Transcript Atrial Fibrillation A Strategic Update

Atrial Fibrillation
A Strategic Update
Paul Calle, Ghent
Stephen Bohan, Boston
Atrial Fibrillation/Strategy
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Stephen Bohan
Setting the Stage
 Basic Approach
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Paul Calle
Common Clinical Decisions
 Special Situations
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Atrial Fibrillation/Strategy
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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
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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
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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
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Atrial Fibrillation/Importance
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1.5 to 1.9 increase in mortality
Atrial Fibrillation/Strategy
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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
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Lexicon/Definitions (ACC/AHA/ESC)
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First Detected Episode
Recurrent (2 or more episodes)
• If episode stops spontaneously = PAROXYMAL
• If episode is sustained = PERSISTENT
• Conversion does not change designation
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Permanent
Lone Patient younger than 60yrs and no
disease clinically or by echo
Atrial Fibrillation
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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
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The many faces of atrial fibrillation in ED ...
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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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Emergency Department Approach:
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Unstable patient:
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hypotension
angina
hyoxemia
wide irregular (hard to tell at high rate)
tachycardia
ELECTRICITY (BIPHASIC) IS YOUR
FRIEND (CIRCULATION 2000;101:1282)
Atrial Fibrillation/Strategy
 Emergency
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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
Atrial Fibrillation/Strategy
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Emergency Department approach
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Stable patient
• Physical Examination
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Evidence of CHF
Evidence of pneumonia (fever)
Evidence of thyroid disease
Careful auscultation (after rate control)
• Record/EKG review
Atrial Fibrillation/Strategy
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Emergency Department approach
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Laboratory examination
• EKG (prior BBB, prior MI, active ischemia)
• Chest X ray (heart size, effusion, pneumonia)
• Metabolic screen including TSH on first episode
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Anti coagulation
• Aspirin
• Low Molecular Weight Heparin
• Coumadin (start in ED)
Atrial Fibrillation/Strategy
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What agent should be used for rate
control?
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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
Atrial Fibrillation/Strategy
Conversion
 Two kinds of conversion
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• conversion of rhythm
• conversion of physicians to new mode of
treatment
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Why convert?
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(common wisdom) “Improved
hemodynamics, less CHF, fewer emboli”
Atrial Fibrillation
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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
Atrial Fibrillation/Strategy
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Conversion
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>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.
Atrial Fibrillation/Strategy
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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
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NO DIFFERENCE IN DEATH OR STROKE
Atrial Fibrillation/Strategy
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Stroke occurred even when in sinus
rhythm
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Stroke occurred when off anticoagulants
or with subtherapeutic INR
Atrial Fibrillation/Strategy
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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
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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
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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
Atrial Fibrillation/Strategy
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 opinion
Class 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
Recommendations for antithrombotic
therapy in patients with AF
Class I
1. Administer antithrombotic therapy (oral anticoagulation or aspirin) to all patients with AF
except those with lone AF, to prevent thromboembolism. (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)
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 therapy
Aspirin (325 mg daily)
I
Aspirin (325 mg daily)
Oral anticoagulation
(INR 2.0 - 3.0)
Addition of aspirin,
81-162 mg daily is
optional
I
I
I
IIb
*Risk factors for thromboembolism include heart failure, LV ejection fraction
< 0.35, and history of hypertension.
Patient features
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
Antithrombotic
therapy
Grade of
recommendation
Oral anticoagulation
(INR  2.0)
Oral anticoagulation
(INR 2.0 - 3.0)
I
Oral anticoagulation
(INR 2.5 - 3.5 or higher
may be appropriate)
I
I
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 contraindications to oral anticoagulation. (Level of
evidence: C)
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)
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)
Class IIb
2. Administer heparin (i.v. or s.c.) respectively in selected high-risk patients or when
a series of procedures requires interruption of oral anticoagulant therapy for
a period longer than 1 week. (Level of
evidence: C)
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)
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.
Recommendations in patients with
AF undergoing cardioversion
4. Screening for thrombus in LA or LA appendage
by TEE is an alternative to routine preanticoagulation. (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).
Atrial Fibrillation/Strategy
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Algorithm for management : newly discovered AF
Newly discovered AF
Paroxysmal
No therapy needed
unless severe
symptoms (eg,
hypotension, HF,
angina pectoris)
Persistent
Accept
permanent AF
Anticoagulation and rate
control as needed
Rate control and anticoagulation as needed
Consider antiarrhythmic
drug therapy
Cardioversion
Anticoagulation
as needed
Long-term
antiarrhythmic drug
therapy unnecessary
Atrial Fibrillation/Strategy
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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 for
prevention of AF
Antiarrhythmic
drug therapy
Atrial Fibrillation/Strategy
 Algorithm
for management : recurrent persistent or permanent AF
Recurrent persistent AF
Minimal or
no symptoms
Disabling
symptoms in AF
Anticoagulation and rate
control as needed
Anticoagulation
and rate control
Antiarrhythmic
drug therapy
Electrical cardioversion as needed
Permanent AF
Anticoagulation and rate
control as needed
Continue anticoagulation
as needed and therapy to
maintain sinus rhythm
Atrial Fibrillation/Strategy
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Guidelines for management in special
situations (ACC/AHA/ESC)
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Acute myocardial infarction
Ventricular preexcitation (WPW-syndrome)
Hyperthyroidism
During pregnancy
Pulmonary diseases
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)
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)
Acute myocardial infarction
Class III
Administer type IC antiarrhythmic drugs in
patients with AF in the setting of acute myocardial infarction. (Level of evidence: C)
Ventricular preexcitation
Kent bundel
Class III
Intravenous administration of ß-blocking agents,
digitalis glycosides, diltiazem, or verapamil. (Level of
evidence: B)
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)
Ventricular preexcitation
Class IIb
Administer intravenous quinidine,
procainamide, disopyramide, ibutilide, or
amiodarone to hemodynamically stable
patients. (Level of evidence: B)
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, recommendations as for patients without hyperthyroidism. (Level of evidence: C)
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)
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 thromboembolic risk. (Level of evidence: C)
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 hemodynamically unstable patients. (Level of
evidence: C)
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)
Atrial Fibrillation/Strategy
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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
Rule of thumb for emergency physicians :
atrial flutter = atrial fibrillation
Atrial Fibrillation/Strategy
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Criteria for hospital admission
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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
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Atrial Fibrillation/Strategy
Questions ??