atrial fibrillation - camcinstitute.orgcamcinstitute.org/professional/snowshoe/2013/pdf/06.pdf ·...

Atrial Fibrillation

William H. Carter, M.D.POC

“Plain Old Cardiologist”Plain Old Cardiologist

My interest in atrial fib in the ED yand office

1. Natural history of recent onset atrial fibatrial fib

2. Options for ED and office tmanagement

3. Involved 2 studies ED atrial fib outcomes

4. Anticoagulation issuesg

At i l Fib ill tiAtrial Fibrillation

•EtiologyEd ti•Education

•Rate Control•Cardioversion

•Maintenance of NSR•Maintenance of NSR•Anticoagulationg

65 ld l i i l k65-year old notes palpitations last weekpresents to ED

No evidence of heart disease on PE or EKG– NIDDM – history hypertension

EKG atrial fibrillation - rate 140/min. – rate controlled in ED on beta blockers –

OPTIONS

1. ADMIT FOR RATE SLOWING , ANTICOAGULATION ,AND DIAGNOSTIC TESTING

2 START OUT PATIENT ANTICOAGULATION AND SEE IN OFICE2. START OUT PATIENT ANTICOAGULATION AND SEE IN OFICEFOR FURTHER TESTING AND TREATMENT

75 year old, prior TIA, history of heart disease and alcoholwith cardiomyopathy, EF 25% - normal coronary Message : AMIODARONE AND/OR DIGOXIN ARE THE SAFEST RATE SLOWING MEDS

Ïangiogram, 6/12, no alcohol last year - on ACE, digoxin, spironolactone, no beta blockers, mild SOB, moderate COPD. Enters rapid AF, ventricular rate 160 – EKG no

FOR BETA BLOCKER NAÏVE PTS. WITH BAD LV

p ,change from6/12 otherwise Bp 110/70. How to slow?

What to do??A. IV DILTIAZEMB. IV BETA BLOCKERSC. IV AMIODARONED. CARDIOVERT.

C St d S P ti tMessage : A fib now exceeds heart failure as a cause for hospital admissions. Are we admitting

Case Study – Same Patientfor our convience?

75 year old, prior TIA, history of heart disease and alcoholwith cardiomyopathy, EF 25% - normal coronary angiogram, 6/12, no alcohol last year - on ACE, digoxin, spironolactone, no beta blockers, mild SOB, moderate COPD. Enters rapid AF, ventricular rate 160 – EKG no change from6/12 otherwise Bp 110/70. How to slow?

C t t NSR i ED b f i d d i t t dConverts to NSR in ED before amiodarone drip started -feels fine

What to do??What to do??A. Admit – start heparin/warfarin other meds and tests as

i ti tinpatientB. D/C from ED – start warfarin as out-patient – titrate up

beta blockers – start dig.

Obstacles to Discharging Atrial Fib g gPatient from ED

1. Arranging follow-upg g p2. Anticoagulation issues3 Need for diagnostic “work up” TSH echo etc3. Need for diagnostic work-up TSH .echo etc.4. Medical legal5. It easier to admit for a busy ED doc

70 year old female with a past history of paroxysmal( rare occasion )70 year old female with a past history of paroxysmal( rare occasion ) a. fib. Office evaluation for a.fib negative 6 months ago .Not on warfarin, On metoprolol 50-mg/day. No hx. of CAD When in sinus rhythm has normal EKG rate of 75/minute CHADS Score 1rhythm has normal EKG rate of 75/minute. CHADS Score 1

Now in the ER atrial fib (?/2-4 days duration) rate 120/min. Very mildly symptomatic. Family worried . Routine ER evaluation neg.

1. Admit for rate slowing and other management issuesmanagement issues

2. Discharge after further ED treatment

100100100100——

8080——

P=0.752P=0.752PropafenonePropafenone

6060——p=0.015p=0.015

pp--0.0600.060

4040——

2020

p=0.005p=0.005

pp

PlaceboPlacebo

2020——

00——| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 1 2 3 4 6 8 10 12 241 2 3 4 6 8 10 12 24time from start of randomized treatment (h)time from start of randomized treatment (h)time from start of randomized treatment (h)time from start of randomized treatment (h)

Eur Heart J., Vol. 18, October 1997Eur Heart J., Vol. 18, October 1997

75 year old female admitted rapid a. fib 140/min. by history present 3 days

Past history TIA’s , intermittent episodes “heart racing”PMH , ROS, PE otherwise neg. BP 100/70 Pulse 150/min

EKG normal except for a fib Echo normal EF severe LVHEKG – normal except for a.fib –Echo normal EF –severe LVHRate slowed with iv diltiazem to 80/ min. and then converts to

NSR – switched to po diltiazem

WHAT MEDS MORE LIKELY TO PREVENTWHAT MEDS MORE LIKELY TO PREVENT RECURRANCE A.FIB ?

1. Digoxin 2. Beta blockers3. Diltiazem4. None of above

Anticoagulation Strategies Subset Consideration

STENTSMEDICATED

A fib

CHADS

MEDICATED< 1 yr

1 yr

CAD StableACS in last year CHADS

0,1 , or 2 or

Bare metalBalloon only

ACS in last year

Prosthetic valvemechanical

more

DVT/PE

Stroke< 1year

1

tissue

> 1 year

Warfarin alone is acceptable for patients with stable CAD( Chest Feb. 2012 Guidelines)

75 year old – CAB 2005 – no angina – class I-II -New atrial fib Hi t ild GI bl di f i d l i dHistory mild GI bleeding from angiodysplasia – needs oral iron to avoid transfusions.

What A/C meds?

A ASA d Cl id lA. ASA and ClopidogrelB. Warfarin and baby ASAC. Warfarin aloneC. Warfarin alone

3.1 For patients with AF and stable coronaryartery disease (eg, no acute coronary syndromey ( g y ywithin the previous year) and who choose oralanticoagulation, we suggest adjusted-dose VKAg , gg jtherapy alone (target international normalizedratio [INR] range, 2.0-3.0) rather thanratio [INR] range, 2.0 3.0) rather thanthe combination of adjusted-dose VKA therapyand aspirin (Grade 2C)and aspirin (Grade 2C)

3.2 For patients with AF at high risk of stroke (eg, CHADS 2 score of 2 or greater) during theCHADS 2 score of 2 or greater) during the first 3 to 6 months after placement of a drug-eluting stent, we suggest triple therapy (eg, VKA therapy,stent, we suggest triple therapy (eg, VKA therapy, aspirin, and clopidogrel) rather than dual antiplatelet therapy (eg, aspirin and clopidogrel)

(Grade 2C) . After this initial period of triple therapy, we suggest a VKA (INR 2.0-3.0) plus a single antiplatelet drug rather than VKA alone (Grade 2C)

. At 12 months after intracoronary stent placement, antithrombotic therapy is suggested as for patients with AF and stable coronary artery disease (see section 3 1)section 3.1).

Case Study - Recent ACS – Stent – A FibIt is reasonable to consider warfarin and clopidogrel without ASA after medicated stents in selected patients50 year old diabetic, hypertensive patient. Non-STEMI 3 months ago – mid RCA – medicated Xience stent used for Type B lesion. Hx remote GI bleed from gastritis needing one transfusion.

without ASA after medicated stents in selected patients after 6 monthsHx remote GI bleed from gastritis needing one transfusion.Meds: ASA 160mg; Prasugrel, ACE, beta blocker, Zocor 40, amlodipine. Enters ED months after 6 months after stent for ACS –atrial fib rate well controlled on beta blockers

O ti f thi ti t ith CHADS 2Options for this patient with CHADS 2 score

A Add f i t ASA d P lA. Add warfarin to ASA and PrasugrelB. Add dibigatran to ASA and prasugrelC Add apixaban or reveroxiban to ASA and prasugrelC. Add apixaban or reveroxiban to ASA and prasugrelD. Stop ASA – add warfarin to clopidogrel ( prasugrel or ticagrelor

?? Dr. Granger)

3.3. For patients with AF at intermediate to high risk of stroke (eg, CHADS 2 score of 1 or greater) whoexperience an acute coronary syndrome and do not undergo intracoronary stent placement, we suggest for the first 12 months, adjusted-dose VKA therapy (INR 2.0-3.0) plus single antiplatelet therapy rather than dualantiplatelet therapy (eg, aspirin and clopidogrel) or p py g p p gtriple therapy (eg, warfarin, aspirin, and clopidogrel) (Grade 2C) . After the first 12 months, antithrombotic ( ) ,therapy is suggested as for patients with AF and stable coronary artery disease (see section 3.1).coronary artery disease (see section 3.1).

Clopidogrel – prasugrel – ticagrelor p g p g gHOW LONG ???

60 year old attorney – A. fib CHADS 0 Xience stent type B for mid LAD lesion 13 months ypago. Moderate ? alcohol – past mild GI bleed from gastritis .g

Options1 C ti l id l l1. Continue clopidogrel , or prasugrel or

ticagrelor2 Contin e ASA 81 mg stop other anti2.Continue ASA 81 mg. - stop other anti -

platelet agents

Wh t ld d ?What would you do?

1 Admit if TEE neg25% 25%25%25%

1. Admit – if TEE neg. cardioversion - heparin– long term warfarin and ASA 80 mg.

2 Double dose of metoprolol start2. Double dose of metoprolol – start warfarin as OP -d/c from ER .consider rhythm control on follow-up in officefollow up in office

3. Start amiodarone po – see in office F/U

4 Admit start heparin dofedilide4. Admit – start heparin,dofedilide warfarin –cardiovert before D/C if doesn’t cardiovert on dofedilide mi

t – if

TEE..

