atrial fibrillation a strategic update paul calle, ghent stephen bohan, boston

Atrial FibrillationA Strategic Update

Paul Calle, Ghent

Stephen Bohan, Boston

Atrial Fibrillation/Strategy

Stephen Bohan Setting the Stage Basic Approach

Paul Calle Common Clinical Decisions Special Situations

Emergency physicians need strategies with regard to recognition clinical evaluation search for precipitating factors heart rate control vs. conversion to sinus

rhythm prevention of thromboembolism management in particular subgroups admission versus discharge



Strategies are plans to accomplish a goal. Goal for atrial fibrillation should be to treat

each patient efficiently and safely based on evidence.

Such a strategy should allow for treatment to be standardized.


Why should treatment be standardized? Standardization reduces variability and

variability is the enemy of efficiency and safety

Atrial fibrillation will become an extremely common presentation to the Emergency Department

Atrial Fibrillation/ Strategy

Atrial Fibrillation/ Prevalence < 55 years-----1/1000 > 79 years-----9/100

Atrial Fibrillation/Importance 1.5 to 1.9 increase in mortality


Before we can develop a goal/strategy we need better taxonomy: (Is this an anglophone problem?) Lone Paroxysmal Persistent Recurrent Chronic

Atrial Fibrillation/Strategy Lexicon/Definitions (ACC/AHA/ESC)

First Detected Episode Recurrent (2 or more episodes)

• If episode stops spontaneously = PAROXYMAL• If episode is sustained = PERSISTENT

• Conversion does not change designation

Permanent Lone Patient younger than 60yrs and no

disease clinically or by echo

Atrial Fibrillation

All of the above terms refer to episodes that are: 1) at least 30 sec in duration and 2) do not have a secondary cause such

as surgery or thyroid disease

The many faces of atrial fibrillation in ED ... Tachycardia-related symptoms (palpitations, chest pain,

lightheadedness, pulmonary edema, ...) bradycardia-related symptoms (cardiogenic shock,

[convulsive] syncope, ...) Trauma Stroke and systemic embolism Symptoms mainly related to precipitating medical

condition (alcoholism, hyperthyreodism, pneumonia, ...) Asymptomatic



Emergency Department Approach: Unstable patient:

• hypotension• angina• hyoxemia• wide irregular (hard to tell at high rate)

tachycardia ELECTRICITY (BIPHASIC) IS YOUR

FRIEND (CIRCULATION 2000;101:1282)


Emergency Department Approach Careful history:

• time of onset• medications• recent surgery• symptoms of chest discomfort (patients often

have ‘sensation” that is not like angina)• symptoms of thyroid disease


Emergency Department approach Stable patient

• Physical Examination• Evidence of CHF• Evidence of pneumonia (fever)• Evidence of thyroid disease• Careful auscultation (after rate control)

• Record/EKG review

Atrial Fibrillation/Strategy Emergency Department approach

Laboratory examination• EKG (prior BBB, prior MI, active ischemia)• Chest X ray (heart size, effusion, pneumonia)• Metabolic screen including TSH on first episode

Anti coagulation• Aspirin• Low Molecular Weight Heparin • Coumadin (start in ED)


What agent should be used for rate control?

calcium channel blockers and beta blockers equally effective at start of treatment

Digoxin slower to take effect

• beta blockers render better control on exercise• beta blockers reduce mortality in CHF• beta blockers reduce mortality post MI


Conversion Two kinds of conversion

• conversion of rhythm • conversion of physicians to new mode of

treatment

Why convert? (common wisdom) “Improved

hemodynamics, less CHF, fewer emboli”

Atrial Fibrillation

Who should be converted?• 50% of patients convert on their own in

24 hours• Young (<55yrs), • first episode • clearly identified cause (cardiac surgery,

catecholamine, medications) • no history of/evidence of valvular heart

disease


Conversion >59 years--16% reversion rate at 30 days

and 30% at one year--- even with antidysrhythmic, worse if structural heart disease

BUT---MOST IMPORTANTLY---- Conversion probably does not make any

difference.


AFFIRM and RACE two studies, two continents, 4,500 patients all patients had had at least one prior

episode mostly age 60+ rate control vs rhythm control

NO DIFFERENCE IN DEATH OR STROKE


Stroke occurred even when in sinus rhythm

Stroke occurred when off anticoagulants or with subtherapeutic INR

Atrial Fibrillation/Strategy How should AFFIRM and RACE change

my practice in the Emergency Department? If patient is stable: control rate and initiate

anticoagulation, observe for conversion if young, first episode, onset within 48 hrs

and no spontaneous conversion consider propafenone 600 mg po or electrical cardioversion--continue anticoagulation.

