Transcript Afib – Powerpoint

Atrial Fibrillation:
Update in ED Management
Susan P Torrey, MD, FAAEM, FACEP
Associate Professor of Emergency Medicine
Tufts University School of Medicine
I have no financial disclosures
but…
www.TorreyEKG.com
@STorreyMD
Atrial fibrillation
• Epidemiology
• Most common arrhythmia in ED
• 0.4% in general population (10X  > 60 years)
• Substantial morbidity and mortality
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Cardiovascular and overall survival
5-fold risk stroke
Diminished quality of life
Significant health care costs
Etiology of atrial fibrillation
• Enlargement of atria
• Ischemic cardiomyopathy
• Hypertensive cardiomyopathy
• Valvular disease (mitral stenosis)
• Excess stimulation
• Hyperthyroid
• Cocaine
• Embolism
Natural history of atrial fib
• Cellular and electrophysiologic remodeling
• Apoptosis, necrosis, and fibrosis
• Occur as early as 1 month
• “Atrial fib begets atrial fib”
• Paroxysmal  Persistent  Permanent
What’s the hurry?
Anter Circ 2009
Predicting progression from
paroxysmal to persistent atrial fib
• HATCH score
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HTN
Age > 75
CVA or TIA
COPD
CHF
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1
2
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2
de Vos JACC 2010
HATCH score
Natural history of atrial fib
• Relapse rate – up to 25% in few weeks
• Spontaneous conversion – 25 - 50%
• Thromboembolic risk
• 5%/year – 1.5% (age 50-59) to 23% (age >80)
• As diverse as the variety of patients
• Progressive over time
ED Management of A Fib
• Unstable vs. stable presentation
• Rhythm vs. rate control
• Anticoagulation?
Algorithm for hypotensive A. Fib
Unstable?
• Hypotensive, conscious pt with atrial fib
• Amiodarone – for rate control
• May cardiovert within 4-6 hours
• Heparin advisable
• Digoxin
• Slow in onset, but may help
• Diltiazem
• Small doses
Algorithm for hypotensive A. Fib
Atzema CL. Managing Atrial Fibrillation. Ann Emerg Med, 2015
The stable patient with A fib
• Rate or Rhythm Control
• < 48 hours since onset – cardioversion?
• ≥ 65 years old – no difference in outcome
• Sinus rhythm is preferable to A fib
• Rate control
• β-blockers or Ca-channel blockers
• ? worse exercise tolerance with β-blockers
• β-blockers with hx CAD
The stable patient with A fib
• Rhythm Control
• Electrical cardioversion – 90% effective
• Chemical cardioversion – 60% effective
• procainamide, propafenone, flecainide, amiodarone
• Questions to consider
• Time from onset of arrhythmia
• Risk of thromboembolic event
Association of the Ottawa Aggressive Protocol
with rapid discharge of ED patients with
recent-onset atrial fibrillation or flutter
Stiell IG, et al. CJEM 12:181, 2010.
• Stable patients with clear onset < 48 hours
• Without ischemia, hypotension or CHF
• Pharmacologic cardioversion
• Procainamide 1 gm over 60 min
• Electrical cardioversion
• 150-200 J biphasic synchronized
Ottawa Aggressive Protocol
• 660 patients
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IV procainamide  58% converted
243 underwent EC  92% converted
Adverse events – 7.6% (minor)
Median LOS – 4.9 hours
7-day relapse – 8.6%
Is Discharge to Home after ED Cardioversion Safe
For the Treatment of Recent-Onset Atrial Fibrillation?
von Besser K. Ann Emerg Med 58:517, 2011
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Michael 1999
Burton 2004
Jacoby 2005
Stiell 2010
Scheuermeyer 2010
#EC
80
388
30
243
141
882
success
89%
86
97
92
96
92%
d/c
100%
91
97
96
96%
Cardioversion of atrial fibrillation in ED:
a prospective randomized trial.
