Pr Wael Chalak

Chief of cardiology division

Faculty of Medical Sciences- Lebanese university

CardioAlex-13 June- 2013

MANAGEMENT

OF

ATRIAL FIBRILLATION

IN

EMERGENCY DEPARTEMENT

Incidence rates of AFMost common cardiac arrhythmia managed by ED. Boriani G. EHJ.2006.27.893-4

Rates are per 1000 person-years

Sphinx enigma: 4th century BC

What is the arrhythmia which will never occur during childhood, will be well tolerated during adulthood &

at high risk to kill at advanced age: AF

Clinical Outcomes Affected by AF

Outcome Parameter Relative Change in AF

Death

stroke

Hospitalization

Left Ventricular function

Quality of Life

Exercise Capacity

Death rate doubled

Risk & severity is increased

Increased

From No change to Tachycardia-

cardiomyopathy

From No effect to major Reduction,

Dyspnea, Palpitation

Euro heart survey on AF in ESC member countries:

AF management Nieuwlaat R.EHJ.2005.26.2422-34

Management of new onset AF in different ED despite the international guidelines is still

- Controversial

- Heterogeneous

Buccelletti F.Intern Emerg Med 2011; 6:149–156

Del Arco C. Ann Emerg Med 2005; 46:424–430

Some AF patient can be managed on ED without the need for hospital admission.

Fuster V .Circulation. 2006.114.700-752

Wakai A & O’Neill J O. Postgraduate Med J.: 2003; 79:313–31

Management goals

1.Initial workup?

2- Medical therapy?

3- Need for electrical cardioversion ? Which method?

4- Hospital admission?

5- Could we discharge the patient safely?

Successful management of AF should reduces CV morbidity & mortality1-5

*Total percentage of time a patient has AF as determined by the number and duration of AF episodes

1. Wolf et al. Stroke 1991;22:983-988.

2. Singh SN, et al. J Am Coll Cardiol. 2006;48:721-730.

3. Prystowsky EN. J Cardiovasc Electrophysiol 2006;17(suppl 2):S7-S10.

4. Hohnloser S, et al. J Cardiovasc Electrophysiol. 2008;19:69-73.

5. Camm AJ, Reiffel JA. European Heart Journal Supplements 2008;10(SH): H55-H78

Prevention

of

thrombo-

embolism

Reduction of

AF burden*

↓ Symptoms

↑ QoL

Reduction in the

risk

of

CV events and

hospitalisations

Reduction

in

mortality

WORKUP

Initial blood test includesEzekovitz MD.Circulation.2011.124.95-99

• Complete blood count,

• INR

• Electrolytes, urea, creatinine,

• Cardiac enzymes,

• Liver function tests,

• Blood glucose,

• Arterial blood gas,

• Thyroid function tests

• Serum toxicology .

Minor elevation in

TnI // with

mortality &

MACVE in pts with

AF.

Van Den Bos E. EHJ.2011.32. 611-7

From: Impact of Atrial Fibrillation on the Diagnostic Performance of B-Type Natriuretic Peptide Concentration

in Dyspneic Patients: An Analysis From the Breathing Not Properly Multinational Study

J Am Coll Cardiol. 2005;46(5):838-844. doi:10.1016/j.jacc.2005.05.057

AF: Predisposing FactorsWyse DG. Circ.2004. 109. 3089-95

• In acute AF, the identification & management of reversible acute clinical triggering factor may be essential to stop or to prevent recurrence of AF

- Alcohol intoxication- Cocaine addiction- Acute sepsis, pneumonia,- Caffeine effect

Hemodynamic stabilityESC-2010 : Mansourati J. Cardiol Pratique 2012.997/998. 3

AF

Hemodynamic stability

Yes No

Goals: VR< 100/mn SR : ECV (100-360 j)

EHRA Score of

AF Related Symptoms

EHRA

Class

AF Symptoms Related

Score

Class I No symptoms

Class II Mild symptoms;

Normal daily activity

Class III Severe symptoms;

Daily activity affected

Class IV Disabling symptoms;

Daily activity discontinued

European Heart Journal (2010) 31,2369-2429l

AF pathophysiology: Implications for management. Iwasaki Y-K et al.Circ.2011.124.2264-74

- Hemodynamic stabilization

- Ventricular rate control* Slowing of the ventricular response rate is the main objective

* No specific efforts are made to maintain sinus rhythm

- Prevention of embolic complications

* Antithrombotics

* “Rhythm-control strategy," to restore normal sinus rhythm:

- Antiarrhythmic drugs

- Electrical cardioversion when necessary,

Estes NAM 3rd. Circulation. 2008.171. 1101-1120 / Connolly SJ.Circulation.2008.118..2029-2037.

