Atrial Fibrillation Update Don’t Miss a Beat VanderbiltEM · 2015-12-21 · 2 5 Step ED Dx - Rx...

10/26/2015

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Atrial Fibrillation UpdateDon’t Miss a Beat

ACEP2015

Corey M. Slovis, M.D.Vanderbilt University Medical Center

Metro Nashville Fire DepartmentNashville International Airport

Nashville, TN

VanderbiltEM.com

AFib

20 Facts on Atrial Fibrillation in 20 minutes

Atrial Fibrillation is Common

• # 1 sustained cardiac arrhythmia

• > 3,000,000 patients

• 1% of US population

• 9% of all those ≥ 80 yo

JAMA 2001;285:2370-75

JAMA 2001;285:2370-75

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5 Step ED Dx - Rx• Secure ABCs with rate control, if needed

• Beta blocker vs Diltiazem

• Determine etiologyR/O ischemia, thyroid, electrolyte, toxins, HF

• Establish stroke risk (CHA2DS2VASc)

• Cardiovert, admit or D/C on meds

Pericardium

5 Causes of Atrial Fibrillation

Myocardium

Endocardium

Pulmonary

Hypersympathetic

There Are 5 Causes of Atrial Fibrillation

• Pericardium

• Myocardium

• Endocardium

• Pulmonary

• Hypersympathetic

Pericarditis

LVH, Myocarditis

Endocarditis, valvular heart disease

PE, pulmonary hypertension

Cocaine, amphetamines, hyperthyroid, ETOH withdrawal, caffeine, beta agonists, fever, dehydration

JAMA 2001;285:2370-75

Paroxysmal

5 Types of Atrial Fibrillation

Persistent

Long Standing

Loan AF

Recurrent

There Are 5 Types of Atrial Fibrillation

• Paroxysmal

• Persistent

• Long Standing

• Loan AF

• Recurrent

Terminates spontaneously < 7 days

> 7 days of continued AF

1 year or more

No risk factors and < 60

Repeated episodes often subclinical and not recognized

There Are 5 Routine Tests for All New AF

• CBC

• BMP

• Thyroid

• CXR

• Echocardiogram (sooner or later)

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Consider Additional Tests

• BNP

• Troponin

• Exercise Testing

R/O HF

R/O ACS

WPW, Inducible, ACS

Don’t Discharge AF Patients Without

• Follow up

• Holter / Event Monitor

• Calculation of CHA2DS2VASc score

• Anticoagulants if indicated

• Warnings

JAMA 2001;285:2370-75

Atrial Fibrillation Equals an Increased Stroke Rate

• About 0.5-1% per year but can be higher

• 5% if no anticoagulation

• CHA2DS2VASC – important determinant

• Silent cerebral ischemia by CT/MRI is 20-40%

• AF doubles risk of death from age 55 onward (2.2/1.42 F/M)

Always Calculate the Patient’s ScoreCHA2DS2VASc

• CHF (1)

• Hypertension (1)

• Age ≥ 75 (2)

• Age 65 – 74 (1)

• Diabetes Mellitus (1)

• Stroke/ TIA/Thromboembolic (2)

• Vascular DSX (AMI, PVD, Aortic Plaques (1)

• Sex Female (1)

Chest 2010;137:263-272

0123456789

10111213141516

0

1.3

0 1 2 3 4 5 6 7 8 9

3.2 4.0

Stroke Risk and CHAD2 Score

9.8

6.7

15.2

2.2

6.7

9.6

JAMA 2001;285:2370-75

Alliance for Aging Research: Stroke prevention in AF; 2015

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Stroke is Biggest AF Risk

• 5% year if no anticoagulation

• 10% year if prior CVA or TIA

• Anticoagulation decreases CVA risk by 2/3

Rate vs Rhythm Control

• Classic article, 4,060 pts, multicenter

• Average age 70 yo ± 9

• Rate controlled patients had less hospitalizations

• More adverse effects in the rhythm group

• Slightly more deaths too (p = ns; 0.08)

NEJM 2002;347:1825-37

In General: Rate Control is Superior to Rhythm Control

But maybe rate control is not always best for some ED patients

Annals Emerg Med 1999;33:379-87

• 289 stable patients, new onset Afib

• Included patients with AF > 48 hrs (51/289)

