Atrial Fibrillation A Strategic Update

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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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Atrial Fibrillation/Strategy

• 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

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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
• lt 55 years-----1/1000
• gt 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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Atrial Fibrillation/Strategy

• 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

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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 20001011282)

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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 (lt55yrs),
• 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
• gt59 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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Atrial Fibrillation/Strategy

• 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

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Atrial Fibrillation/Strategy

• 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

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Atrial Fibrillation/Strategy

• Class IIaThe weight of evidence or opinion
  is in favor of the procedure or treatment
• Class IIb Usefulness/efficacy is less well
• established by evidence or opinion
• Class IIIConditions 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

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Recommendations for antithrombotic therapy in
patients with AF

• Class I
• 1. Administer antithrombotic therapy (oral anti-
  coagulation or aspirin) to all patients with
  AF except 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 evidenceA)

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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 lt 60 yrs No heart disease (lone AF) Age lt 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 therapy Aspirin (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 lt 0.35, and
history of hypertension.
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Patient features Antithrombotic therapy Grade of recommendation
Age ? 75 yrs especially women Heart failure LV ejection fraction ? 0.35 Thyrotoxicosis Hypertension Rheumatic heart disease (mitral stenosis) Prosthetic heart valves Prior thromboembolism Persistent 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 IIb
• 1. 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 IIb
• 2. 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 I
• 1. 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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Recommendations in patients with AF undergoing
cardioversion

• 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.

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Recommendations in patients with AF undergoing
cardioversion

• 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).

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Atrial Fibrillation/Strategy

• Algorithm for management newly discovered AF

Newly discovered AF
Paroxysmal
Persistent
Accept permanent AF
Rate control and anti-coagulation as needed
No therapy neededunless severe symptoms (eg,
hypotension, HF, angina pectoris)
Anticoagulation and rate control as needed
Consider antiarrhythmic drug therapy
Cardioversion
Anticoagulation as needed
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
Disabling symptoms in AF
Anticoagulation and rate control as needed
Anticoagulation and rate control as needed
No drug forprevention of AF
Antiarrhythmicdrug therapy
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Atrial Fibrillation/Strategy

• Algorithm 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 as needed
Anticoagulation and rate control
Antiarrhythmicdrug therapy
Continue anticoagulation as needed and therapy to
maintain sinus rhythm
Electrical cardio-version as needed
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Atrial Fibrillation/Strategy

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

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Acute myocardial infarction

• Class I
• 1. 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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Acute myocardial infarction

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

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Ventricular preexcitation
Kent bundel

• Class III
• Intravenous administration of ß-blocking agents,
  digitalis glycosides, diltiazem, or verapamil.
  (Level of evidence B)

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Ventricular preexcitation

• 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)

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Ventricular preexcitation

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

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Hyperthyroidism

• 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)

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Pregnancy

• 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)

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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 thrombo-
  embolic risk. (Level of evidence C)

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Pulmonary diseases

• 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)

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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)

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Atrial Fibrillation/Strategy

• 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

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Atrial Fibrillation/Strategy

• Management of flutter

Rule of thumb for emergency physicians atrial
flutter atrial fibrillation
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Atrial Fibrillation/Strategy

• 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

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Atrial Fibrillation/Strategy

• 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

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Atrial Fibrillation/Strategy

• Questions ??