.

ble do

se of

...

t ami

odaro

...

mit –

start

...

dofedilide

Adm

Doub

l

Start

a

Adm

Summaryy• March 2012 Chest Guidelines for first time in US

guidelines recommend at moderate embolic riskguidelines recommend at moderate embolic risk for patients or high (Grad 2-C): in stable CAD patients in AF at intermediate risk for embolismpatients in AF at intermediate risk for embolism warfarin alone

• After 3-6 months following stenting of selected patients at moderate to high bleeding risk warfarin p g gplus either ASA or clopidogrel. (grade 2-C)

75 –year old diabetic male - recent Non STEMI – medicated stent proximal LAD, lesion 3 mm in length 2.0 in diameter. Has chronic -

100%

AF CHADS score 3 due to hypertension , DM , and age. Past GI bleeds needing 3 units for angio dysplasia 2-3 times/year

For 1st 6 months what to use ?

100%

For 1st 6 months what to use ?

1. ASA, clopidogrel, oral A/C2. ASA Clopidogrel

0% 0%3. Oral AC and Clopidogrel

idogr.

..

dogre

...

nd Cl

...

0% 0%

ASA,

clopid

ASA C

lopido

g

Oral

AC an

d

Same patient for 6-12 months60 –year old diabetic - recent non stemi – medicated stent60 year old diabetic - recent non stemi medicated stent proximal LAD, lesion 3 mm in length 2.0 in diameter. Has chronic AF CHADS score 1 due to hypertension always

100%

yp ywell controlled.

For 1st 6 months what to use

1. ASA, clopidogrel, oral A/C2 ASA Clopidogrel2. ASA Clopidogrel3. Oral AC and Clopidogrel 0% 0%

ASA,

clopid

ogr...

ASA C

lopido

gre...

Oral

AC an

d Cl...

66 –year old - non STEMI 2 years ago - Has chronic AF66 year old - non STEMI 2 years ago. - Has chronic AF CHADS score 2 due to hypertension , and heart failure.

What to use ?100%

1. ASA, clopidogrel warfarin2 ASA Clopidogrel2. ASA Clopidogrel3. Oral AC and Clopidogrel4 Warfarin alone4. Warfarin alone

0% 0%0%

ASA,

clopid

ogr...

ASA C

lopido

gre...

Oral

AC an

d Cl...

Warf

arin a

lone

3.1 Chest 2012 For patients with AF and stable CAD (no ACS in last year) and who choose(no ACS in last year) and who choose warfarin alone ( ? dabigatran *) , we suggest adjusted dose VKA therapysuggest adjusted dose VKA therapy alone rather than the combination of warfarin and ASA

RELY study showed a trend for increased MI’s in the dibagatran group

THUS NEED TO CONSIDERTHUS NEED TO CONSIDER

Risk/benefit of various combinations anti thrombotic agentsg

Risk of embolism or ischemic eventBl di i kBleeding riskPatient preference

80-year-old medicated sirolimus stent 5 months ago , Type A lesion stent mid RCA- high bleeding risk – age, anemia, prior GIlesion stent mid RCA high bleeding risk age, anemia, prior GI bleed not needing Tx, GFR 30 cc/min. History of atrial fribrillation – prior TIA felt to be embolic. What are the options.

1. Triple RX 1 year2 ASA d Cl id l f 12. ASA and Clopidogrel for1 year

then warfarin and ASA3. Triple Rx 6 months then warfarin 3. p e 6 o t s t e wa a

plus clopidogrel /or warfarin plusASA



Risk of embolism or ischemic event

Bl di i kBleeding riskPatient preferencep

Case Study # 1Case Study # 1

• 70-year old male• Chronic CHF-EF 20%• Post op colon surgeryp g y• Rapid atrial fibrillation 160/min• BP stable 100/80BP stable 100/80• Creatinine 2.5

Choices # 1Choices # 1

• Cardiovert• i.v. digoxin• iv ßeta blockers• iv. ßeta blockers• i.v. diltiazem• i.v. amiodarone

Acceptable drugs for atrial fibrillation slowing in pts. with bad LV

L i• Lanoxin

•Amiodarone

65 year old hypertensive diabetic hospitalized for pneumonia – he is felt to need three days in the hospital for pneumonia treatment.

On admission he has newly discovered atrial fibrillation rate 150/minute. Echo, EKG, TSH, , , ,and general evaluation is negative.

CASE 10CASE 10

Which are acceptable options?p p1. 1. Amiodarone2. 2. TEE - if negative for

embolic risk cardioversion and t t h i til INR

17% 17% 17%17%17%17%

start heparin until INR therapeutic

3 3 Coumadin consider3. 3. Coumadin – consider chemical or electrical cardioversion at six weekscardioversion at six weeks

4. 4. All of the above5 5 B&C 1.

Amiod

arone

‐ if ne

gativ

e for

...

madin

– co

nside

r...

4. All

of th

e abo

ve 5.

B&C

6.C o

nly

5. 5. B&C6. 6.C only

CASE 10

2. T

EE ‐

3. Co

um

At six weeks patient is cardioverted to NSR after pstarting dofedilide in the hospital. What other medications are needed?

1. None33% 33%33%

1. None2. Beta-blockers3 L i3. Lanoxin

e rs in

CASE 10

None

Beta‐

blocke

rs

Lano

xin

70 year old female with a past history of paroxysmal( rare occasion ) a. fib on warfarin, metoprolol 50-mg/day No hx Of CAD When in sinus rhythm hasmg/day. No hx. Of CAD When in sinus rhythm has normal EKG rate of 75/minute.

Now in the ER atrial fib rate 120/min. Very mildly symptomatic Family worried Routine ER evaluationsymptomatic. Family worried . Routine ER evaluation neg.

CASE 11

1. Admit – if TEE neg. 74 year old female with a past history of paroxysmal( rare occasion ) a. fib.

cardioversion - heparin– long term warfarin and ASA 80 mg.

Office evaluation for a.fib neg 6 months ago .Not on warfarin, On metoprolol50-mg/day. No hx. of CAD When in i h h h l EKG f 2. Double dose of metoprolol –

start warfarin as OP -d/c from ER .consider rhythm control

f ll i ffi

sinus rhythm has normal EKG rate of 75/minute.

on follow-up in office3. Start amiodarone po – see in

office F/U

Now in the ER atrial fib (?/2-4 days duration) rate 120/min. Very mildly symptomatic. Family worried . Routine ER l i 4. Admit – start

heparin,dofedilide warfarin –cardiovert before D/C if d ’t di t

ER evaluation neg.

What would you do?doesn’t cardiovert on dofedilide

75 year old female on routine officevisit noted to be in atrial fib – rate 120/minute. Patient is asymptomatic except for mildasymptomatic except for mild palpations. The rest of the Hx, PE, EKG were normal except forEKG were normal except for COPD recent increase in inhaler use.

70 year old female with a past history of paroxysmal rare occasion a. fib on warfarin, metoprolol 50-mg/day. Hx COPD – slight recent increase inhalers When in sinus rhythm has normal EKG rate ofincrease inhalers. When in sinus rhythm has normal EKG rate of 75/minute. Now in the ER atrial fib rate 120/min. Mildly symptomatic.

20% 20% 20%20%20%Options1. 1. Admit start heparin –

rate control medications

20% 20% 20%20%20%

rate control medications2. 2.Start Metoprolol and

Warfarin as OP3. 3. Start Digoxin and

Warfarin as OP4. 4. Start Diltiazem and

Warfarin as OP5 5 Cardiovert in ER (drug sta

r...

etop..

.

Digo..

.

Dilt...

vert.

..5. 5. Cardiovert in ER (drug or shock)

CASE 12

1. A

dmit s

t 2

.Start

Meto

3. S

tart D

ig 4

. Star

t D 5

. Card

iove

55 year old male – new onset of atrial fib noted in the office – rate 100/minthe office rate 100/min.No Hx of hypertension, diabetes, heart failure, CVA, TIA.

Options:20% 20% 20%20%20%

1. Warfarin2 ASA 300 mg2. ASA 300 mg3. ASA 160 mg.4. ASA 160 mg plus g p

clopidogrel5. No A/C

War

farin

A 300

mg

A160

mg.

opido

...

No A/

C

W

ASA

ASA 1

ASA 1

60 m

g plus

clop

80 year old female with atrial fibrillation, CHF with EF 25% hypertension LA 5 cm over last year has fallen25%, hypertension, LA 5 cm over last year has fallen three times once fractured a wrist and uses NSAIDs for arthritis. Creatinine 1.5 GFR 40 cc/min, Hbg 10.5, stoolsarthritis. Creatinine 1.5 GFR 40 cc/min, Hbg 10.5, stools are negative for blood.

1 W f i20% 20% 20%20%20%

1. Warfarin2. ASA 300 mg3 ASA 1603. ASA 160 mg.4. ASA 160 mg plus

l id lclopidogrel5. No A/C

Warfa

rin

300 m

g

160 m

g.

ido...

No A/

C

War

ASA 3

0

ASA 1

60

ASA 1

60 m

g plus

clopid No

What patients can have warfarin held for five days without bridging?

*Low dose SC LMWH ok

CHADS score 0-2 and no prior CVA or TIA

Bileaflet AV prosthesis without atrial fib and no risk factors for CVA.and no risk factors for CVA.

Single VTE occurred > 12 months ago and no other risk factorsno other risk factors.