• Excluded unstable patients

• Excluded underlying illness requiring admission

• Average age 64 ± 14; HR 125 ± 26

• Used Procainamide (180 pts, 62% of total)

• 500 mg then, if needed, to 1,000 mg

• 50% converted pharmacologically

• 500 mg converted 44%, 56% took 1,000 mg

Pharmacological CardioversionAnnals Emerg Med 1999;33:379-87

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• Not if prolonged Q-T or Hypotensive

• 35-50 mg / min j beware QRS widening

• Up to 17.1 mg/kg total

• My bias is not above 1,000 mg

• Up to 50% will convert

Procainamide Dosing• 13% converted spontaneously

• 62% had chemical cardioversion attempted

• Chemical conversion was 50% effective (90/180)

• 28% had electrical conversion attempted

• DC cardioversion was 89% successful (71/80)

• 10% of D/C’d pts returned ≤ 7d, never due to complication

ED Cardioversion ResultsAnnals Emerg Med 1999;33:379-87

• This study made ED conversions for new onset AF a viable practice option

• It is common in Canada and variable in USA

• Many centers do a cardiologist-performed TEE before cardioversion



• Michael: 50% medical converted and 99% D/C89% success electrically all D/C

• Burton: 86% success electrically, 91% D/C

• Jacoby: 97% (29/30) electrical success, 75% D/C

• Stiell: 58% of 660 success with procainamide92% of failed electrically converted, 97% D/C

• Scheuermeyer: 141 electrical conversion, 96.5% success & D/C

PACE 2013;36:122-33

• Rate vs. rhythm control, 10 studies, 7,867 pts

• Stroke, AMI, bleeding and mortality, all similar

• ED and admissions increased in rhythm control

• But rhythm control better if < 65

• Lower mortality: RR 3.03 p=0.0007

Annals of Emerg Med 2015;65:540-2

• Meta-analysis of 4 ED relevant studies

• 1438 patients with new onset AF

• Rate control if older, chronic AF

• Rhythm > rate control if < 65 yo and healthy

ED Rate vs. Rhythm Control

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Younger, healthier patients do better with therapy directed at keeping them

in sinus rhythm

Older, sicker patients do better with their AF rate controlled


• Beta Blocker vs Diltiazem




Rate Control in AF• Calcium Channel Blocker

- Diltizem 25 mg over 1-2 minMay to 35 mg over1-2 min if inadequate response after 5 min

• Beta Blocker- Metoprolol 5 mg IV q 5 min

up to 3 doses

- Esmolol 0.5 mg/kg over 1 min0.05 – 0.1 mg/kg/mintitrate to effect

J Emerg Med 2015;49:175-82

• Double blind study of 52 pts with AF (135-145)

• Measured HR < 100 within 30 min

• 0.25 mg/kg Diltiazem vs 0.15 mg/kg Metoprolol

• Maximum 30 mg Diltiazem vs 10 mg Metoprolol

• Escalated at 15 min to 0.35 mg/kg vs 0.25 mg/kg

Is Diltiazem or Labetalol superior in rate control Atrial Fibrillation and Flutter with RVR

0

10

20

30

40

50

60

70

80

90

100

10.7

50.0

Heart Rate Less than 100

5 Min 15 Min

31.0

73.0

J Emerg Med 2015;49:175-82

%

M MD D

46.4

95.8

30 Min

M D

Blue Box = MetoprololRed Box = Diltiazem

J Emerg Med 2015;49:175-82

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IV Diltiazem appears to be better and faster at rate control for AF with RVR

than Metoprolol

• Although cardiologists seem to prefer Metoprolol, Diltiazem is as good or better for AF with RVR

• No increased toxicity

• Be careful with dosing

• Older, frailer patients should get less

Rate Control for AF with RVRTake Homes

European Heart 2013;34:1481-88; 1489-97

• The role of Digoxin in Atrial Fibrillation is controversial – it may increase mortality or be a marker for those who will do badly regardless of its use

• In general – don’t be the one to start it

ED Conversion of Atrial Fibrillation

• Medical followed by electrical

• Procainamide is effective in about 50%

• Electricity is 86%-90% effective

• No significant underlying diseases(HF, pneumonia, ACS, etc.)

