ACEP 2019 Atrial Fibrillation management of selected cases ... · 10/28/2019 1 ACEP 2019 Atrial Fibrillation Management of Selected Cases Corey M. Slovis, M.D. Vanderbilt University

10/28/2019

1

ACEP 2019

Atrial Fibrillation

Management of Selected Cases

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

Metro Nashville Fire DepartmentNashville International Airport

Nashville, TN

Atrial Fibrillation is Common

• # 1 sustained cardiac arrhythmia

• > 3,000,000 patients

• 1% of US population

• 9% of all those ≥ 80 yo

• AFib ED visits 2014

411,406

ED Visits for Atrial FibrillationAre Dramatically Increasing

JAHA 2018;Online August

537,801

30.7%

2007

X100

600

500

400

300

200

100

0

JAMA 2001;285:2370-75

Incidence of Atrial Fibrillation by Age Atrial Fibrillation Heart Failure

JAMA Network Open 2018;1:e180941

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Atrial Fibrillation Ischemic Strokes


Atrial Fibrillation All Cause Mortality


There Are 5 Causes of Atrial Fibrillation

• Pericardium

• Myocardium

• Endocardium

• Pulmonary

• Hypersympathetic

Pericarditis

LVH, Myocarditis

Endocarditis, Valvular

PE, pulmonary hypertension

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

What are the 5 steps in the treatment of ED patients who

present with either new AFib/Flutter or AFib with RVR?

Secure ABCs

5 Step ED Dx - Rx

Determine etiology

Beta Blocker vs Diltiazem for RVR

Establish stroke risk (CHA2DS2-VASc)

Cardiovert, Admit or D/C on meds

Why is Atrial Fibrillation so dangerous?

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Stroke Is The Biggest AF Risk

• 5% year if no anticoagulation

• 10% year if prior CVA or TIA

• Anticoagulation decreases CVA risk by at least 2/3

AFib = Stroke Risk

Always Calculate the Patient’s ScoreCHA2DS2-VASc

• CHF (1)

• Hypertension (1)

• Age ≥ 75 (2)

• Age 65 – 74 (1)

• Diabetes Mellitus (1)

• Stroke/ TIA/Thromboembolic (2)

• Vascular (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 CHADS2 Score

9.8

6.7

15.2

2.2

6.7

9.6

JAMA 2001;285:2370-75

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

in sinus rhythm

Older, sicker patients do better with their AF rate controlled

Rhythm Control

Rate Control

Secure ABCs

5 Step ED Dx - Rx

Determine etiology




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There Are 5 Routine Tests for All New AF Patients

• CBC

• BMP

• Thyroid

• CXR

• Echocardiogram (sooner or later)

Consider Additional Tests

• BNP

• Troponin

• Exercise Testing

• TEE

R/O HF

R/O ACS

WPW, Inducible, ACS

Pre cardioversion ifAF > 48 hrs duration

A 67 year old woman presents with atrial fibrillation with rapid ventricular

response, HR between 140-160.

She has a history of controlled HTs and takes an ARB, multivitamin, and

Vitamin E daily

BP is 160/100

Rate Control in AF with RVR• Calcium Channel Blockers

- Diltiazem 0.25 mg/ks over 1-2 minMay to 0.35 mg/ks over1-2 min if inadequate response after 5 min

• Beta Blockers- 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

• 1,091 pts, mean age 63.9 years, 2010-2012

• 6 academic centers, 84.7% AFib, 15.3%Aflutter

• Clear history of onset ≤ 48 hrs

• Clear 7d history and no thrombus by TEE

Ann Emerg Med 2017;69:562-71

Canadian “aggressive care” focuses on in-ED Cardioversion

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PharmacologicRhythm Control

• Procainamide used in 85%

• Converted 52.2% of patients

• Use 35-50 mg/min (up to 20 mg/kg)

• Can go faster - but careful!

