acep atrial fibrillation update 2017 for...

10/27/2017

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ACEP 2017

Atrial Fibrillation Update 2017

Don’t Miss a BeatCorey M. Slovis, M.D.

Vanderbilt University Medical CenterMetro 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 33% in past 5 years

JAMA 2001;285:2370-75

Incidence of Atrial Fibrillation by Age

JAMA Cardiol 2017 Aug; ePub ahead of print

How common is occult Atrial Fibrillation?

• Stroke may be the first manifestation of AFib

• Evaluated high risk for AF pts who were in sinus(CHADS2 ≥ 3)

• Used implantable device in 385 pts

• Followed patients over 30 months

• Evaluated for runs of AFib > 6 minutes

0

10

20

30

40

50

24 mos

6.2

20.4

Incidence of Transient Atrial Fibrillation

30 d 6 mos

JAMA Cardiol 2017 Aug; ePub ahead of print

27.1

12 mos

%

30 mos

33.6

40.0 Atrial Fibrillation is more common than we previously knew in high risk patients

These episodes are unlikely to be picked up if patients only monitored for 30 days

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How many causes of Atrial Fibrillation are there?

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?

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

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AFib = Stroke Risk

Atrial Fibrillation Equals an Increased Stroke Rate

• About 0.5-1% per year but can be higher

• 5% if no anticoagulation

• CHA2DS2-VASc – important determinant

• Silent cerebral ischemia by CT/MRI is 20-40%

• AF doubles risk of death from age 55 onward

You need to calculate another score:

CHA2DS2-VASc

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

Which is best for patients: Rate or Rhythm Control

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• Classic article, 4,060 pts, multicenter

• Average age 70 yo ± 9

• Rate controlled patients had less hospitalizations

• More adverse effects in the rhythm group

• Slightly more deaths too (p = ns; 0.08)

NEJM 2002;347:1825-37

In General: Rate Control is Superior to Rhythm Control

Annals of Emerg Med 2015;65:540-2

• Meta-analysis of 4 ED relevant studies

• 1,438 patients with new onset AF

• Rate control if older, chronic AF

• Rhythm > rate control if < 65 yo and healthy

ED Rate vs. Rhythm Control

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




There Are 5 Routine Tests for All New AF Patients

• CBC

• BMP

• Thyroid

• CXR

• Echocardiogram (TEE sooner or later)

Consider Additional Tests

• BNP

• Troponin

• Exercise Testing

R/O HF

R/O ACS

WPW, Inducible, ACS

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

repsonse, HR between 140-160.

She has a history of HF, is very SOB, and sounds wet.

BP is 160/100

Should you always provide rate control in borderline sick patients with Atrial Fibrillation and RVR?


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 differenceRR=5.7

82% relative decrease

No rate or Rhythm Control

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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

Electrical cardioversion was only effective in 13.3 % of

these sick patients

AF Rate or Rhythm Control in Sick Patients

Take Homes

• Rarely effective

• Dangerous

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

Be aggressive with fluids, oxygenation, correcting electrolyte abnormalities before using antiarrhythmics

Beta blockers first line if spontaneous conversion does not occur

Mortality from 26.1% to 61.3% if pts stay in AFib

Crit Care Med 2016;20:373-82

Study is not about acute AFib in ED septic patients….do not try to convert septic pts in ED

A patient presents with likely PSVT –is 6 mg or 12 mg adenosine better ?

Adenosine can kill patients with bypass tracks if: Wide and Irregular

Adenosine increases rapid bypass tract conduction and can result in very fast

refractory VFib

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Wide complex Afib and Adenosine =

A rapid Vfib death

Don’t Use Adenosine

• Never give if wide and irregular

• Never give if rate < 150

• Never if only slows during vagal stim

• Careful if hx of AFib, Aflutter, MAT

• Careful if hx of CHF, COPD, WPW

Rate Control in Stable PatientsAFib/AFlutter

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Rate Control in AF with RVR• Calcium Channel Blockers

- Diltiazem 25 mg over 1-2 minMay to 35 mg 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

European Heart 2013;34:1481-88; 1489-97

• The role of Digoxin in Atrial Fibrillation is controversial – it may increase mortality or be a marker for those who will do poorly regardless of its use

• In general – don’t be the one to start it

A 47 year old man presents with new onset atrial fibrillation.

He has well controlled hypertension and no history of AFib.

He felt his heart start to beat “funny” a few hours ago after running?

Can you safely convert rate stable Atrial

Fibrillation and Flutter?

