2023, ESC-AF-2024, CAST-1989 · AF guideline 8.2.3/8.3.1–2; ESC AF rhythm-control recommendations; CAST abstract

Applies to: Atlas drill pip-flecainide-normal-heart: stem, correct option, all four option feedback lines, explanation

D-flutter-ibutilide-cardioversion · The class III that converts flutter, under a torsades watch

Guidance applied to an original synthetic drill · Reviewed 2026-10-08

Check: QT/electrolyte/EF and post-infusion continuous ECG requirements retained; conversion does not replace stroke planning.

Source / location: ACC-AF-2023, LABEL-IBUTILIDE · Ibutilide boxed warning and monitoring; AF pharmacological cardioversion

Applies to: Atlas drill flutter-ibutilide-cardioversion: stem, correct option, all four option feedback lines, explanation

D-infranodal-block-pacing · High-grade block: prepare pacing while supporting perfusion

Guidance applied to an original synthetic drill · Reviewed 2026-10-08

Check: After failed atropine and ongoing shock, pacing plus protocol epinephrine/dopamine bridge rather than routine isoproterenol; mechanical capture and no-delay emphasis.

Source / location: AHA-ALS-2025 · AHA 19: bradycardia recommendations

Applies to: Atlas drill infranodal-block-pacing: stem, correct option, all four option feedback lines, explanation