•Education •Etiology•Rate ControlA ti l ti•Anticoagulation

•Cardioversion•Maintenance of NSRMaintenance of NSR

Atrial FibrillationPatient Education

HandoutHandout

Internet


•EducationEti l•Etiology

•Rate control•Cardioversion•Maintenance of NSR•Maintenance of NSR•Anticoagulation

Case #3 more options

Diagnostic work-up What tests ?Diagnostic work up What tests ?MgCalciumCalciumTSHlung scanlung scanechospiral CTspiral CTTEE

Mechanisms of Atrial FibMechanisms of Atrial Fib

Elevation of left atrial pressureAny left heart failureMitral valve diseaseMitral valve diseaseVolume overload

HypoxiaToxic – ALCOHOL (may not be heavy) , thyroidOther post thoracotomy“Zebras” – myxoma , ASD in adults , etcIdiopathic – 30%

Etiology of At i l Fib ill tiAtrial Fibrillation

•Toxic•Alcohol•Thyroid

•Post Thoracotomy

•Idiopathicp• “ Zebras ““ASD in adult , myxoma etc.


•Education •EtiologyEtiology

•Rate Control•Anticoagulation•Cardioversion•Cardioversion•Maintenance of NSR

Case #3 options (1)11. Admit ? Yes - no2. Cardiology consult ? What tests ??3. Cardiovert ?

a. Nowb 4 6 weeksb. 4-6 weeksc. Never

4. Slow rate ?4. Slow rate ?a. digoxinb. diltiazemc. beta blockersd. amiodarone

i ic. amlodipine5. Anticoagulate ?

Methods to Slow Atrial Fibrillation

•Beta Blockers ? Magnesium

•Digoxin Clonidine (poor fifth)

•Calcium Blockers AV Node ablation or modification

•Amiodarone

Lanoxin

Good NewsGood News•Positive inotropic effect•No hypotension•No hypotension•easy to give•InexpensiveInexpensive

Bad NewsL ff i h b bl k•Less effective than beta blockers or

calcium blockers when catechols are higherD ’ NSRDoesn’t convert to NSR

Calcium BlockersCalcium Blockers

Good News•Rapidly effectivep y•Easy to use

Bad NewsN ti i t i ff t•Negative inotropic effect

•More hypotension than βeta Blockers

Beta Blockers

Good News•Rapid Slowing•May convert AND maintain NSR•Simple to give IV

Bad News•Negative inotropic effect•Negative inotropic effect•Other usual side effects asthma, fatigue•May have symptomatic sinus brady post•May have symptomatic sinus brady post

conversion

Adequate Rate Controlq

•At office visit-Apical heart rate (sitting): <80/min

•On 24-hour Holter monitor-Goal: Average hourly heart rat <80/min;no hour >100-110/min

•Exercise testing (if available)• -Inadequate: > 85% age-predicted maximum

in stage I (Bruce) or 3 min of exercise

Moderate risk factorsModerate risk factors

DiabetesCoronary artery diseaseA 65 * t 75Age 65 * to 75 years

* Age 60 to 75 AHA /ACC/ ESC Guidelines OCT: 2001

Case Study # 5• 70-year old male• Chronic CHF-EF 20%• Post op colon surgery• Rapid atrial fibrillation 160/min• BP stable 100/80• Creatinine 2.5

Which drug to maintain NSR ?propaferoneQuinidineQuinidinediltiazemdofedilidesotolol

Choices # 5• 70-year old male• Chronic CHF-EF 20%• Post op colon surgery• Rapid atrial fibrillation 160/min• BP stable 100/80 – hx.

•Creatinine 2.5

• Cardiovert• I V digoxin• I.V. digoxin• ßeta blockers• I V diltiazem• I.V. diltiazem• I.V. amiodarone

Choices # 5• 70-year old male• Chronic CHF-EF 20% - Hx COPD• Post op colon surgery• Rapid atrial fibrillation 160/min• BP stable 100/80 – hx.

•Creatinine 2.5

• Cardiovert• I V digoxin• I.V. digoxin• ßeta blockers• I V diltiazem• I.V. diltiazem• I.V. amiodarone

Case #2 ER Visit

28-year old healthy male, chief complaint waspalpitations for 6 hours.

•PMH ROS PE EKG TSH normal except•PMH, ROS, PE , EKG , TSH normal except sleep deprived , weekend heavy alcohol and caffeinecaffeine

•Apical rate 170/min, BP 100/70

•EKG - rapid atrial fibrillation

Case #2 options (1)

25% 25%25%25%

p ( )

How to slow?1 IV di i

25% 25%25%25%

1. IV digoxin 2. IV beta-blockers3. IV diltiazem4 IV procainamide4. IV procainamide

digox

in

ocke

...

tiazem

amid.

..

IV di

g

IV be

ta‐blo

c

IV di

ltia

IV pr

ocain

am

Case #2 options (2)p ( )

Rate now 100/min. 1 hour after treatment

How to cardiovert ?25% 25%25%25%

1. Shock2 IV diltiazem2. IV diltiazem3. IV pronestyl 4. p.o. propafenone

k m l

Shoc

k

IV di

ltiazem

IV pr

ones

tyl

p.o.

propa

feno..

.

Case #2 options (3)

20% 20% 20%20%20%

Patient cardioverted after two hours with no further Rx

What medications on discharge ?

20% 20% 20%20%20%

1. Diltiazem2 Beta blockers2. Beta blockers3. Sotalol4. Amiodarone5. None

em ers lol ne one

Diltia

zem Be

ta blo

cker

Sotal

o Am

iodaro

n

Non

T pes of Atrial FibTypes of Atrial Fib

First episodeParoxysmalPersistentP tPermanent

Case #2 ER Visit

28-year old healthy male, chief complaint was palpitations for 6 hours. PMH, ROS, PE , EKG , TSH normal except sleep deprived , weekend heavy alcohol and caffeine

33% 33%33%

weekend heavy alcohol and caffeine •Apical rate 170/min, BP 100/70•EKG - rapid atrial fibrillation

What diagnostic tests after D/C ?

1. Echo/doppler2. CT angiogram2. CT angiogram3. Dual isotope rest

thallium/stress MIBI er m ..thallium/stress MIBI

Echo

/dop

pler

CT an

giogra

m

Dua

l isot

ope r

...


•Rate Control•AnticoagulationAnticoagulation•CardioversionM i t f NSR•Maintenance of NSR

•Etiology•Education

Drugs to Cardiovert Atrial Fib of Less 2 Days D rationDuration

Agents with proven efficacyAgents with proven efficacy Dofedilide IAPropafenone IAPropafenone IAFlecainide IAIbutilide IAIbutilide IAAmiodarone IIaQuinidine IIBQuinidine IIB

Less proven effective : Procainimide Digoxin SotololLess proven effective : Procainimide, Digoxin, SotololACC/AHA/ESC Guidelines OCT. 2001

Atrial fib Case #8

75 year old female admitted rapid a. fib 140/min. b hi t t 3 dby history present 3 days

Past history TIA’s , intermittent episodes “heart i ”racing”

and Hx severe asthmaPMH , ROS, PE otherwise neg. BP 100/70 Pulse

150/minEKG – normal except for a.fib –Echo normal EF

–severe LVHRate slowed with iv diltiazem to 80/ min. and then

converts to NSR – switched to po diltiazem

WHAT MEDS NOW TO PREVENT RECURRANCE A.FIB ?

20% 20% 20%20%20%1. Digoxin 2. sotolol

20% 20% 20%20%20%

3. propafernone 4 amiodarone4. amiodarone 5. no antiarrhythymic meds –

l f i donly warfarin and diltiazem (and digoxin if

d d) Digox

in

sotol

ol

one

...

daron

e

hyth.

..

needed) Dig so

prop

aferno

n

amiod

a no

antia

rrhy

Presumed Benefits of MaintaininggSinus Rhythm

•Fewer symptoms/better exercise tolerance

•Lower risk of stroke•Long-term anticoagulation may not be needed ifg g ySinus rhythm is successfully maintained•Better quality of lifeBetter quality of life

•Better survivalAFFIRM ` ACC MAR 02

Five trials have shown no benefit from rhythm control vs. rate control and warfarin

in terms of :in terms of :

D hDeathCVAQuality of life

Maintenance Sinus Rhythm at 1-2 Years

1. Amiodarone 60-80%2 A 40 0%2. All others 40-50%

A i fAmiodarone - long-term follow-up•120 patients - follow-up 5 years40% ill f l R•40% still on successful Rx

Pharmacological ManagementRecurrent

Paroxysmal AF

Minimal or no symptoms

Disabling symptoms in AFno symptoms

Anticoagulation and rate

in AF

Anticoagulation and rateAnticoagulation and rateControl as needed

gControl as needed

AAD thNo drug for

prevention of AF

AAD therapy

AF ablation if AADAF ablation if AADTreatment failsACC/AHA/ESC Practice Guidelines

Fuster et al Circulation August 15, 2006

Maintenance of Sinus Rhythm

Hypertension Coronary ArteryDisease

Heart Failure

No (or minimal)Heart disease

Flecainide Propafenone

Substantial LVH

Dofetilide Sotalol

Amiodarone Dofetilidep

Sotalol

No Yes

FlecainidePropafenone

No Yes

CatheterAblation AmiodaroneAmiodarone

Dofetilide Amiodarone CatheterAblation

CatheterAblationp

Sotalol

AmiodaroneDofetilide

CatheterAblation

CatheterAblation

ACC/AHA/ESC Practice Guidelines Fuster et al Circulation August 15, 2006

What to do when atrial fibrillationWhat to do when atrial fibrillationconverts to NSR?“Shut the door when the horse is in the barn”the barn”

Atrial FibrillationClinical DecisionsClinical Decisions

Case # 3 - Office VisitCase # 3 - Office Visit

70 ld l i i l k70-year old notes palpitations last week

No evidence of heart disease or hypertension on PE or EKG –NIDDM

EKG atrial fibrillation - rate 140/minEKG atrial fibrillation - rate 140/min

Atrial FibrillationClinical DecisionsClinical Decisions

Case # 10 - Office Visit

78-year old notes palpitations last week78 year old notes palpitations last week.Hx of hypertension NIDDM , stable angina angiodysplasia needing rareangina , angiodysplasia needing rare transfusion on PE or EKG E h EF 50% L f i l i. Echo EF 50% Left atrium normal size

EKG atrial fibrillation - rate 80/min

Case #10 options (2)Case #10 options (2)

Options:33% 33%33%

1. Warafrin INR 1.8 –2.5

2. Plavix and ASA3. Ablation

NR ...

d ASA

lation

Wara

frin IN

Plav

ix and

A

Ablat

NEW GUIDELINES !