• Must be less than 48 hrs of AFib


Safety of ED Cardioversion

• Very safe if no thrombus

• Risk of CVA increases over time

• TEE required if onset unknown or > 48 hrs

• New evidence suggests maybe > 12 hrs

JAMA 2014;312:647-8

0.00.10.20.30.40.50.60.70.80.91.01.11.2

< 12 12-24

0.3%

1.1%

OR=4.0

Risk of CVA S/P Cardioversion without anticoagulants

0-48 hrs onset = 0.7% JAMA 2014;312:647-8

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• AHA recommends 120-200J biphasic

• 50-100J for flutter

• Use highest recommended

• AP or AL – your choice

• Switch portions if unsuccessful

Cardioversion for Fib/Flutter

Acad Of EM 2014; 21:717-26

• Meta-analysis 13 studies

• 836 AP pts vs 856 AL pts

• Trend toward AL > AP if biphasic

Neither A-P nor A-L Pad Placement is Superior

• If CHA2DS2VASc = 0 not needed pre or post

• Others, if no TEE – 3 weeks pre cardioversion

Anticoagulation Pre Cardioversion

• Transesophageal (TEE) not Transthoracic

• Used to R/O thrombus pre cardioversion

• Mandatory if sx > 48 hrs or unknown

• May be used if > 12 hrs or older pts

• Not required in younger healthy pts if onset is acute and heralded by specific symptoms

Who Needs an Echo in AF


“We conclude that it would be within the standard of care to

discharge home stable patients with AFib after cardioversion with

adequate follow-up”...“The return rate for relapsed AFib is 3%-17%”

Anticoagulation and Atrial Fibrillation

Even if Converted

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JACC 2015;65:643-4

• Always DC on anticoagulation if CHA2DS2VASc score 2 or greater

• None needed if score = 0

• CHA2DS2VASc of 1 is controversial “no antithrombotic …or oral anticoagulant…or ASH…therapy should be individualized…based on shared decision making…after discussion of absolute and RR of stroke and bleeding”

• 0

• 1

• 2

• 0

• NOAC or discuss

• NOAC or Warfarin

JAMA 2015; 314:291-2

CHA2DS2VASc Agent

JACC 2015;65:643-4

• Increasing evidence for anticoagulation if CHA2DS2VASc = 1

• Yearly strokes = 2.75% (m), 2.55% (f)

• Incremental risk if age 65-74

• Do not D/C unless you, patient and cardiologist have all agreed on plan

NOACs now endorsed in ACC/AHA guidelines.

Check carefully for use/dosage in CRF, valvular disease, obese,

fluid and s/p cardioversion

NOACs, DOACsNovel Oral AnticoagulantsDirect Oral Anticoagulants

• Apixaban

• Dabigatran

• Edoxaban

• Rivaroxaban

Eliquis anti-xa

Pradaxa direct antithrombin

Savaysa anti-xa

Xaralto anti-xa

Apixaban

Dabigatran

Edoxaban

Rivaroxaban

Warfarin use is decreasing and is becoming relegated to mainly those

patients with:Mechanical Heart Valves

Mitral StenosisChronic Renal Failure

Lancet 2014;383:955-62

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Anticoagulation for AFib• Warfarin:

• Apixaban:

• Edoxiban:

• Dabigatran:

• Rivaroxaban:

INR 2-3; not < 2

5 mg BID2.5 mg BID < 60 kg, > 80 y, Cr > 1.5

60 mg QD > 60 kg30 mg QD > 30 kgNot for pts CrCl > 95

150 mg BID if CrCl > 30

20 mg / d15 mg / d if CrCl 30-49

Anticoagulation and ED Discharge

Annals Emerg Med 2013;62:557-65 Annals Emerg Med 2013;62:566-8

Annals Emerg Med 2015;65:1-12 Annals Emerg Med 2015;66:347-54

• EM MDs need to pay close attention to CHA2DS2VASc scores

• Anticoagulants started in ED increase compliance and decrease stroke risk

JACC 2015;65:643-4

• Always DC on anticoagulation if CHA2DS2VASc score 2 or greater

• None needed if score = 0

• CHA2DS2VASc of 1 is controversial “no antithrombotic …or oral anticoagulant…or ASH…therapy should be individualized…based on shared decision making…after discussion of absolute and RR of stroke and bleeding”

Atrial Fibrillation 2015-2016

What’s New or Different?