Talajic, M. et al. J Am Coll Cardiol 2010;55:1796-1802

Current rhythm vs. rate control treatment strategywas not predictive of cardiovascular mortality, total mortality, or worsening HF.

Results of multivariate regression analysis as a time-dependent variable

Wyse G. Circ.2009. 120.1444-52

Impact of pharmacological maintenance of SR vs. HR control on clinical outcome of AF Wyse G. Circ.2009. 120.1444-52

HF worsening

Wyse G. Circ.2009. 120.1444-52. Anter E. Circ.2009.120. 1436-43

Pharmacological cardioversion

AJM .104. 1998

Major clinical trials on AAD vs placebo for AF , Proportions of patients SR at Fup meta-analysis ( Nichol G. Heart.2002.87.535-43)

Agents Proportion in sinus rhythm Proportion in in treatment arm (%) sinus rhythm

in control arm(%)IA vs Placebo 54.7 33.1 IC vs Placebo 60.2 27.1III vs placebo 46 29.11C vs IV 77.8 43.2

No differences in the effect ofDigoxine vs placebo class III vs Classes IA or IC

Decision of cardioversion mode of AF // tolerance & presence of pre-existing HD .

ESC-2010 : Mansourati J. Cardiol Pratique 2012.997/998. 3

Persistant AF > 48 h or 7d PxAF < 48h & no underlying HD:Amiodarone Flecain/Propafenon

Rapid AF +WPW with anterograde conduction:

- Flecainide iv

- ECV

Recent AF

Non Hemodynamically

Stable

ECV Underlying HD

Yes

Yes No

ACC/AHA Rx algorithms for the management of PxAF. Cinitz J. Circ.2013. 127.408-16

Clinical conditions &

Contraincated antiarrhythmic

drug Rx.

Blaau Y. Heart.2002.88.432-7

LAV at diagnosis in Lone AF predicts CVE during follow up /30y

Olmested County –USA Osranek M.EHJ.2005.26.2556-61

Clinical outcome of lone AF is benign with normal LA volume & demonstrates adverse events

with increasd LAV at diagnosis or during Fup

Pts w/o events Pts with events

AF: Classification & pattern of AF

ACC/AHA ESC 2006 GuidelinesEuropean Heart Journal (2010) 31,2369-2429l

Lasting < 7d mostly <1d

Recurrent

Lasting > 7d

Requiring CV

Recurrent

Failed/Not attempted cardioversion

Management of recurrent/ paroxysmal AFAF & Cardioversion

Boveda S. Cardiol Pratique. 2012.1014. 14-5 ( ESC-10) Fuster V.Circ.2006.114.700-52

Anticoagulation & rate control as needed

EHRA I/ II EHRA III/IV

Recommendations ACC/AHA/ESC.EHJ.2010 .31.2396-29

of AF cardioversion

1- Persistent AF recently discovered

2- Recurrent AF with invalidating Sx.

Rudaut R. Cardiol Pratique. 2012-992.

Newly discovered AF

ACC/AHA ESC 2006 Guidelines Fuster V.Circ.2006.114.700-52

,

.

Pharmacological CV of

AF of up to 7-d duration

ACC/AHA ESC 2006 Guidelines Fuster V.Circ.2006.114.700-52

Pharmacological CV of

AF of > 7-d duration

ACC/AHA ESC 2006 Guidelines Fuster V.Circ.2006.114.700-52

Success rate & complications of ECVSbragia P. AMC.2002.95.561-6/ Boveda S. Cardiol Pratique. 2012.1014. 14-5

Age & EECV

182 AF of 25-89y.:Age does not significantly influence the immediate results of EECV

Sbragia P.AMC.2002.95.561-6

• Complications of ECV- Embolic event : 1-7 % // Poor INR- VF if:

* Not synchronized on R wave* HypoK* High Digoxinemia* M. Ischemia

• ECV & PM/ICD:- Possible- Reprogrammation after ECV

• Recurrence AF: 50% at 1y

Pharmacological treatment before cardioversion in patient with

persistent AF: Effectiveness of various AAD on acute & subacute outcome of transthoracic DC shock