Hi h i k f t kHigh risk for stroke

Prior thromboembolismCVA TIA or systemic embolismCVA, TIA or systemic embolismRheumatic mitral stenosis

Any of the above are Class I indications for warfarin !

Moderate risk for stroke

Age > 74 Impaired LV ٠ EF less 36%Impaired LV EF less 36%Heart failure ( includes diastolic dysfunction)Di bDiabetesHypertension

Any 2 moderate risk factorsyis a Class I indication for warfarin

Over age 80Over age 80 CVA i k 25 %CVA risk 25 %

ARCH . Int Med 1987 147: 1564

“Less well” validated risk factors for CVA in atrial fibrillation patients

Age 65-75Female genderFemale genderCoronary disease

Preventing Thromboembolism

It is reasonable to select antithrombotic therapy using the same criteria irrespective of the pattern (i ethe same criteria irrespective of the pattern (i.e., paroxysmal, persistent, or permanent) of AF. (Level of Evidence: B))

In patients with AF who do not have mechanicalprosthetic heart valves, it is reasonable to interrupt anticoagulation for up to 1 week without substituting heparin for surgical or diagnostic procedures thatheparin for surgical or diagnostic procedures that carry a risk of bleeding. (Level of Evidence: C)



For primary prevention of thromboembolism in patients with nonvalvular AF who have just 1 of thepatients with nonvalvular AF who have just 1 of thefollowing validated moderate risk factors, antithrombotic therapy with either aspirin or aantithrombotic therapy with either aspirin or a vitamin K antagonist is reasonable, based upon an assessment of the risk of bleeding complications, g p ,ability to safely sustain adjusted chronic anticoagulation, and patient preferences: age greater than or equal to 75 y (especially in female patients), hypertension, HF, impaired LV function, or diabetes mellitus (Level of Evidence: A)mellitus. (Level of Evidence: A)

ACC/AHA/ESC Practice GuidelinesFuster et al Circulation August 15, 2006


For patients with nonvalvular AF who have 1 or more of the following less well-validated risk factorsof the following less well-validated risk factors, antithrombotic therapy with either aspirin or a vitamin K antagonist is reasonable for prevention of g pthromboemblism: age 65 to 74 y, female gender, or CAD. The choice of agent should be based upon the risk of bleeding complications, ability to safely sustained adjusted chronic anticoagulation and

ti t f (L l f E id B)patient preferences (Level of Evidence: B)

ACC/AHA/ESC Practice Guidelines Fuster et al Circulation Aug

“It’s a hassle to take Coumadin but it’s a bigger h l t h t k !hassle to have a stroke !




•Maintenance of NSR•Maintenance of NSR•Anticoagulationg

Case # 10 - Office Visit78-year old notes palpitations last weekHx of hypertension NIDDM stable angina angiodysplasia.Hx of hypertension NIDDM , stable angina , angiodysplasia

needing frequent transfusion PE normal EKG –LVH. EchoEF 40% Left atrium normal size

33% 33%33%EKG atrial fibrillation - rate 80/min

Options:

1. Warfarin INR 1.5 – 2.52. Plavix and ASA3. Ablation

– 2.5

ASA

ation

Warf

arin

INR 1

.5 –

Plav

ix and

A

Ablat

Major Risk Factors for CVA inMajor Risk Factors for CVA in Atrial Fibrillation

P i TIA CVA b li•Prior TIA, CVA, or embolism•Poor LV function•Hypertension•Age over 75g• Mitral disease•Prosthetic valve•Prosthetic valve

CHEST 1/2001

Why Maintain Sinus Rhythm?y y

•CT scan demonstrates silent ischemia infraction 25% patients with atrial fibrillationfibrillation

Atrial fibrillation begets atrial fibrillation•Atrial fibrillation begets atrial fibrillationloose windows of opportunity

•Chronic tachycardia may cause LV dysfunction

Eligibility Criteria (1)g y ( )•Atrial fibrillation documented by ECG

6 or more hours of atrial fibrillation in last 66 or more hours of atrial fibrillation in last 6monthsQualifying episode occurred in last 12 weeksQualifying episode occurred in last 12 weeksQualifying episode no more than 6 months in murationmuration

•Eligible for at least 2 drugs in each treatment strategystrategy•Long-term therapy thought to be necessary•Able to take anticoagulants•Able to take anticoagulants

AFFIRM ` ACC MAR 02

Primary endpoint (composite)y p ( p )

•Cardiovascular deathCardiovascular death

•Hospital admission for heart failure

•Thromboembolic complications

S bl di•Severe bleeding

•Pacemaker implantationce e p o

•Severe adverse effects of therapyAFFIRM ` ACC MAR 02

Functional Status and Quality

•Functional Statusof Life

Functional Status6-minute walkNYHA CHF classNYHA CHF classCCS angina class

•Quality of LifeQuality of LifeSF-36Symptoms checklisty pLadder of LifeQuality of Life Index

No differences between rate and rhythm controlAFFIRM ` ACC MAR 02

Implicationsp• AFFIRM results pertain to patients with AF:

• And risk factors for stroke/death• For whom drug therapy-either rate rhythmFor whom drug therapy either rate rhythm

Control-was thought to be necessary• AFFRIM has demonstrated that rate controlAFFRIM has demonstrated that rate control

is an acceptable primary therapy• Continuous anticoagulation seems warrantedContinuous anticoagulation seems warranted

in all patients with risk factors for stroke ; evenif sinus rhythm is restored according to many

AFFIRM ` ACC MAR 02

if sinus rhythm is restored according to manyexperts.


•Etiology•Education •Rate Control•Cardioversion•Maintenance of NSR•AnticoagulationAnticoagulation

Class III

Long-term anticoagulation with a vitamin K antagonist is not recommended for primary prevention ofis not recommended for primary prevention of stroke in patients below the age of 60 y without heart disease (lone AF) or any risk factors fromdisease (lone AF) or any risk factors from thromboembolism. (Level of Evidence: C)

Cardioversion of Atrial FibrillationPharmacological Cardioversion


Atrial FibrillationAtrial Fibrillation Case Management

•48 year old female•Recurrent symptoms of PAF•PMH and PE negative - no medsg

–? Evaluation–? Anticoagulation? Anticoagulation–? Therapy

Atrial FibrillationAtrial FibrillationAnticoagulation Issues

• Chronic atrial fibrillation• Paroxysmal atrial fibrillation• Paroxysmal atrial fibrillation• Cardioversion

• Less than 2 days• Over 2 days

80—

60—Normal Range

40—

Normal Range

20—20

00

Immediate 1d 1wk 4wk 3 moC di i Ti ft C di iCardioversion Time after Cardioversion

Arch Intern Med/Vol 157, May 26,1997

Atrial Fibrillation < 48 hoursAtrial Fibrillation < 48 hours

Control ventricular rate Consider antithrombotic therapyControl ventricular rate Consider antithrombotic therapyControl ventricular rate Consider antithrombotic therapyControl ventricular rate Consider antithrombotic therapyObserve for spontaneous conversionObserve for spontaneous conversion

Prompt electrical orPrompt electrical orpharmacologic conversionpharmacologic conversion

Antiarrhythmic therapyAntiarrhythmic therapyIfIf

No antiarrhythmic therapyNo antiarrhythmic therapyifif

Unstable hemodynamics orUnstable hemodynamics orfrequent recurrencesfrequent recurrences

Stable hemodynamics Stable hemodynamics infrequent recurrences infrequent recurrences

or first episodeor first episodeor first episodeor first episodeAnnals of Internal Medicine, Vol 125, No. 4, August 15, 1996Annals of Internal Medicine, Vol 125, No. 4, August 15, 1996

> 48 hours Atrial Fibrillation ControlControl ventricular rate Start antithrombotic therapyventricular rate Start antithrombotic therapy

(heparin and/or warfarin or aspirin(heparin and/or warfarin or aspirin

Duration < 1 yearDuration < 1 year Duration > 1 yearDuration > 1 year

ororWarfarin therapy 3Warfarin therapy 3 4 weeks*4 weeks*Warfarin therapy 3Warfarin therapy 3--4 weeks*4 weeks*

Cardioversion or Pharmacologic conversionCardioversion or Pharmacologic conversion

Antiarrhythmic therapy *Antiarrhythmic therapy *IfIf

No antiarrhythmic therapyNo antiarrhythmic therapyifif

gg

ChronicChronicUnstable hemodynamics orUnstable hemodynamics or

frequent recurrencesfrequent recurrencesStable hemodynamics Stable hemodynamics infrequent recurrences infrequent recurrences

or first episodeor first episode

Chronic Chronic antithromboticantithrombotic

therapytherapyAssure control ofAssure control of

Annals of Internal Medicine, Vol 125, No. 4, August 15, 1996Annals of Internal Medicine, Vol 125, No. 4, August 15, 1996

ventricular rateventricular rateContinue warfarin Continue warfarin 11--2 months2 monthsMonitor for recurrencesMonitor for recurrences