Anticoagulation strategy : ACC/AHA/ESC guidelines Recommendations to prevent ischemic

stroke and systemic embolism Recommendations to prevent ischemic

stroke and systemic embolism related to cardioversion


Class I: Conditions for which there is evidence for and/or general agreement that the procedure or treatment is useful and effective

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment


Class IIa:The weight of evidence or opinion is in favor of the procedure or treatment

Class IIb: Usefulness/efficacy is less well

established by evidence or opinionClass III:Conditions for which there is evidence and/or general agreement that the procedure or treatment is not useful/effective and in some cases can be harmful


Recommendations for antithrombotic therapy in patients with AF

Class I1. Administer antithrombotic therapy (oral anticoagulation or aspirin) to all patients with AFexcept those with lone AF, to prevent thromboembolism. (Level of evidence: A)2. Individualize the selection of the antithrombotic agent based on assessment of the absolute risks

of stroke and bleeding and the relative risk and benefit for a particular patient. (Level of evidence:A)

Recommendations for antithrombotic therapy in patients with AF based on thromboembolic risk stratification

Patient features Antithrombotic therapy

Grade of recommendation

Age < 60 yrs No heart disease (lone AF)Age < 60 yrs Heart disease but no risk factors*Age 60 yrs, no risk factors*Age 60 yrs With diabetes mellitus or coronary artery disease

Aspirin (325 mg daily) or no therapyAspirin (325 mg daily)

Aspirin (325 mg daily)Oral anticoagulation (INR 2.0 - 3.0)Addition of aspirin, 81-162 mg daily is optional

I

I

I I

IIb

*Risk factors for thromboembolism include heart failure, LV ejection fraction < 0.35, and history of hypertension.

Patient features Antithrombotic therapy

Grade of recommendation

Age 75 yrs especially women

Heart failureLV ejection fraction 0.35ThyrotoxicosisHypertensionRheumatic heart disease (mitral stenosis)

Prosthetic heart valvesPrior thromboembolismPersistent atrial thrombus on TEE

Oral anticoagulation (INR 2.0)Oral anticoagulation (INR 2.0 - 3.0)

Oral anticoagulation (INR 2.5 - 3.5 or higher may be appropriate)

I

I

I

Class IIa

1. Target a lower INR of 2 (range 1.6 to 2.5) for primary prevention of ischemic stroke and systemic embolism in patients over 75 years old considered at increased risk of bleeding complications but without frank contra-indications to oral anticoagulation. (Level of evidence: C)

Class IIa

2. Manage antithrombotic therapy for patients with atrial flutter, in general, as for those with AF. (Level of evidence: C)

3. Select antithrombotic therapy by the same criteria irrespective of the pattern of AF (i.e., for patients with paroxysmal,

persistent, or permanent AF). (Level of evidence: B)

Class IIb1. Interrupt anticoagulation for a period of

up to 1 week for surgical or diagnostic procedures that carry a risk of bleeding, without substituting heparin in patients with AF who do not have mechanical prosthetic heart valves. (Level of

evidence: C)

Class IIb2. Administer heparin (i.v. or s.c.) respecti- vely in selected high-risk patients or when a series of procedures requires inter- ruption of oral anticoagulant therapy for

a period longer than 1 week. (Level of evidence: C)

Recommendations in patients with AF undergoing cardioversion

Class I1. Administer anticoagulation therapy regardless of the method (electrical

or pharmacological) used to restore sinus rhythm. (Level of evidence: B)

2. Anticoagulate patients with AF lasting more than 48h or of unknown

duration for at least 3 to 4 weeks before and after cardioversion (INR 2 to 3).

Level of evidence: B)

3. Perform immediate cardioversion in patients with acute (recent-onset) AF accompanied by symptoms or signs of hemodynamic instability without waiting for prior anticoagulation. (Level of evidence: C)a. If not contraindicated, administer heparin intravenously concurrently.b. Next, provide oral anticoagulation for a period of at least 3 to 4 weeks.c. Limited data from recent studies support low molecular-weight heparin.


4. Screening for thrombus in LA or LA appendage by TEE is an alternative to routine preantico-agulation. (Level of evidence: B)

a. Anticoagulate patients in whom no thrombus is identified with intravenous unfractionated heparin before cardioversion.

b. Next, provide oral anticoagulation (INR 2 to 3) for a period of 3 to 4 weeks.

c. Limited data support low-molecular-weight heparin. (Level of evidence: C)

d. Treat patients whit thrombus on TEE with oral anticoagulation (INR 2 to 3).