Is rate control for atrial fibrillation always the best strategy?

• 416 patients with AF

• All patients had “complex” AF

• Complex = an acute underlying illness

• 2 Canadian University affiliated EDs

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• Sepsis (35.6%

• HF (32%)

• ARF (6.7%)

• COPD (4.4%)

• CVA (3.7%)

• GI Bleed (3%)

• PE (2.2%)


Acute Concomitant IllnessesAnnals of Emerg Med 2015;65:511-22

• Shock requiring vasopressors

• Intubation or NIPPV

• Bradycardia requiring pacing or meds

• Stroke or embolic complication

• CPR or death

Major Complications

0%

10%

20%

30%

40%

50%

Rate or RhythmControl

Attempted

No Rate orRhythm Control

40.7%

7.1%

RR=5.733.6% absolute difference

Major Adverse Complications Annals of Emerg Med 2015;65:511-22


• Fluid bolus

• O2 by bag valve mask

Minor Complications

0%1%2%3%4%5%6%7%8%9%

10%11%12%13%14%15%

Rate or RhythmControl

Attempted

No Rate orRhythm Control

14.1%

19/135

1.1%

3/281

RR=11.713% absolute difference

Total Adverse Events Annals of Emerg Med 2015;65:511-22

0%

10%

20%

30%

40%

50%

ControlAttempted

No Attempt atControl

19.0%

44.5%

RR=2.325.5% absolute difference

Effective Rate Control (> 20 BPM)Annals of Emerg Med 2015;65:511-22

(Elec, D;1+, BB) (Crystalloid, Bronchodilator)

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• 60% (9/15) had cardiovascular complications

• 26.7% (4/15) had medication complications

• 19.0% had pulse reduction of 20 BPM with medical control

• 20% (3/5) had successful electrical conversion

Complication Rate vs. Effectiveness

Trying to Control AF in Sick PatientsTake Homes

• Rarely effective

• Dangerous

• Focus on underlying disease before attempting to control rate or rhythm

Rate control is rarely effective in complex AF with RVR patients –

and can be very dangerous

AF Rate Control in Complex PatientsTake Homes

• Treat the underlying disease(s)

• It’s dangerous to try to control rate immediately

• Beware underlying sepsis, dehydration, HF

• Beta blockade + HF = ETI

Older pts and higher CHADs scores often denote who has an underlying cause of AF with RVR

JACC 2014;64:2246-80

• Definitive recommendations from AHA-ACC

• 201 references, up to 2014

• Every possible table & resource

The Best Single Current Cardiology Reference


• Authoritative review

• ED focused

• 48 references including from 2015

The Best Single Current EM Reference

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There Are 5 Causes of Atrial Fibrillation

• Pericardium

• Myocardium

• Endocardium

• Pulmonary

• Hypersympathetic

Pericarditis

LVH, Myocarditis

Endocarditis, valvular heart disease

PE, pulmonary hypertension

Cocaine, amphetamines, hyperthyroid, ETOH withdrawal, caffeine, beta agonists, fever, dehydration

JAMA 2001;285:2370-75

Always Calculate the Patient’s ScoreCHA2DS2VASc

• CHF (1)

• Hypertension (1)

• Age ≥ 75 (2)

• Age 65 – 74 (1)

• Diabetes Mellitus (1)

• Stroke/ TIA/Thromboembolic (2)

• Vascular DSX (AMI, PVD, Aortic Plaques (1)

• Sex Female (1)

Chest 2010;137:263-272


• Beta blocker vs Diltiazem




Atrial Fibrillation is common

Summary

Stroke is high risk

Always calculate CHA2DS2VASc score

Anticoagulate if indicated

2 = yes, 0 = no, 1 = consult

Treat underlying conditions

Summary

Dilt or BB for rate control

Cardioversion can be safe < 12-48 hrs

Procainamide works 50-60%

200 Joules biphasic works 90%

VanderbiltEM.com

Atrial Fibrillation Update Don’t Miss a Beat VanderbiltEM · 2015-12-21 · 2 5 Step ED Dx - Rx...

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