* Amiodaronne as OP for 4-6 wks an option

Major Risk Factors for CVA inMajor Risk Factors for CVA in Atrial Fibrillation

P i TIA CVA b li•Prior TIA, CVA, or embolism•Poor LV function•Hypertension•Age over 75g• Mitral disease•Prosthetic valve•Prosthetic valve

CHEST 1/2001

Atrial Fib

65 75 (ACCP)>75 years (ACCP)<65 years (ACCP)

65-75 years (ACCP)

ASA W f i

No RF

No RF

1 High RFOR 2 Moderate RF

1 High RF

WarfarinASA

ASA WarfarinWarfarin

1 Moderate RF

No RF

1 Moderate RF

WarfarinASA or Warfarin

1 Moderate RF

High Risk Factors (RF)

ACCP Recommended Goal INR- 2.5(range 2.0-3.0)

ACC Recommended Goal INRHigh Risk Factors (RF)Previous TIA or StrokeHypertensionHeart FailureMitral Stenosis

Moderate Risk Factors (RF)Diabetes MellitusCoronary Artery Disease

ACC Recommended Goal INR(Age <75) 2.5 (range 2.0-3.0)(Age >75) 2.0 (range 1.6-2.5)

*ACC stratifies age as follows:Mitral StenosisProsthetic Heart ValveAge >75

ACC stratifies age as follows:<60; 60-75; and >75

“It’s a hassle to take Coumadinbut it’s a bigger hassle to have abut it’s a bigger hassle to have a stroke !

Atrial Fibrillation UpdateAtrial Fibrillation Update

Cardiovascular Conference at Snowshoe, February 3-6, 2008

Sana M. Al-Khatib, MD, MHS, FACCDuke Clinical Research InstituteDuke University Medical CenterDuke University Medical Center

Stroke Risk Classification Scheme: CHADS2 ScoreStroke Risk Classification Scheme: CHADS2 Score

Patients Adjusted stroke risk (%/yr) CHADS2Patients Adjusted stroke risk (%/yr) CHADS2

120 1 9 (1 2 3 0) 0120 1.9 (1.2, 3.0) 0463 2.8 (2.0, 3.8) 1523 4 0 (3 1 t 5 1) 2523 4.0 (3.1 to 5.1) 2337 5.9 (4.6, 7.3) 3

( )220 8.5 (6.3, 11.1) 465 12.5 (8.2, 17.5) 5

ACC/AHA/ESC 2006 guidelines

Risk-Based Approach to Antithrombotic Therapy in Patients with Atrial Fibrillation

Patient features Anti-thrombotic therapyClass ofPatient features Anti thrombotic therapyClass of recommendation

Age < 60 yrs, no heart dz ASA or no rx IAge < 60 yrs, heart dz, no RFs ASA IAge of 60-74 yrs, no RFs ASA IAge of 65-74 yrs, with DM or CAD Warfarin IAge of 65 74 yrs, with DM or CAD Warfarin IAge ≥ 75 yrs, women Warfarin IAge ≥ 75 yrs, men, no other RFsWarfarin or ASA IAge ≥ 65, heart failure Warfarin ILVEF < 35% and HTN Warfarin IPrior TE or persistent LA clot Warfarin IPrior TE or persistent LA clot Warfarin I

ACC/AHA/ESC 2006 guidelines

AnticoagulationAnticoagulation

In patients with AF, multiple randomized clinical trials showed a significant reduction in gthe risk of stroke with coumadin. TO DATE NOT A SINGLE CLINICAL TRIALshowed a reduction in the risk of stroke by an antiarrhythmic medication y

ACC/AHA/ESC Guidelines: Class I Indications for h h C lRhythm Control

ACC/AHA/ESC Guidelines: Class I Indications for Rhythm ControlControl

AF-CHF Study DesignAF CHF Study Design

LVEF ≤ 35%, NYHA class II-IV (patients (pwith NYHA class I were included if LVEF ≤

25% or prior hospitalization for CHF)1 episode of AF ≥ 6 hrs within 6 months or1 episode of AF ≥ 6 hrs within 6 months, or 1 episode of AF ≥ 10 min within 6 months

and prior D/C shock

R t t lRate control strategy

N = 694

Rhythm control strategy N = 682N = 694 N = 682

AFAF--CHFCHFPrimar endpoint as CV death ith mean follo p of 3 ears

10ResultsNo difference in primar endpoint of30

Primary endpoint was CV death, with mean follow-up of 3 years

CV Death(HR 1.06, p = 0.59)

Bradyarrhythmia(p = 0.007)

8.5

8

10 •No difference in primary endpoint of CV death between groups (Figure)

•Cardioversion 39% vs 8%

26.725.2

30

4.96

•Also no difference in total mortality (31.8% vs. 32.9%, p = 0.73), stroke (2.6% vs. 3.6%, p = 0.32),

20

%

4worsening heart failure (27.6% vs. 30.8%, p = 0.17), or composite (42.7% vs. 45.8%, p = 0.20)

10

0

2

( p )•Higher hospitalization rates (46% vs 39% p=.006) and cost with rhythm control0 0 control

•Bradyarrhythmias ↑ in rhythm control group

0

Rhythm Control

Rate Control

Atrial Fibrillation SummaryAtrial Fibrillation Summary

•Education•EtiologyEtiology•Rate ControlA i i•Anticoagulation

•Cardioversion•Maintenance of NSR

Summary of RecommendationsRi kRisk

Age Factors (major) Recommendation

< 65 yr * Absent AspirinPresent Warfarin [range 2.0-3.0]

65 - 75 yr Absent Aspirin or WarfarinPresent Warfarin

75 yr All Patients Warfarin

2 moderate* factors Warfarin1 moderate* risk factor Aspirin or Warfarin1 moderate* risk factor Aspirin or Warfarin

*DM, CAD, age 65-75 (60 –75 AHA) CHEST Jan. 2001 supplement

Cardiomyopathy Due to RapidAtrial FibrillationAtrial Fibrillation

Presentation Follow-up

Rate[BMP] 140 60Rate[BMP] 140 60[120-180] [50-80]

Ejection Fraction 25 52[12-13] [40-64]

10 patients -mean follow-up 30 months

Grogan AJC 69:1570, 1992

PlaceboMERIT TRIAL

20— Metoprolol CR/XL

p=0 0062 (adjusted)15—

10—

p=0.0062 (adjusted)p=0.00009 (nominal)

10

5 —

0| | | | | | | || | | | | | | |0 3 6 9 12 15 18 21

MONTHS

The Lancet Vol 353 June 12, 1999

Amiodarone for Rate Slo ingAmiodarone for Rate Slowing

Good NewsSafe in bad left ventricleEffective acutely and chronically

Bad NewsExpensive (intravenous)p ( )Need large veinSerious long term toxicity

Atrial Fibrillation -Why Cardiovert?

SymptomsSymptoms

Avoid CoumadinAvoid Coumadin

Window of OpportunityWindow of Opportunity“Atrial Fibrillation begets Atrial Fibrillation”

What’s Ne in Cardio ersion?What’s New in Cardioversion?

Biphasic shockPaddle placementPaddle pressurepShock during expiration“Conscious sedation”

“Conscio s Sedation”“Conscious Sedation”

Intravenous DiazepamIntravenous DiazepamCan reverse with Mazicon if no history

f iof siezures

Intravenous Brevital

Paroxysmal Atrial FibrillationParoxysmal Atrial Fibrillation••55 patients randomized55 patients randomized

placebo placebo -- 26 patients26 patientspropafenone propafenone -- 29 patients29 patients

5050--64 Kg 64 Kg -- 450 mg450 mg6565--85 Kg85 Kg -- 600 mg600 mg6565 85 Kg 85 Kg 600 mg600 mg> 85 Kg > 85 Kg -- 750 mg750 mg

••Duration atrial Fibrillation Duration atrial Fibrillation -- 20 hours20 hours••Conversion to NSRConversion to NSR••Conversion to NSRConversion to NSR

PlaceboPlacebo PropafenonePropafenone2 hours2 hours 5%5% 40%40%6 hours6 hours 30%30% 62%62%12 hours12 hours 40%40% 62%62%24 hours24 hours 70%70% 72%72%ou sou s 70%70% 7 %7 %

Eur. Heart Journal 18:1649 10/97Eur. Heart Journal 18:1649 10/97

Summary of RecommendationsRi kRisk

Age Factors (major) Recommendation

< 65 yr * Absent AspirinPresent Warfarin [range 2.0-3.0]

65 - 75 yr Absent Aspirin or WarfarinPresent Warfarin

75 yr All Patients Warfarin

2 moderate* factors Warfarin1 moderate* risk factor Aspirin or Warfarin1 moderate* risk factor Aspirin or Warfarin

*DM, CAD, age 65-75 (60 –75 AHA) CHEST Jan. 2001 supplement

Non Pharmacological Treatment of Atrial Fib

Catheter or Surgical Ablation of Atrial Fib Focus

Catheter ablation of AV Node for Rate ControlControl

Catheter Ablation of Atrial Flutter (high success rate)success rate)

Internal Cardioversion

Treatment of Rare Paroxysmal AtrialTreatment of Rare Paroxysmal Atrial Fibrillation

“Pill in PocketPill in Pocket

Consider if:Consider if:•No heart diseaseN b dl b h bl k•No bundle branch block

•Tested in the ER•No sinus bradycardia•Patient intelligentg


•Rate Control•AnticoagulationAnticoagulation•CardioversionM i t f NSR•Maintenance of NSR

•Etiology•Education

Eligibility Criteria (2)

• One or more risk factors for stroke /death:Age > 65HypertensionDiabetesCongestive heart failurePrior stroke or TIA or systemic embolusLeft atrium > 50 mm by echocardiogramLV shortening fraction < 25% by

echocardiogramLV ejection fraction < 0.40 by any technique

AFFIRM ` ACC MAR 02

AFFIRM ACC MAR 02

Eligibility Criteria (2)

•One or more risk factors for stroke/death:Age > 65HypertensionDiabetesCongestive heart failureP i t k TIA t i b lPrior stroke or TIA or systemic embolusLeft atrium > 50 mm by echocardiogramLV shortening fraction < 25% byLV shortening fraction < 25% by echocardiogramLV ejection fraction < 0 40 by any technique

AFFIRM ` ACC MAR 02

LV ejection fraction < 0.40 by any technique

HypothesisypRace

Rate control of persistentAF is not inferior to rhythm

C t l i t f biditControl in terms of morbidityAnd mortalityAnd mortality.