Bellone A, et al. Emerg Med J 29:188. 2012
• Prospective, randomized trial from Italy
• 247 patients with AF < 48 hours
• Excluded comorbid disease and CHADS2 ≥ 2
• 108/121 EC (89%) vs 93/125 PC (74%)
• ED LOS – 180 min EC vs 420 PC
• Relapse 2 month – 26% EC vs 28% PC
ED cardioversion of atrial fib
• ED cardioversion is effective and safe
• With identification of appropriate patient, and
• With attention to thromboembolic risk
• Saves time, money and resources
• Patient satisfaction
• Spare admission and unnecessary meds
CHADS2
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CHF
Hypertension
Age ≥ 75
Diabetes
Stroke/TIA
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1
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2
CHA2DS2-VASc
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CHF
Hypertension
Age ≥ 75
Diabetes
Stroke/TIA
Vascular dz
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2
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• (MI, CABG, PVD)
• Age 65-74 y
• Sex (female)
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1
To anticoagulate or not
• 2012 European Society (ESC)
• 2014 Canadian Cardiovasc Society (CCS)
• 2014 American Coll Card (ACC/AHA)
• All groups recommend anticoagulation for:
• Age > 65 years
• Mechanical heart valves
• Rheumatic valvular disease
HAS-BLED
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H
A
S
B
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E
D
Hypertension
Abnl renal or liver fx
Stroke
Bleeding hx
Labile INRs
Elderly
Drugs or alcohol
≥ 3 = high risk of bleeding
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1 or 2
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1 or 2
Atrial fibrillation in Sub-Saharan Africa
Stambler BS. Internat J Gen Med 8:231, 2015
Atrial fibrillation in Sub-Saharan Africa
Stambler BS. Internat J Gen Med 8:231, 2015
Thomboembolic Complications after
Cardioversion of Acute Atrial Fibrillation
Airaksinen KE, et. Al. J Am Coll Card 62;1187, 2013
• 5,116 cardioversions in 2,481 patients
• No peri-procedural anticoagulation
• Embolic events within 30 days
• 38 embolic events (31 strokes) – 0.7%
• Occurred median 2 days / mean 4.6 days
FinVC (Finnish CardioVersion) Study
Thomboembolic Complications after
Cardioversion of Acute Atrial Fibrillation
Airaksinen KE, et. Al. J Am Coll Card 62;1187, 2013
• Independent predictors
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Age > 60 years
Heart failure
Female sex
Diabetes
• Highest risk (CHF and DM)
• Lowest risk (no CHF, < 60)
9.8%
0.2%
Time to Cardioversion for Acute Atrial Fibrillation
and Thromboembolic Complications.
Nuotio I, et. al. JAMA 312:647, 2014
Time to cardioversion
• < 12 hours
• > 12 hours
Incidence emboli
• 0.3%
• 1.1%
Risk of stroke with anticoag – 0.3-0.8%
Risk without anticoag < 48 hrs – 0.7%
Should Atrial Fib Patients with 1 Risk Factor
(Beyond Sex) Receive Oral Anticoagulation?
Chao TF, et al. J Am Coll Card 65:635, 2015
•12,935 males (score 1) – 2.75%/yr stroke rate
• 1.96% with vascular disease
• 3.50% those 65-74 years old
•7,900 females (score 2) – 2.55%/yr
• 1.91% with HTN
• 3.34% those 65-74 years old
Should Atrial Fib Patients with 1 Risk Factor
(Beyond Sex) Receive Oral Anticoagulation?
Chao TF, et al. J Am Coll Card 65:635, 2015
•CHA2DS2-VASC risk factors are not equal
• Age 65 – 74 associated with highest risk
•Anticoagulation for 1 additional risk factor
Anticoagulation, CHA2DS2VASC score, and
thromboembolic risk of cardioversion of acute A fib.
Gronberg T, et al. Am J Cardiol 117:1294-98, 2016
• CHA2DS2VASC was significant predictor of
thromboembolic complications in cardioversion
of acute atrial fib
• Periprocedural anticoagulation reduced risk 82%
• High CHA2DS2VASC score had high rate of
failed cardioversion or early recurrence of A fib
 ? rationality of rhythm control
NOACs
Novel Oral Anticoagulants
• Dabigatran (Pradaxa®) – inhibits thrombin
• Rivaroxaban (Xarelto®) – blocks factor Xa
• Apixaban (Eliquis®)
• compared to warfarin, NOACs cause significant
reduction in strokes, intracranial hemorrhage,
major bleeding events and mortality
Ruff CT, et al. Comparison efficacy and safety NOACs with warfarin in
atrial fib – meta-analysis. Lancet 2014
Comparison of Efficacy and Safety of new Oral
Anticoagulants with Warfarin in Atrial Fib
Ruff CT, et al. Lancet 383; 955, 2014
NOACs
Novel Oral Anticoagulants
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Fewer interactions with medications
Fewer restrictions of foods
No lab monitoring
Rapid onset action – peak 3 hours
• Contraindicated:
• Mechanical heart valves
• Mitral stenosis
Impact on outcomes of changing treatment
guideline recommendations for stroke prevention
Chao TF, et al. Mayo Clin Proc 91:567-574, 2016.
•Patients with atrial fib recommended OAC
• 2011 guidelines
• 2014 guidelines
- 69%
- 86%
• Most woman with a fib (94%)
• Most patients > 65 years (97%)
•New guidelines =  risk adverse outcomes
• Hazard ratio – 0.89
In conclusion…
• Respect atrial fibrillation
• Not exactly a benign arrhythmia
• For ED management consider…
• Rhythm control
• Rate control
• Anticoagulation
30-day Death after
ED Visit for A. Fib –
The AFTER Study
Atzema CL, et al.
Ann Emerg Med
66:658, 2015
1. Troponin positive
2. Other acute ED dx
3. COPD
4. Bleeding risk
5. Age ≥ 75
Age 65 – 74
6. CHF
30-day Death after ED Visit for Atrial Fibrillation
- the AFTER Study
Atzema CL, et al. Ann Emerg Med 66:658, 2015
CaCl before IV diltiazem in management of
atrial fibrillation.
Kolkebeck T, et al. JEM 26:395-400, 2004.
•Prospective, double-blind, placebo-control
•75 pts with a fib > 120/min
• ½ received CaCl / ½ placebo
•Rate control same between groups
•No significant side-effects noted
•No benefit to maintaining BP