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Atrial FibrillationA Strategic Update
Paul Calle, Ghent
Stephen Bohan, Boston
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Atrial Fibrillation/Strategy
Stephen Bohan Setting the Stage Basic Approach
Paul Calle Common Clinical Decisions Special Situations
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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
Atrial Fibrillation/Strategy
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Atrial Fibrillation/Strategy
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.
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Atrial Fibrillation/Strategy
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
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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
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Atrial Fibrillation/Strategy
Before we can develop a goal/strategy we need better taxonomy: (Is this an anglophone problem?) Lone Paroxysmal Persistent Recurrent Chronic
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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
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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
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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
Atrial Fibrillation/Strategy
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Atrial Fibrillation/Strategy
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)
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Atrial Fibrillation/Strategy
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
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Atrial Fibrillation/Strategy
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
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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)
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Atrial Fibrillation/Strategy
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
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Atrial Fibrillation/Strategy
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”
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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
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Atrial Fibrillation/Strategy
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.
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Atrial Fibrillation/Strategy
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
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Atrial Fibrillation/Strategy
Stroke occurred even when in sinus rhythm
Stroke occurred when off anticoagulants or with subtherapeutic INR
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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.
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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
Atrial Fibrillation/Strategy
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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
Atrial Fibrillation/Strategy
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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
Atrial Fibrillation/Strategy
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Recommendations for antithrombotic therapy in patients with AF
Class I1. Administer antithrombotic therapy (oral anti- coagulation or aspirin) to all patients with AFexcept those with lone AF, to prevent thrombo- embolism. (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)
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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.
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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
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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)
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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)
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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)
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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)
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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)
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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.
Recommendations in patients with AF undergoing cardioversion
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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).
Recommendations in patients with AF undergoing cardioversion
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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
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Atrial Fibrillation/Strategy Algorithm for management : recurrent paroxysmal AF
Recurrent paroxysmal AF
Minimal or no symptoms
Anticoagulation and rate control as needed
No drug forprevention of AF
Disabling symptoms in AF
Antiarrhythmicdrug therapy
Anticoagulation and rate control as needed
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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 as needed
Anticoagulation and rate control
Continue anticoagulation as needed and therapy to maintain sinus rhythm
Anticoagulation and rate control as needed
Antiarrhythmicdrug therapy
Electrical cardio-version as needed
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Guidelines for management in special situations (ACC/AHA/ESC) Acute myocardial infarction Ventricular preexcitation (WPW-syndrome) Hyperthyroidism During pregnancy Pulmonary diseases
Atrial Fibrillation/Strategy
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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)
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Acute myocardial infarction
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)
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Class III
Administer type IC antiarrhythmic drugs in patients with AF in the setting of acute myo-cardial infarction. (Level of evidence: C)
Acute myocardial infarction
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Ventricular preexcitation
Class IIIIntravenous administration of ß-blocking agents, digitalis glycosides, diltiazem, or verapamil. (Level of evidence: B)
Kent bundel
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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)
Ventricular preexcitation
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Class IIb
Administer intravenous quinidine, procainamide, disopyramide, ibutilide, or amiodarone to hemodynamically stable patients. (Level of evidence: B)
Ventricular preexcitation
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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, recommen- dations as for patients without hyper- thyroidism. (Level of evidence: C)
Hyperthyroidism
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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
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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 thrombo- embolic risk. (Level of evidence: C)
Pregnancy
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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
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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
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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
Atrial Fibrillation/Strategy
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Management of flutter
Atrial Fibrillation/Strategy
Rule of thumb for emergency physicians :
atrial flutter = atrial fibrillation
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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
Atrial Fibrillation/Strategy
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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
Atrial Fibrillation/Strategy
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Atrial Fibrillation/Strategy
Questions ??