AFFIRM ` ACC MAR 02

Selected Patient Chracteristics• Age - + 9.0 years• 39% female; 11% minority• 39% female; 11% minority• Primary diagnosis

Hypertension: 51% (prevalence = 71%)Hypertension: 51% (prevalence 71%)CAD: 26% (prevalence = 38%)

• < 2 days of atrial fibrillation in 69%2 days of atrial fibrillation in 69%• First episode in 36%• LA size enlarged in 61%g• LV function abnormal in 24%; CHF class > II in 9%

AFFIRM ` ACC MAR 02

No differences between rate and rhythm control arms

Initial Therapypy

•Rate arm •Rhythm armDigoxin: 51%Beta adrenergic

yAmiodarone: 39%Sotalol: 33%g

blockers: 49%Calcium Channel

Propafenone: 10%Procainamide: 6%

blockers: 41% Quinidine: 5%Flecainide: 5%Disopyramide: 2%Moricizine: 1%

AFFIRM ` ACC MAR 02

RAte Control Versus Electrical Cardioversion for Persistent


A Randomized Comparison of Rate Control and

Rhythm Control Concerning Mortality and MorbidityRhythm Control Concerning Mortality and Morbidity

RACERACEAFFIRM ` ACC MAR 02

Inclusion criteria

• Persistent AF/AFL> 24 hours and < 1 year> 24 hours and < 1 year

• 1-2 ECVs in the past 2 years

• On oral anticoagulation

AFFIRM ` ACC MAR 02

Exclusion criteria

•Transient AF/AFLTransient AF/AFL

•Heart failure NYHA IV•Sick sinus syndrome•PacemakerPacemaker

•Previous amiodarone

•Severe systemic disease

AFFIRM ` ACC MAR 02

Severe bleedingg

•Symptomatic with Hb decrease > 2 g/l•Symptomatic with Hb decrease > 2 g/l

•Retroperitoneal or intracranial

•Requiring transfusion

•Requiring hospital admission

•Fatal•Fatal

AFFIRM ` ACC MAR 02

Severe adverse effects• Ventricular proarrhythmia• Rapid ventriccular response during AF (L)• Digitalis intoxication• Digitalis intoxication• Sick sinus syndrome, drug induced• Persistent third degree AV block• Syncope drug induced• Syncope, drug induced• Heart failure due to negative inotropic

ff tAFFIRM ` ACC MAR 02

effects

AFFIRM TRIAL

Rhythm ControlECV

SR ← Sotalol → late recurrence↓

Early recurrenceEarly recurrence ↓

ECVSR ← flecainide or propafenone

↓E l

→ Late recurrence

Early recurrence↓

Amiodarone → Late recurrenceSR←ECV

↓ Accept AF or

→ Late recurrence

↓ Accept AF orEarly recurrence →AV ablation

AFFIRM ` ACC MAR 02

Antithrombotic treatment

•Rate control:Rate control:

-If lone AF, aspirin-Otherwise, OAC (INR 2.0-3.5)

•Rhythm control:Rhythm control:-1 month before and after ECV, OACIf chronic SR is obtained OAC is stopped-If chronic SR is obtained, OAC is stopped

-Otherwise, OAC/aspirin is continued

AFFIRM ` ACC MAR 02

Baseline Chracteristics

Rate control Rhythm controlRate control Rhythm controln=256 n=266

Age 68 + 9 68 + 8Male 63% 64%e 63% 6 %AF 93% 93%

AF total duration 337 309 daysAF present duration 32 34 days

AFFIRM ` ACC MAR 02

p y

Baseline characteristicsRate control Rhythm control

256 266n=256 n=266

H i 43% 55%Hypertension 43% 55%CAD 29% 26%Valve disease 18% 16%Cardiomyopathy 11% 7%

Lone AF 21% 21%AFFIRM ` ACC MAR 02

Lone AF 21% 21%

DIAMOND MI St dDIAMOND - MI Study

•1510 Patients2•Recent MI 2-7 days

•Dofetilide .25 - 1 mg/dayg y•Monitored for 3 days [at least]•1/3 on Beta Blockers•1/3 on Beta Blockers

DIAMOND Study3 Year Follow-up

Placebo DofetilidePlacebo Dofetilide

Deaths 243 230

Torsades 0 7*

Monomorphic VT 17 20

Polymorphic VT 3 4Polymorphic VT 3 4

V.Fib 12 12

*5 occurred the first three days

Maintenance Sinus Rhythm at 1 2 YearsMaintenance Sinus Rhythm at 1-2 Years

1. Amiodarone 60-80%2. All others 40-50%

Amiodarone - long-term follow-up•120 patients - follow-up 5 years•40% still on successful Rx

Expectations of Arrhythmia Drug Therapy Expectations of Arrhythmia Drug Therapy i T t t f AFi T t t f AFin Treatment of AF in Treatment of AF

C l i♦Complete suppression–Best, but AF recurrence likely

(>50% of patients)(>50% of patients)–Recurrence, per se, is not failure of therapy

♦Frequency of recurrence–More realistic measure of efficacyy–May vary from patient to patient

Current Studies for Atrial Fibrillation Current Studies for Atrial Fibrillation

•Affirm: Maintainance of NSR/ vs. rate control /WarfarinWarfarin

CTAF: Aminodrome vs. Sotalol orpropafenonep p

•VA Coop: Aminodrome vs. Sotalol vs.Placebo

•PIAF: Aminodrome vs. Diltiazem•RACE: Rate control vs. electrical

cardioversioncardioversionPACFIC: Sotolol vs. Quinidine/Verapamil post CV

Options Atrial Fibrillation StrokeOptions Atrial Fibrillation StrokePrevention

•Coumadin•ASA•Removal left atrial appendage•Maintenance NSRMaintenance NSR

•Medication•Ablation•Ablation

•SurgicalC th t•Catheter

At i l Fib ill tiAtrial Fibrillation•Education •Etiology•Etiology•Rate Control•Cardioversion•Maintenance of NSR•Anticoagulation

Summary of RecommendationsM jMajor

Age Risk Factors Recommendation

< 65 yr Absent AspirinPresent Warfarin [range 2.0-3.0][ g ]

65 - 75 yr Absent Aspirin or WarfarinP t W f iPresent Warfarin

75 yr All Patients Warfarin y

2 moderate* factors Warfarin1 moderate* risk factor Aspirin or Warfarin

*DM, CAD, age 65-75 CHEST Jan. 2001 supplement

100— Ibutilide (n=10)

80— Ibutilide and transthoraciccardioversion (n=54)A

tria

l(%

)

60—

40— T th im fr

om

illat

ion

40

20—

Transthoraciccardioversion (n=36)

Free

doFi

bri

0—| | | | | | | | | | | | |0 2 4 6 8 10 120 2 4 6 8 10 12

Months after CardioversionFacilitating Transthoracic Cardioversion of Atrial Fibrillation

i h b ilidwith Ibutilide Pretreatment

The New England Journal of Medicine, Volume 340, Number 24, Page 1851


•Etiology•Education•Education •Rate ControlC di i•Cardioversion

•Maintenance of NSR•Anticoagulation

SPAF III StudySPAF III StudyPrimary Events in Subgroups

•Patients with prior thromboembolism:C i i 11 9%/–Combination RX: 11.9%/yr

–Adjusted AC: 3.4%/yr (p=0.002)i i•No prior thromboembolism:

–Combination RX: 5.4%/yrAdj d AC 1 1% ( 0 001)–Adjusted AC: 1.1% yr (p=0.001)

Charles Tegler MD ACC Snowshoe February 1998Charles Tegler, MD - ACC Snowshoe February 1998

Rate ControlIntravenous

•Calcium BlockersDiltiazemDiltiazemVerapamil

B t Bl k•Beta Blockers•Digoxing•Amiodarone

Adverse Events (2)Rate

ControlRhythmControlControl Control

Ischemic Stroke 79 (5.7%)* 84 (7.3%)*

INR > 2.0 24 (35%) 17 (20%)

INR < 2 0 28 (35%) 17 (20%)INR < 2.0 28 (35%) 17 (20%)

Not taking warfarin 26 (33%) 48 (58%)

AF at time of event 45 (69%) 25 (36%)

*Event rates derived from Kaplan-Meier analysis, p=0.680AFFIRM ` ACC MAR 02

To Maintain Sinus Rhythm“Overchoice”

I. Type I-A III. Type IIIQuinidine SotalolDi id A i dDisopyramide AmiodaronePronestyl Dofedilide

PropafenoneII. Type I-C

Flecainide IV. ?Digoxin

V. Beta blockers




M i t f NSR•Maintenance of NSR•AnticoagulationAnticoagulation

Five trials have shown no benefit from rhythm control vs. rate control and warfarin

in terms of :in terms of :