Synchronized Cardioversion Effectiveness

• 90.0% successful electrical conversion

- Mean max energy 148 joules

- 1.4 mean shocks required

Ann Emerg Med 2017;69:562-71

• 80.1% conversion to sinus rhythm

• 1 stroke and no deaths at 30 days(89 yo F on coumadin who had

spontaneously converted in ED)

Ann Emerg Med 2017;69:562-71

Is Canadian “aggressive care” with cardioversion effective and safe?

Acad Emerg Med 2019; online August

Which is faster to cardiovert new onset Atrial Fibrillation: Electricity or Drug?

• 84 patients, new onset AFib, all CHADs 0-1

• Randomized to DC Cardioversion vs Procainamide

• All patients discharged home

• Evaluated in-ED time and initial success rates

Treatments

• Procainamide: 17 mg/kg over one hour (maximum dose 1500 mgs)

• DC Cardioversion: 100 then 150 then 200 joules (Propofol 0.50 mgs/kg then 0.25 mg/kg q min)


67% of DC Cardioverted patients left within 4 hours vs 32% treated with

procainamide (p<0.001)Acad Emerg Med 2019; online August

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Conversion with Initial Method

Procainamide

53.7%

Electrical


88.4%

p<0.001

Eur Heart J 2019; online August

Which is superior when electrically converting AFib: Escalating Energy or Maximum Energy?

• 276 pts randomized, single Danish Center trial

• 125-150-200 J vs 360-360-360 J shocks

• Used biphasic truncated exponential waveform

• Most AF ≥ 1 mos, CHA2DS2Vasc ≥ 2

• All anti-coagulated and/or TEE as needed

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

First Shock Successful Cardioversion

Escalating

34%

Maximum


75%

p< 0.001

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Overall Sinus Rhythm

Escalating

66%

Maximum


88%

p< 0.001

How Much Energy to CardiovertTake Homes

As much as you have!

First time, every time

Acad Emerg Med 2019; 26:1034-43

Patients clearly prefer Sinus Rhythm

• Rhythm control decreases admissions

• Rates need to be below 110 to d/c

• Heart Failure equals Admit

Spanish study using Amiodarone, Flecainide, and Propafenone not directly applicable to US

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How to best achieve Sinus Rhythm in new onset Atrial Fibrillation

Do you really need to spend hours doing an in-ED Cardioversion?

Acad Emerg Med 2018;25:641-9

Can a simple to follow protocol allow more discharges in AFib/AFlut patients?

• 1,108 patients

• Retrospective before-after trial

• Academic community hospital

• Evaluated percent of pts admitted in 1 year

• Also 3 and 30 day returns Acad Emerg Med 2018;25:641-9

• Arranged follow up within 3d

• Seen then in cardiology clinic

• Anticoagulation held until then

• Discharged on BB or Calcium Blocker

• Metoprolol 50 BID

• Diltiazem 120-180 ext release


St. Joseph Murphy AlgorithmExclusions and Admit

• Underlying Acute Illness(sepsis, PE, etc.)

• Acute Coronary Syndrome

• Acute Heart Failure

• Syncope

• Hemodynamic instability


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NEJM 2019;380:1499-1508

Can Cardioversion be safely delayed in ED patients with new onset Atrial Fibrillation?

• 427 pts assigned to early vs delayed cardioversion

• Randomized 1:1, multicenter trial

• Atrial Fibrillation of < 36 hours studied

• Evaluated rhythm at 4 weeks

• Also evaluated complications including CVA

Methods

• 15 Hospitals in the Netherlands

• October 2014 - September 2018

• Only hemodynamically patients

• Rate Control via BB, CAB or Digoxin

• Wait and See pts discharged when HR < 110

NEJM 2019;380:1499-1508

Wait and See patients were seen 24 - 48 hours later and if still in

Atrial Fibrillation were sent to theED for Cardioversion

Delayed Cardioversion

• 69% (150/218) spontaneously converted by 48 hours

• 28% (61) required ED Cardioversion

• 9 by flecainide and 52 electrically

NEJM 2019;380:1499-1508

NEJM 2019;380:1499-1508

Sinus Rhythm at 4 Weeks Complications at 4 weeks

• 1 Stroke / TIA each in Immediate vs Delayed

• 3 ACS episodes in each group

• Same incidence of AF recurrence in both groups (29% vs 30%)

NEJM 2019 epub

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Rate Controlling AF and Discharging Take Homes

Appears safe and effective as long as stable patients are discharge rate controlled AND

seen for follow up in 24-48 hours

This I believe will be the new US “standard of care”

Can J Card 2019 online Sept

Why are patients with AFib and RVR not able to be converted and/or optimally rate controlled?