Safety of ED Cardioversion

• Safe if AF is acute

• Very safe if no thrombus

• Risk of CVA increases over time

• TEE required if onset unknown or > 48 hrs

• New evidence suggests maybe > 12 hrs

JAMA 2014;312:647-8

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0.00.10.20.30.40.50.60.70.80.91.01.11.2

< 12 12-24

0.3%

1.1%

OR=4.0

Risk of CVA S/P Cardioversion without anticoagulants0-48 hrs onset = 0.7% JAMA 2014;312:647-8

Annals Emerg Med 1999;33:379-87

• 289 stable patients, new onset AFib

• Included patients with AF > 48 hrs (51/289)

• Excluded unstable patients

• Excluded admission-requiring illnesses

• Average age 64 ± 14; HR 125 ± 26

• Used Procainamide (180 pts, 62% of total)

• 500 mg then, if needed, to 1,000 mg

• 50% converted pharmacologically

• 500 mg converted 44%, 56% took 1,000 mg

• Not if prolonged Q-T or Hypotensive

Pharmacological CardioversionAnnals Emerg Med 1999;33:379-87

• Transesophageal (TEE) not Transthoracic

• Used to R/O thrombus pre cardioversion

• Mandatory if sx > 48 hrs or unknown

• May be used if > 12 hrs or older pts

• Not required in younger healthy pts if onset is acute and heralded by specific symptoms

Who Needs an Echo in AF

• 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

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

• Study excludes patients with other primary diagnoses or complaints including:

- ACS- CHF- Pneumonia- PE- Sepsis and/or SIRS criteria

Ann Emerg Med 2017;69:562-71

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Rapid ED CardioversionInitial Therapy

• Rhythm control in 72.8%

- 39.1% electrocardioversion first

- 33.7% rhythm converting drug first

• Just rate control in 17.8%

- Metoprolol 65.1%

- Diltiazem 32.2%

Ann Emerg Med 2017;69:562-71

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

Electrical Conversion

• AHA recommends 120-200J biphasic

• 50-100J for flutter

• My bias: Use highest recommended: 200 or more

• AP or AL – your choice

• Switch positions if unsuccessful

Cardioversion for Fib/Flutter

Acad Emerg Med 2014; 21:717-26

• Meta-analysis 13 studies

• 836 AP pts vs 856 AL pts

• Trend toward AL > AP if biphasic

Neither A-P nor A-L Pad Placement is Superior

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• 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?

Do patients you see in new AFib need to be

anticoagulated…?How about if you can

convert them?

• 0

• 1

• 2

• 0

• NOAC or 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

Xaralto anti-xa

Apixaban

Dabigatran

Edoxaban

Rivaroxaban

Eliquis anti-xa

Pradaxa direct antithrombin

Xaralto anti-xa

Savaysa anti-xa• 76,354 pts

• Compared each non-vit K drug to Warfarin

• Apixaban lowered stroke risk 33% vs Warfarin

• Apixaban and dabigatran lowered GI bleed risk

• All decreased risk of intracranial bleeding

J Am Heart Assoc 2016;5:e003725

Are the non-vitamin K oral anticoagulants safer than Warfarin?

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Warfarin use is decreasing and is becoming relegated to mainly those

patients with:

Mechanical Heart Valves

Mitral Stenosis

Chronic Renal FailureLancet 2014;383:955-62

Anticoagulation and ED Discharge

Annals Emerg Med 2013;62:557-65 Annals Emerg Med 2013;62:566-8

Annals Emerg Med 2015;65:1-12 Annals Emerg Med 2015;66:347-54

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• Two populations: CHADS2 ≥ 2 and CHA2DS2VASc ≥ 2

• 38.2% of 210,380 CHADS2 ≥ 2 got only ASA

• 40.2% of 294,642 CHA2DS2VASc ≥ 2 got only ASA

JACC 2016;67:2913-23

How often do we not follow current recommended anticoagulation guidelines for

high risk AFib patients?

• More than 1 in 3 high risk for stroke AF pts treated below the standard of care!

Non-vitamin K oral anticoagulants are here

Become expert in using one• 5,738 pts from the ORBIT-AF II Registry

• Routine lab evaluation not required with NOACs

• Considered safer than Warfarin

• Some patients require dosing modifications

JACC 2016;68:2597-604

Are we dosing non-vitamin K antagonists correctly?

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• 87% being dosed correctly

• 9.4% underdosed

• 3.4% overdosed

• Renal disease was # 1 cause of dosing errors

• More strokes, bleeds, AMIs & hospitalizations

Results JACC 2016;68:2597-604

Take HomesNon Vitamin K Oral Anticoagulants

NOACs

• 1 in 8 AF patients are dosed incorrectly

• Under and over dosing increases morbidity and mortality

• Do not discharge patients with renal impairment on a NOAC without working with an ED or hospital pharmacist and/or an AFib focused cardiologist

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

Treat underlying conditions

Summary

Dilt or BB for rate control

Cardioversion can be safe < 12-48 hrs

Antiarrhythmics convert half

200 Joules biphasic works 90%

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