D hDeathCVAQuality of life

Pharmacological Management

RecurrentParoxysmal AF

Minimal or no symptoms

Disabling symptoms in AFno symptoms

Anticoagulation and rate

in AF

Anticoagulation and rateAnticoagulation and rateControl as needed

gControl as needed

AAD thNo drug for

prevention of AF

AAD therapy

AF ablation if AADAF ablation if AADTreatment failsACC/AHA/ESC Practice Guidelines

Fuster et al Circulation August 15, 2006

Maintenance of Sinus Rhythm

Hypertension Coronary ArteryDisease

Heart Failure

No (or minimal)Heart disease

Flecainide Propafenone

Substantial LVH

Dofetilide Sotalol

Amiodarone Dofetilidep

Sotalol

No Yes

FlecainidePropafenone

No Yes

CatheterAblation AmiodaroneAmiodarone

Dofetilide Amiodarone CatheterAblation

CatheterAblationp

Sotalol

AmiodaroneDofetilide

CatheterAblation

CatheterAblation


CVA Prevention in Atrial FibrillationCVA Prevention in Atrial FibrillationImportance of AF in CVA

•AF associate with half of CE strokes•IHD is second most common CE causeIHD is second most common CE cause•When occur, stroke with AF are often large, tend to recur (1%//d over first 2 wks) andtend to recur (1%//d over first 2 wks), and turn hemorrhagic

•How to safely, effectively reduce risk?How to safely, effectively reduce risk?

Charles Tegler, MD-ACC Snowshoe February 1998

55 year old male – new onset of atrial fib noted in the office – rate 100/min.No Hx of hypertension, diabetes, heart failure, CVA, TIA.

Options100%

1. Warfarin2. ASA 300 mg3 ASA 1603. ASA 160 mg.4. ASA 160 mg plus clopidogrel5 Admit for evaluation and Rx5. Admit for evaluation and Rx

n g g. .

0% 0%0%0%

Warf

arin

ASA 3

00 m

g AS

A 160

mg.

ASA 1

60 m

g plu.

.. Ad

mit fo

r eva

l...

100100100100——

8080——

P=0.752P=0.752PropafenonePropafenone

6060——p=0.015p=0.015

pp--0.0600.060

4040——

2020

p=0.005p=0.005

pp

PlaceboPlacebo

2020——

00——| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 1 2 3 4 6 8 10 12 241 2 3 4 6 8 10 12 24time from start of randomized treatment (h)time from start of randomized treatment (h)time from start of randomized treatment (h)time from start of randomized treatment (h)

Eur Heart J., Vol. 18, October 1997Eur Heart J., Vol. 18, October 1997

74 ld f l ith t hi t f l(74 year old female with a past history of paroxysmal( rare occasion ) a. fib. Office evaluation for a.fib neg 6 months ago Not on warfarin On metoprolol 50-mg/day No hxago .Not on warfarin, On metoprolol 50 mg/day. No hx. of CAD When in sinus rhythm has normal EKG rate of 75/minute. On routine O/V found to be in a.fib

Now in the ER atrial fib (?/2-4 days duration) rate ( y )120/min. Very mildly symptomatic. Family worried . Routine ER evaluation neg.

What would you do?What would you do?

25% 25%25%25%1. Admit – if TEE neg.

cardioversion - heparin– long 25% 25%25%25%cardioversion heparin long term warfarin and ASA 80 mg.

2. Double dose of metoprolol –2. Double dose of metoprolol start warfarin as OP -d/c from ER .consider rhythm control on follow-up in office

3. Start amiodarone po – see in office F/U

4. Admit – start

f TEE

neg.

card.

..se

of m

etopro

l..od

arone

po –

s..tar

t hep

arin,d

...

. d s aheparin,dofedilide warfarin –cardiovert before D/C if doesn’t cardiovert on

Admi

t – if

T Do

uble

dose

Start

amiod

Admi

t – st

a

dofedilide

75 year old female on routine office visit noted to be in atrial fib rateto be in atrial fib – rate 120/minute. Patient is asymptomatic except for asy p o a c e cep omild palpations. The rest of the Hx, PE, EKG were normal except for COPD recent increase in inhaler

CASE 12use. CASE 12

80 year old female with atrial fibrillation, CHF with EF 25% hypertension LA 5 cm over last year has fallen25%, hypertension, LA 5 cm over last year has fallen three times once fractured a wrist and uses NSAIDs for arthritis. Creatinine 1.5 GFR 40 cc/min, Hbg 10.5, stoolsarthritis. Creatinine 1.5 GFR 40 cc/min, Hbg 10.5, stools are negative for blood.

1 W f i100%

1. Warfarin2. ASA 300 mg3 ASA 1603. ASA 160 mg.4. ASA 160 mg plus

l id lclopidogrel5. No A/C

Warfa

rin

300 m

g

160 m

g.

ido...

No A/

C

0% 0% 0%0%

War

ASA 3

0

ASA 1

60

ASA 1

60 m

g plus

clopid No

70-year old male – 3 AMChronic CHF-EF 20% no pasr B/BChronic CHF-EF 20% , no pasr B/BPost op colon surgeryRapid atrial fibrillation 160/minBP t bl 100/80BP stable 100/80Creatinine 2.5

What to do?1. Cardiovert2. i.v. Digoxin3. i.v. ßeta blockers4 i v diltiazem4. i.v. diltiazem5. i.v. amiodarone

Choices # 1Choices # 1

• Cardiovert• i.v. digoxin• iv ßeta blockers• iv. ßeta blockers• i.v. diltiazem• i.v. amiodarone

Acceptable drugs for atrial fibrillation slowing in pts. with bad LV

L i• Lanoxin

•Amiodarone

CHA2DS2VASc score and stroke rate



Risk of embolism or ischemic eventBleeding riskBleeding riskPatient preference

In a recently stented patient which agent is the least risky to stop in regards to stent

thrombosis.

1. ASA2. Clopidogrel

45-year old male a-fib 3 hours duration at rate 160/min. presents to ED. After 24 hours and rate slowing with beta-

What would you advise? 100%

p gblockers still in a- fib.

What would you advise?1. Start heparin shortly after

i h d

100%

presentation then proceed to cardioversion 24-48 hours – d/c on oral A/C 4 6 weekson oral A/C 4-6 weeks.

2. No heparin after cardioversion discharge from ED on ASA 0% 0%discharge from ED on ASA.

3. Pre-cardioversion drug/electrical) heparin - after ari

n ...

n aft.

..

vers.

..

0% 0%

drug/electrical) heparin after cardioversion d/c on ASA St

art he

par

No he

parin

a

Pre‐c

ardiov

e



Risk of embolism or ischemic eventBleeding riskBleeding riskPatient preference


STENTSMEDICATEDMEDICATED

< 1 yr1 yr

CAD StableACS in last year

A fib CHADS 0,1,


ACS in last year CHADS 0,1,0,1 , or 2 or

more

Prosthetic valveDVT/PE

Stroke< 1year


tissue< 1year> 1 year


Risk/benefit of various combinations anti thrombotic agentsanti thrombotic agents

Risk of embolism or ischemic eventBleeding riskPatient preference

Arch Intern Med. 2010;170(16):1433-1441( atrial fib patient)

CHA DS VAS d t k tCHA2DS2VASc score and stroke rate

CHA2DS2VASc score and stroke rate

Very weak data

Arch Intern Med. 2010;170(16):1433-1441

62-year old female with atrial fib. No history of hypertension, heart failure, diabetes, stroke or embolism.

100%

yp , , ,Smokes . PE negative except absent right pedal pulse –echo and TSH negative.

A/C options include:

100%

1. No ASA, no warfarin2. ASA 80 mg daily3. Warfarin or dabigartan4. # 2 and 3

o war.

..

g dail

...

or da

...

# 2 or

#3

e abo

...

0% 0%0%0%

No AS

A, no

w AS

A 80 m

g W

arfari

n o # 2

All o

f the

75-year old male, 3rd generation medicated 2 cm stent mid RCA 7 months ago. Creatinine 2.2 Chronic a-fib with a

100%

CHADS score 3. hx stroke 2 years ago – minimal residual defect

Which would you feel is reasonable?

100%

reasonable?1. Clopidogrel, ASA, warfarin2. Warfarin and (clopidogrel

/or ASA)3. Warfarin plus ASA4 2 or 3 el,

A...

nd (..

.

plus ..

.

2 or 3

0% 0%0%

4. 2 or 3

Clop

idogre

l,

Warf

arin a

nd

Warf

arin p

lu 2

Bleeding risk is:g

1 Higher with ASA1. Higher with ASA

2 Higher with warfarin2. Higher with warfarin

3. Both about the same3. Both about the same

Clinical characteristics comprising the HAS-BLED bleeding risk scoreBLED bleeding risk score

Circulation 2011:124:824-829

S h t d th id li ?So o o – what do the guidelines say?