ACC/AHA ESC 2006 Guidelines Fuster V.Circ.2006.114.700-52

SRAF: Subacute Recurrence of AF

Maintenance of SR

ACC/AHA ESC 2006 GuidelinesFuster V.Circ.2006.114.700-52

Antiarrhythmic drugs

New and old

New

Class III agentsNovel drugs

Dofetilide Azimilide

DronedaroneTedisamil Adenosine

agonist

Connexin

modulators

5-HT4

antagonist

SAC

blockers

ARDAs

Na+/Ca2+

inhibitor

Na+/H+

inhibitor

Upstream

therapies

Amiodarone

Sotalol

Class

III

Propafenone

Flecainide

Class

IC

Multi-channel

blockers Celivarone

Antiarrhythmic medical therapies

Courtesy of J Camm, MD.

Atrial selective

Vernakalant hydrochloride for rapid ( 90 mn) conversion of AF.Roy D. Circ.2008.117.1518-25

Vernakalant iv :

3mg /Kg/10 mn iv & after 15 mn: 2mg/Kg/10mn

Ranolazine

Circulation 2011,124

The American journal of cardiology.september

2012.volume 110,Issue 5

ESC-2010

cardioversion of AF Pill-in-pocket strategyAlboni et al-2004/ Mansourati J. Cardiol Pratique 2012.997/998. 3

Next episodes of AF if the first is well tolerated: Rx in ER or at home with single dose of AAD by MD

- Flecaine (200-300 mg) or Propafenone (600 mg) //

- Use of AAD within 36 mn after Sx onset

- Efficacy: 90% & Sx disappear within 113 mn

- Hospitalisation reduced

- Sides effects: 7% mainly non cardiac

- Main indications: PxAF of rare episodes

- CI: LV dysfunction

ACTIVE-W:

AF “| high AF risk of TEA in 6707

Interrupted because of 47% excess of TEA in Clopidogrel+ASA

CVA, PAE, MI, CV death

Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events

AVK in AF patient previously not anti-coagulated

Balancing risk of ischemic stroke & intracranial bleeding

INR: 2-3Turpie A. EHJ. 2007.29.155-65

Strategy of AC with CV (Electrical or medical) ACC/AHA/ESC.EHJ.2010 .31.2396-29 of AF cardioversion

AC INR

1- AF > 24h or undetermined duration AVK=/> 3w pre & 4w post CV (1B: AF & 1C:A.Flutter) ) 2-3

2- AF < 24h

RR Stroke & Bleeding Voller H.EHJ.2005. 7. Supl E.4-9

Anticoagulant Rx in AF of elderly pts

Annual risk of CVA in placebo group patients with AF in randomized trials.Hanon O. Cardiol Pratique. 2012. 992

ATRIA. Singer DE. Chang Y. Fang MC. Et al. Ann Intern Med.2009..151.297-305 (13559 AF pts )

Benefit of AVK Rx of AF appears at age =/> 75 y

LMH in NVAF// clinical status Ederhy S. AMC.2006.99.1210-4

• The most studied anticoagulant drug is unfractioned heparin UFH and, less validated,

subcutaneous enoxaparin.

• In symptomatic patients already taking antivitamin-K, emergency management of

acute AF depends on the INR .

Steinberg JS. Circulation . 2004. 109.1973-1980

Anti-coagulation in patient with AF & not previously anti-coagulated

Heparin: UFH / LMWHPengo V. Circ.2009. 119. 2920-7

M M

Risk stratification for TEA & bleeding

Letter Risk factors for

bleeding

Points awarded

H Hypertension 1

A Abnormal renal &

liver function (1pt

each)

1 or 2

S Stroke 1

B Bleeding 1

L Labile INR’s 1

E Elderly > 65 years 1

D Drugs or Alcohol

(1pt each)

1 or 2

Max 9 points

Risk Factor for TEA Score

C CHF / LV Dysfunction 1

H Hypertension 1

A2 Age > 75 years 2

D Diabetes Mellitus 1

S2 Stroke / TIA / Thromboembolism 2

V Vascular disease (MI, PAD, Aortic plaques) 1

A Age 65 – 74 y 1

Sc Sex category (female) 1

Maximum score 9

European Heart Journal (2010) 31,2369-2429l

Stroke or TEA rates based on CHADS2 & CHAD2DS2VASc

scores & bleeding rates based on HAS-BLED score in AF. Cinitz J. Circ.2013. 127.408-16