• 665 AF with RVR pts; x ̄ HR 121 bpm

• Evaluated patients who had ≥ 100 bpm at D/C

• 10% complication rate if underlying medical cause

• Only 59% had successful rate control

• #1 cause was suboptimal dosing of meds

Annals of Emerg Med 2015;65:511-22

Is rate control for atrial fibrillation with RVR always the best strategy?

• 416 patients with AF

• All patients had “complex” AF

• Complex = an acute underlying illness

• 2 Canadian University affiliated EDs


• 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% 40.7%

7.1%

Rate or Rhythm Control

Attempted

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

33.6% absolute difference RR=5.7

82% relative decrease

No rate or Rhythm Control

0%

10%

20%

30%

40%

50%

19.0%

44.5%

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

Control Attempted(Elec, Dilt, BB)

No Attempt at Control(Crystalloid, Bronchodilator)

25.5% absolute differenceRR=2.3

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AF Rate or Rhythm Control in Sick Patients Take Homes

• Rarely effective

• Dangerous

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

Do not focus on rate control in patients with pulmonary edema,

sepsis, fever, or acute bronchospasm.

Focus on treating the underlying disease

Wide complex Afib and Adenosine =

A rapid Vfib death

A thin woman presents with palpitations, a history of weight

loss, and feeling minimally paranoid. She is on two anti-

anxiety medications

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There Are 5 Causes of Atrial Fibrillation

• Pericardium

• Myocardium

• Endocardium

• Pulmonary

• Hypersympathetic

Pericarditis

LVH, Myocarditis

Endocarditis, Valvular

PE, pulmonary hypertension

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

Do patients you see in new AFib need to be

anticoagulated…?How about if you can

convert them?

• 0

• 1

• 2

• 0

• Discuss

• NOAC or Warfarin

JAMA 2015; 314:291-2

CHA2DS2-VASc AgentNon-vitamin K anticoagulants now endorsed in ACC/AHA guidelines.

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

s/p cardioversion

Non-Vitamin K AnticoagulantsNovel Oral AnticoagulantsDirect Oral Anticoagulants

• Apixaban

• Dabigatran

• Edoxaban

• Rivaroxaban

Eliquis anti-xa

Pradaxa direct antithrombin

Savaysa anti-xa

Xarelto anti-xa

If you don’t discharge a patient on a non-vitamin K antagonist when

indicated, it can take weeks-months for it to be started…and allow a

preventable stroke to occur

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Non-vitamin K oral anticoagulants are here

Become expert in using one


• Canadian before and after study

• 631 pts, average 69 yo ± 14

• Median CHA2DS2 – VASC of 3

Can a “tool kit” increase anticoagulation at ED discharge from CHADS2 ≥ 1 Afib pts


Summary

Secure ABCs

5 Step ED Dx - Rx

Determine etiology




Atrial Fibrillation is common

Summary

Stroke is high risk

Always calculate CHA2DS2-VASc score

Anticoagulate if indicated

2 = yes, 0 = no, 1 = yes or discuss

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Treat underlying conditions

Summary

Diltiazem or BB for rate control

Antiarrhythmics convert half

Use maximum output to cardiovert

Just rate control and follow up

VanderbiltEM.com

Documents

ACEP 2019 Atrial Fibrillation management of selected cases ... · 10/28/2019 1 ACEP 2019 Atrial Fibrillation Management of Selected Cases Corey M. Slovis, M.D. Vanderbilt University