ACC/AHA2011- NSTEMI STEMI Atrial fib2011 NSTEMI , STEMI , Atrial fib

Chest 2012 – all aspects anti thrombotic RxE S i f C di l lEuropean Society of Cardiology – plus

rhythm and EP societies 2010Canadian CV Society – A.fib 2010

Grade of Benefit vs Risk Methodologic ImplicationsRecommendation and Burdens Strength of

SupportingEvidence

Weak recommendation, low-or very-low-

Uncertainty in the estimates of benefits, risks, and

Evidence for at least one critical outcome from

Other alternatives may be equally reasonable.

quality evidence (2C)

burden; benefits, risk and burden may be closely b l d

observational studies, case series, or

d i d

Higher-quality research is likely to have an i t t i tbalanced randomized

controlled trials, with serious flaws or indirect

important impact on our confidence in the estimate of effect and mayor indirect

evidenceeffect and may well change the estimate

Chest – Methodology for the Guidelines 62S

Wh t t i l ti l ti RWhen to use triple anticoagulation Rx

High risk AF stroke patients CHADS >Bare metal stent for 30 daysBare metal stent for 30 daysDrug eluting stents 12 months – ACC/AHA

GuidelinesPossible only 6 months Chest Guidelines

> 6 months high risk ACS medicated stented 6 months high risk ACS medicated stented patient ( CHEST3/12)

DiabetesLong lesionNarrow coronary diameter

Secondary Endpoint

Death from any cause or MIy

24 mo DAPT 6 mo DAPTCEC adjudicated

12

8 99.6

P=0.62

12

%

8.9

8

%

4

Hazard Ratio: 1.07 (0.80-1.43)0

No. at Risk24-Month Clopidogrel 987 925 884 6-Month Clopidogrel 983 919 881

0 180 360 540 7200

LOG HAZARD RATIO HAZARD RATIO (95% CI) P‐VALUES

Subgroup analysis of the Primary Endpoint

Overall

Male

OG O(95% CI)

( )

Superiority

0.98 (0.74‐1.29)

0 91

0.91

0.851.09 (0.77‐1.55)

Interaction

< 65 yr

≥ 65 yr

Female

Diabetes

0.09

0.91

0.48

0.12

1.00 (0.60‐1.68)

1.12 (0.82‐1.51)

0.57 (0.28‐1.16)

0 85 (0 53‐1 38)

0.66

0.72Diabetes

No Diabetes

bl

Bare metal stents

Drug‐eluting Stents

0.47

0.530.64

0 16

0.85 (0.53 1.38)

1.06 (0.76‐1.50)

1.13 (0.68‐1.86)

0.93 (0.67‐1.30)

0 60 (0 29 1 23)

0.52

0.66

0.72

Stable Coronary Disease

Unstable Coronary Disease

Single Lesion Treatment0.38

0.140.160.63

Multiple Lesions Treatment

0.60 (0.29‐1.23)

1.07 (0.79‐1.45)

0.88 (0.62‐1.28)

1.14 (0.74‐1.76)

0.51

0.55

Creatinine Clearance ≤ 60 ml/min

Creatinine Clearance > 60 ml/min

0.31

0.38

0.68

0.62

0.50

Complex Lesion(s) Treated

Simple Lesion(s) Treated

1.07 (0.77‐1.49)

0.78 (0.46‐1.32)

0.90 (0.58‐1.38)

1.14 (0.78‐1.65)

0.35

24‐month DAPT better 6‐month DAPT better

110 0.1

Key Safety Endpoint

Type II, III or V BARC bleeding yp , g

24 mo DAPT 6 mo DAPTCEC adjudicated

12

P=0.00018

12

%

7.48

%

3.54

Hazard Ratio: 0.46 (0.1-0.69)0

No. at Risk24-Month Clopidogrel 987 925 884 6-Month Clopidogrel 983 919 881

0 180 360 540 7200

Steps to Decrease Adverse pOutcomes on Triple A/C (TOAT)

• Try to avoid stopping TOAT (especially all three) for mild ‘nuisance bleeding”

• ASA dose < 100 mg/day• INR

– Target INR 2.0-2.5 for most AF patients – Target INR 2.5 – 3.0 in selected patients with mechanical valves

f What you say– More frequent INR’s• PPI protection • Duration of TOAT

Q i G id li

What you say Dr, McJunkin?

– Question use European Guidelines– Need to know definition low and intermittent vs. high bleeding

risk.

Recommendations for patients felt to need initial triple A/C thearpy ( TOAT)triple A/C thearpy ( TOAT)

European H. J. 2010 ,31:1311

For elective procedures in patients at lower or intermediate bleeding risk who receive bare-metal stents (BMS): TOAT for one monthmonth.

For elective procedures in patients at low or intermediate bleedingFor elective procedures in patients at low or intermediate bleeding risk who receive sirolimus drug-eluting stents (DES): TOAT for three months and six months with paclitaxel DES. After this initial

iperiod, up to 12 months of OAC with either aspirin orclopidogrel. ( not both)

Recommendations for patients felt to need initial triple A/C thearpy ( TOAT)initial triple A/C thearpy ( TOAT)

European H. J. 2010 ,31:1311*

For procedures in ACS patients at low to intermediate bleeding risk with BMS): TOAT for six months. After this initial period

t 12 th f OAC ith ith i i l id l, up to 12 months of OAC with either aspirin or clopidogrel. (not both)

now in Chest 2012 and ESC guidelinesFor elective procedures in patients at high bleeding risk (only

BMS): TOAT for two to four weeks. Should try to avoid

now in Chest 2012 and ESC guidelines

For urgent procedures in ACS patients at high bleeding risk ( l BMS) TOAT f f k Aft thi i iti l i d

Drug eluting stents

(only BMS): TOAT for four weeks. After this initial period, up to 12 months with OAC with either aspirin or clopidogrel (not both) * Presented by David Holmes in Up To Date

75-year old female, CHADS score 3 and h i bl i C i i 2 3

Wh t ld d ?

chronic stable angina. Creatinine 2.3

What would you do?

1 ASA 80 l1. ASA 80 mg. plus warfarin (AC)

2. Warfarin alone3 ASA 325 mg plus3. ASA 325 mg plus

warfarin

67-year old female – chronic a.fib - recent NSTEMI no PCI CHADS score 1- is veryNSTEMI, no PCI, CHADS score 1- is very concerned about even a slight increase of stroke risk- low bleeding riskrisk- low bleeding risk

What would you do ?.

1. ASA plus clopidogrel2. Warfarin plus ASA3. Warfarin, ASA, clopidogrel, , p g4. Warfarin alone

Approach to thromboprophylaxis in patients with AF European guidelines , but may be used for decisions in p g , y

Chest guidelines 3/12 for certain patients

BUT wont get beatup on if you don’tuse thisuse this

Clinical flo chart for se of oral anticoag lation for strokeClinical flowchart for use of oral anticoagulation for stroke prevention in AF

Steps to Decrease Adverse pOutcomes on Triple A/C (TOAT)

• Try to avoid stopping TOAT (especially all three) for mild ‘nuisance bleeding”

• ASA dose < 100 mg/day• INR

– Target INR 2.0-2.5 for most AF patients – Target INR 2.5 – 3.0 in selected patients with mechanical valves

f h– More frequent INR’s• PPI protection • Duration of TOAT

Q i G id li

What you say Dr, McJunkin?

– Question use European Guidelines– Need to know definition low and intermittent vs. high bleeding

risk.

Recommendations for patients felt to need initial triple A/C thearpy ( TOAT)p py ( )

European H. J. 2010 ,31:1311

For elective procedures in patients at lower or intermediateFor elective procedures in patients at lower or intermediate bleeding risk who receive bare-metal stents (BMS): TOAT for one month.

For elective procedures in patients at low or intermediate bleeding i k h i i li d l i ( ) frisk who receive sirolimus drug-eluting stents (DES): TOAT for

three months with –serolimus and six months with paclitaxel DES. After this initial period, up to 12 months of OAC with either aspirinp , p por clopidogrel. ( not both)


STENTSMEDICATED

A fib

CHADS

MEDICATED< 1 yr

1 yr

CAD StableACS in last year CHADS

0,1 , or 2 or


ACS in last year


more

DVT/PE

Stroke< 1year

1

tissue

> 1 year

Bleeding Risk From Anti-platelet Agents ( f l hi h )from lowest to highest)

Dipyridamole aloneClopidogrel (CP) alonep g ( )Low dose ASA and warfarin sameHigher dose ASAHigher dose ASAASA and CPCP plus ASA ???CP plus ASA ???Ever a trial comparing CP alone vs. CP/ASA

for CAD ?for CAD ?

Bl di Ri k CURE T i lBleeding Risk CURE TrialASA+ < 200 mg and Clopidogrelno increaseASA+ < 200 mg and Clopidogrel no increaseASA > 200 mg and Clopidogrel 4.5% vs.

3 3% CI3.3% CI 0.75-2.57

No decrease ischemic events higher ASA dose

In a recently stented patient which agent is the least risky to stop in regards to stent

thrombosis.

1. ASA2. Clopidogrel

Case Study – A Fib in ED Rate Control – Bad LVMessage ; digoxin and amiodarone are preferred meds to slow AF in patients with bad LV and beta blocker naive

75 year old, prior TIA, history of heart disease and alcohol

p

with cardiomyopathy, EF 25% - normal coronary angiogram, 6/12, no alcohol last year - on ACE, digoxin, spironolactone, no beta blockers, mild SOB, moderate COPD. Enters rapid AF, ventricular

t 160 EKG h frate 160 – EKG no change from6/12 otherwise Bp 110/70. Lab: BMP, serum markers normal

HOW TO SLOW ?A. CardiovertA. CardiovertB. DiltiazemC. Beta BlockersD IV i dD. IV amiodarone

Case #3 options (1)1 Admit ? Yes - no1. Admit ? Yes - no2. Cardiology consult ? What tests ??3. Cardiovert ?3. Cardiovert ?

a. Nowb. 4-6 weeksc. Never

4. Slow rate ?di ia. digoxin

b. diltiazemc beta blockersc. beta blockers

5. Anticoagulate ?g6. Ablation

atrial fibrillation - camcinstitute.orgcamcinstitute.org/professional/snowshoe/2013/pdf/06.pdf ·...

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