Atrial Fibrillation in Real Life

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Atrial Fibrillation in Real Life

• Michael K Howlett MD CCFP(EM) MHSA
• Assistant Professor, Department of Emerngency
  Medicine, Dalhousie University
• Clinical Department Head, Department of Emergency
  Medicine, Horizon Health Network Saint John Zone

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ESC 2010 AF Guidelines

• www.escardio.org/guidelines
• Guidelines for the management of atrial
  fibrillation The Task Force for the Management
  of Atrial Fibrillation of the European Society of
  Cardiology (ESC) 2010

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AF Risk

• 5 x risk of CVA
• 20 of all strokes
• Often fatal
• More disability

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Only antithrombotic therapy has been shown to
reduce AF-related deaths
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Presentations Problems

1. Diagnosis
2. Anticoagulation
3. Rate vs. Rhythm
4. Contributing Comorbid Medical Problems
5. Care environment
6. Resources

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Jane, 49 year old female

• Recently took up running on a treadmill
• Hypertension, on a diet
• Getting palpitations that last up to 3 or 4 hours
  after running in past two weeks
• Visits office
• BP 158/92 resting
• HR 72 regular

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Presentation of AF
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Problem 1 Diagnosis

• EKG
• More intense monitor if
• Symptomatic
• Syncope
• Indication for anticoagulation (esp. post CVA)
• EKG Monitoring
• Holter
• Event Recorder

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Jane presents to ED next week . . .

• Palpitations for the past 12 hours after being on
  the treadmill, wont go away
• Pounding feeling uncomfortable but no SOB,
  presyncope or pain
• HR 135-150
• absolute or irregularly irregular on EKG
• Exam normal
• Is in AF

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Problem 2 AF Treatment Goals

1. Symptom control
2. Reduce severe complications

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Control Symptoms . . .

• Sx of AF
• Establish Time of Onset of Episode
• lt or gt 48 hours
• Rate
• Rhythm

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Rate vs Rhythm
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Rhythm ControlCardioversion
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79 year old female

• Off and on SOB for past three weeks
• Lives at home previously in good health
• Takes ASA
• HR 145
• BP 189/97
• Atrial fibrillation
• Control rate with metoprolol to 102
• Feels better

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Problem 3 Risk Assessment for CVA CHA2DS2 VASc
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CVA Primary Prevention
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CVA Risk Algorithm
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Atrial FibrillationRisks of Anticoagulation
Score 3 or greater is high risk
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Vitello, 58 year old male

• one hour 7/10 RSCP, diaphoresis
• 3 days of SOB cant lie flat, HR 156 irregular
• Past history of MI, CHF, type 2 DM
• BP 90 systolic
• EKG shows lateral ST depression, narrow QRS
  irregular rhythm
• CXR shows interstitial edema

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Problem 4 Investigate Treat Underlying medical
illness

• CHF
• Renal
• Thyroid
• ACS
• COPD
• Cardiomyopathy
• Upstream care
• Diabetes mellitus
• Hypercholesterolemia
• Hypertension

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Eva, 92 year old female

• Fall at home, 4th in past month
• Vascular dementia
• Bruise over right eye
• AF rate 133-148, BP 118/69
• Takes Clopidogrel previous mild CVA
• Lives with husband who is diabetic

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Problem 5 Care Environment

• Home environment Safety
• Own home
• Supervised
• Nursing home
• Cultural norms expectations
• Family network
• Home
• Extended
• Other care givers
• Social network
• Transportation
• Health network
• Functional Health
• Trending for the individualchange?

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AF Differs in Elderly . . .

• Fragile, multiple co-morbidities, including
  cardiovascular and non-cardiac disease.
• High incidence and prevalence rates of AF.
• Higher thrombo-embolic and bleeding risks.
• Most often permanent and not recurrent
  (paroxysmal and/or persistent) AF.
• Atypical symptoms and complaints are common.
• Less sensitive to sympathetic effects on
  ventricular response rates in AF (aged
  conduction system).
• More sensitive to proarrhythmic effects of drugs
  (decreased renal and hepatic function).
• More often underdiagnosed than in younger
  patients.

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Eva wants to go home

• Somewhat confused
• 2 person assist to stand
• Has small subdural
• No beds on medicine
• Rate is 115, still in AF
• Choices?

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Problem 6 Tools Resources for Disposition

• Health Living Resources
• Physio, utilization, social worker, discharge
  planning, home hospital
• Anticoagulation clinics, home testing, family
  medicine
• transportation, economic status, home personal
  care
• Acute, transitional respite, long term care
  resources

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Summary Real Life Issues

• Diagnosis is Important
• Symptoms
• Time of Onset of Episode
• Treat Rate, Rhythm
• CVA Risk
• CHA2DS2 VASc
• Risk of anticoagulation
• Conditions predisposing Comorbid
• CAD, CHF, CRF, COPD, etc.
• Upstream care
• Care Environment
• Functional status
• Socioeconomic, primary health support
• Tools Resources
• Health system
• Community

Disposition
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AF Care Checklist Care Plan
Onset- Dx HPI Score CHA2DS2 VASc Case Presentation Care Environment Support Resources Actions at Disposition
Diagnosis Timing Symptoms CVA Risk Contraindications Comorbidities ACS CHF TIA/CVA Bleeding Family Social Home Functional Health Economic Primary Health Care Monitoring Followup Falls Prevention other Chronic Disease Programs Hospital Based ED Inpatient Community Living Home/Supervised Family Supports Home support Programs Acute Care Rate vs Rhythm Anticoagulation Comorbidities Investigations Treatments Discharge Plan Home Acute Care Transitional Care LTC
Team Care Plan Team Care Plan Team Care Plan Team Care Plan Team Care Plan Team Care Plan

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79 y. o. female, palpitations

• HR 125-140 irregular. BP 150/94 both arms
• No other symptoms
• Converts spontaneously after 2 hours
• What if
• Never had before, feels started 3 hours PTA
• Felt it off and on x last week, in your office
• Has chest pain
• 10 minutes Left arm weakness and speech trouble
• SOB increasing for past 3 days, cant lie down at
  nite
• Poor compliance?

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What if . . .

• Hb 89, Poor diet, microcytic hypochromic
• Rate control, Discuss OAC vs antiplatelet, treat
  anemia
• Hb 78, Black stools frequently in recent past
  taking aspirin for her arthritis in right hip,
  normal looking RBCs
• Control rate, no OAC or Antiplatelet, consult,
  admit
• In CHF
• avoid Ca channel blockers, treat, admit
• On warfarin, INR 1.6
• Increase OAC
• TIA CT, heparin, increase OAC
• On warfarin INR 8
• No bleed hold
• Major bleeding FFP, Prothrombin Complex
  Concentrates (Octaplex), ? Vit K

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What if . . .

• 67 year old large Anterior MI
• Standard Rx, then OAC
• 77 year old chronic AFib on Warfarin, new NSTEMI
• Still use standard Rx
• 34 year old male with Wolf Parkinson White
• Wide complex AF with aberrancy B blockers,
  digoxin, calcium channel blockers
  contraindicated.
• Flecainide, Propafenone, Amiodarone.
  (procainamide)
• Hyperthyroidism
• OAC, correct T4, B blockers
• May stop OAC when fixed

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What if . . .

• No Family Doctor
• Alternative monitoring
• Dabigatran
• Pregnancy AF
• No OAC esp early pregnancy
• DCC, Flecainide, calcium channel blockers
• Post operative AF
• Pretreat with B Blockers
• Amiodarone
• Protocols for ceasing OAC in patients with
  chronic AF
• Do not cease B blockers

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