Atrial Fibrillation/Strategy Algorithm for management : newly discovered AF

Newly discovered AF

Paroxysmal Persistent

No therapy neededunless severe

symptoms (eg, hypotension, HF, angina pectoris)

Anticoagulation as needed

Accept permanent AF

Anticoagulation and rate control as needed

Rate control and anti-coagulation as needed

Consider antiarrhythmic drug therapy

Cardioversion

Long-termantiarrhythmic drug therapy unnecessary

Atrial Fibrillation/Strategy Algorithm for management : recurrent paroxysmal AF

Recurrent paroxysmal AF

Minimal or no symptoms


No drug forprevention of AF

Disabling symptoms in AF

Antiarrhythmicdrug therapy


Atrial Fibrillation/StrategyAlgorithm for management : recurrent persistent or permanent AF

Recurrent persistent AF Permanent AF

Minimal or no symptoms

Disabling symptoms in AF


Anticoagulation and rate control

Continue anticoagulation as needed and therapy to maintain sinus rhythm


Antiarrhythmicdrug therapy

Electrical cardio-version as needed

Guidelines for management in special situations (ACC/AHA/ESC) Acute myocardial infarction Ventricular preexcitation (WPW-syndrome) Hyperthyroidism During pregnancy Pulmonary diseases


Acute myocardial infarction

Class I1. Electrical cardioversion for patients with severe hemodynamic compromise or intractable ischemia. (Level of evidence: C)

2. Intravenous administration of digitalis or amiodarone to slow a rapid ventricular

response and improve LV function. (Level of evidence: C)


3. Intravenous ß-blockers to slow a rapid ventricular response in patients without clinical LV dysfunction, bronchospastic disease, or AV block. (Level of evidence:

C)

4. Heparin for patients with AF and acute MI, unless contraindications to anticoagulation are present. (Level of evidence: C)

Class III

Administer type IC antiarrhythmic drugs in patients with AF in the setting of acute myo-cardial infarction. (Level of evidence: C)


Ventricular preexcitation

Class IIIIntravenous administration of ß-blocking agents, digitalis glycosides, diltiazem, or verapamil. (Level of evidence: B)

Kent bundel

Class I 1. Immediate electrical cardioversion in case

of hemodynamic instability. (Level of evidence: B)2. Intravenous procainamide or ibutilide in patients without hemodynamic instability in association with a wide QRS-complex. (Level of evidence: C)3. Refer for catheter ablation of the accessory pathway in symptomatic patients. (Level of evidence: B)


Class IIb

Administer intravenous quinidine, procainamide, disopyramide, ibutilide, or amiodarone to hemodynamically stable patients. (Level of evidence: B)


Class I 1. Administer a ß-blocker as necessary to control heart rate, unless contraindicated. (Level of evidence: B)2. In circumstances when a ß-blocker cannot

be used,administer diltiazem or verapamil to control the ventricular rate. (Level of evidence: B)3. Use oral anticoagulation (INR 2 to 3) (Level of evidence: C); once euthyroid, recommendations as for patients without hyperthyroidism. (Level of evidence: C)

Hyperthyroidism

Class I 1. Control the rate of ventricular response with digoxin, a ß-blocker, or a calcium channel

antagonist. (Level of evidence: C)

2. Electrical cardioversion in hemodynamically unstable patients. (Level of evidence: C)

3. Administer antithrombotic therapy (anticoagulant or aspirin) throughout pregnancy. (Level of evidence: C)

Pregnancy

Class IIb 1. Attempt pharmacological cardioversion by

administration of quinidine, procainamide, or sotalol in hemodynamically stable patients. (Level of evidence: C)

2. Administer heparin (i.v. or s.c.) to patients with risk factors during the first trimester and last month of pregnancy. (Level of evidence:

B)3. Administer an oral anticoagulant during the

second trimester to patients at high thromboembolic risk. (Level of evidence: C)

Pregnancy

Class I 1. Correction of hypoxemia and acidosis are

the primary therapeutic measures. (Level of evidence: C)2. In patients with obstructive pulmonary disease who develop AF, a calcium channel antagonist agent (diltiazem or verapamil) is preferred for ventricular rate control. (Level of evidence: C)3. Attempt electrical cardioversion in hemo-dynamically unstable patients. (Level of evidence: C)

Pulmonary diseases

Class III 1. Use of theophylline and ß-adrenergic

agonist agents. (Level of evidence: C)

2. Use of ß-blockers, sotalol, propafenone, and adenosine. (Level of evidence: C)

Pulmonary diseases

Management of bradycardia-related symptoms Increase ventricular rate (atropin, dopamine,

epinephrine, pacemaker, ...) Stop all agents slowing the ventricular response Continuous ECG-monitoring Beware of torsade de pointes


Management of flutter


Rule of thumb for emergency physicians :

atrial flutter = atrial fibrillation

Criteria for hospital admission Highly symptomatic patients Structural heart disease Embolic event or high risk of thromboembolism Failure to control heart rate in ED Start of oral antiarrhythmic therapy with high

proarrhythmia potential after cardioversion Need for admission for appropriate management of

underlying disease


Criteria for discharge from ED No structural heart disease No need for in-hospital management of

underlying disease No or minimal symptoms (after rate control

or cardioversion) No need for proarrhythmic drugs Appropriate follow-up as out-patient possible



Questions ??

atrial fibrillation a strategic update paul calle, ghent stephen bohan, boston

Documents

atrial fibrillationimportance

emergency department

faces of atrial fibrillation

safety atrial fibrillation

boston slide

mortality slide

echo slide

emergency physicians