Approach to Thrombo-Prophylaxis in AF

Risk Category CHA2-DS2-VASc

score

Recommended Anti-

Thrombotic Therapy

One major risk factor

or ≥ 2 clinically

relevant non major RF

≥ 2 OAC

One clinically relevant

non major risk factor

1 Either OAC or Aspirin

But preferred OAC

No risk factor 0

Either Aspirin or no

antithrombotic

But preferred no

antithrombotic rather

than aspirin

European Heart Journal (2010) 31,2369-2429l

AF Voller H.EHJ.2005. 7. Supl E.4-9

Risk Stratification for Anti-thrombotic Rx

,

Optimal strategy of AC in cardioversion (CV) .Caims JA. Can J Cardil. 2011.27: 74-90/ Rudaut R. Cardiol Pratique. 2012-992

,

Indications of TEE before ECV Lesbre JP.AMC.2003.96.871-9 / Rudaut R. Cardiol Pratique. 2012-992.

• AF+ CVA/ Recent embolic event

• Valvular AF

• Hemodynamic instability requiring rapid

CV on UFH or therapeutic LMWH ( I-B)

• AF at High embolic risk:

* H/o CVA

* LA>50 mm ,

* HF

* DM,

* Permanent HBP.

• Lone AF + avoid LgT AC

Indications of TEE before ECV // number of RF

Optimal strategy of AC in cardioversion (CV) TEE-Guided CV :

ACUTE: Klein AI. NEJM. 201.344.1411-20./. Rudaut R. Cardiol Pratique. 2012-992.

- No LA/LAA Thrombus: UFH/LMWH + CV

- LA/LAA Thrombus: > 3w of AC

* No more Thrombus: CV & AVK for 1m

or for life according to RF ( IIac)

* Persistence of Thrombus: CI for CV !

* LA sludge : AC & if persistent: CI for CV & for RFA

Novel anticoagulants. Eikelboom J. Circ.2010.121.1523-32

No difference in embolic event rate

between Dabigatran 110 x2 vs 150 mg x2 vs AVK for =/ >3 w

prior to CV Nagarakanti R. Circ.2011.123.131-6

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Dabi

110 x2

Dabi

150 x2

AVK

TEA %

Place of new AC (Can J Cardiol 2011. 27.74-90) & (ACCF/AHA/HRS Revision. Circ.2011.123.144-50)

1- Dabigatran 150 mg x2/ for =/> 3w before & 4w post CV

2- Anti-Xa: No recommendations

CVA, AF & ACFauchier . Cardiol Pratique. 2012.1010-1011. 3.

• Dabigatran 150 mg x2Apixaban 5 mg x2Rivaroxaban 20mg x1

- Less CVA & Systemic embolism vs AVK- Hemorrhagic CVA: - 40to -70% vs AVK

- Ischemic CVA: -25%

• Risk vs benefit- CHADS2 : 0 & high bleeding risk:

Dabigatran 110 x2 & Apixaban:Benefit > Risk

- CHA2DSVASc: 1 Dabigatran 110 / 150 & Apixaban

Benefit > Risk- Higher TE riskDabigatran 110 / 150 & Apixaban 5 &Rivaroxaban 20mg x1

Benefit > Risk vs AVK - High TE risk & high bleeding risk Dabigatran 110 / 150 & Apixaban 5 & Rivaroxaban 20mg x1

Benefit > Risk vs AVK

Clinical conditions of AC Rx of AF. Ederhy S. Cardiol Pratique. 2012. 995-996.

Remaining indications for AVK

1- All VAF & PHV

2- Well equilibrated patients on AVK

3-No H/o CVA on Rx

4- H/o GI bleding

5-Cr Cl < 25 ml/mn

6-CAD

7- Intracardiac thrombus

WHICH SUBSET OF AF PATIENTS NEEDS HOSPITAL

ADMISSION?

• Highly symptomatic patients & Poor AF tolerance Specially in Elderly

• Structural heart disease

• Embolic event or are at high risk of thromboembolism

• Non-cardiac causes of AF

• Failure of rate control in the ED

Mansourati J. Cardiol Pratique 2012.997/998. 3

WHICH SUBSET OF AF PATIENTS CAN BE SAFELY

DISCHARGED FROM THE ED?

• No structural heart disease

• Controlled ventricular rate

• Age < 60 years

• Lone AF

• Persistent AF whose rhythm is converted to normal SR

• Patients started on Amiodarone may be safe for discharge afteremergency cardioversion

`