VanderbiltEM.com. Atrial Fibrillation Update Don t Miss a Beat ACEP AFib. 20 Facts on Atrial Fibrillation in 20 minutes

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1 Atrial Fibrillation Update Don t Miss a Beat ACEP 2015 Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport Nashville, TN VanderbiltEM.com AFib 20 Facts on Atrial Fibrillation in 20 minutes Atrial Fibrillation is Common # 1 sustained cardiac arrhythmia > 3,000,000 patients 1% of US population 9% of all those 80 yo JAMA 2001;285: JAMA 2001;285:

2 5 Step ED Dx - Rx Secure ABCs with rate control, if needed Beta blocker vs Diltiazem Determine etiology R/O ischemia, thyroid, electrolyte, toxins, HF Establish stroke risk (CHA 2 DS 2 VAS c ) Cardiovert, admit or D/C on meds 5 Causes of Atrial Fibrillation Pericardium Myocardium Endocardium Pulmonary Hypersympathetic There Are 5 Causes of Atrial Fibrillation Pericardium Myocardium Endocardium Pulmonary Hypersympathetic Pericarditis LVH, Myocarditis JAMA 2001;285: Endocarditis, valvular heart disease PE, pulmonary hypertension Cocaine, amphetamines, hyperthyroid, ETOH withdrawal, caffeine, beta agonists, fever, dehydration 5 Types of Atrial Fibrillation Paroxysmal Persistent Long Standing Loan AF Recurrent There Are 5 Types of Atrial Fibrillation Paroxysmal Persistent Long Standing Loan AF Recurrent Terminates spontaneously < 7 days > 7 days of continued AF 1 year or more No risk factors and < 60 Repeated episodes often subclinical and not recognized There Are 5 Routine Tests for All New AF CBC BMP Thyroid CXR Echocardiogram (sooner or later) 2

3 Consider Additional Tests BNP R/O HF Troponin R/O ACS Exercise Testing WPW, Inducible, ACS Don t Discharge AF Patients Without Follow up Holter / Event Monitor JAMA 2001;285: Calculation of CHA 2 DS 2 VAS c score Anticoagulants if indicated Warnings Atrial Fibrillation Equals an Increased Stroke Rate About 0.5-1% per year but can be higher 5% if no anticoagulation CHA 2 DS 2 VAS C important determinant Silent cerebral ischemia by CT/MRI is 20-40% AF doubles risk of death from age 55 onward (2.2/1.42 F/M) Always Calculate the Patient s Score CHA 2 DS 2 VAS c CHF(1) Hypertension (1) Age 75 (2) Age (1) Diabetes Mellitus (1) Stroke/ TIA/Thromboembolic (2) Vascular DSX (AMI, PVD, Aortic Plaques (1) Sex Female (1) Chest 2010;137: Stroke Risk and CHAD 2 Score JAMA 2001;285: Alliance for Aging Research: Stroke prevention in AF;

4 Stroke is Biggest AF Risk 5% year if no anticoagulation 10% year if prior CVA or TIA Anticoagulation decreases CVA risk by 2/3 Rate vs Rhythm Control In General: Rate Control is Superior to Rhythm Control NEJM 2002;347: 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) But maybe rate control is not always best for some ED patients Pharmacological Cardioversion Annals Emerg Med 1999;33: Annals Emerg Med 1999;33: stable patients, new onset Afib Included patients with AF > 48 hrs (51/289) Excluded unstable patients Excluded underlying illness requiring admission 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 4

5 Procainamide Dosing Not if prolonged Q-T or Hypotensive mg / min j beware QRS widening Up to 17.1 mg/kg total My bias is not above 1,000 mg Up to 50% will convert ED Cardioversion Results Annals Emerg Med 1999;33: % converted spontaneously 62% had chemical cardioversion attempted Chemical conversion was 50% effective (90/180) 28% had electrical conversion attempted DC cardioversion was 89% successful (71/80) 10% of D/C d pts returned 7d, never due to complication This study made ED conversions for new onset AF a viable practice option It is common in Canada and variable in USA Many centers do a cardiologistperformed TEE before cardioversion Annals Emerg Med 1999;33: Annals Emerg Med 2011;58: Michael: 50% medical converted and 99% D/C 89% success electrically all D/C Burton: 86% success electrically, 91% D/C Jacoby: 97% (29/30) electrical success, 75% D/C Stiell: 58% of 660 success with procainamide 92% of failed electrically converted, 97% D/C Scheuermeyer: 141 electrical conversion, 96.5% success & D/C ED Rate vs. Rhythm Control Annals of Emerg Med 2015;65:540-2 PACE 2013;36: Rate vs. rhythm control, 10 studies, 7,867 pts Stroke, AMI, bleeding and mortality, all similar ED and admissions increased in rhythm control But rhythm control better if < 65 Lower mortality: RR 3.03 p= Meta-analysis of 4 ED relevant studies 1438 patients with new onset AF Rate control if older, chronic AF Rhythm > rate control if < 65 yo and healthy 5

6 Younger, healthier patients do better with therapy directed at keeping them in sinus rhythm Older, sicker patients do better with their AF rate controlled 5 Step ED Dx - Rx Secure ABCs with rate control, if needed Beta Blocker vs Diltiazem Determine etiology R/O ischemia, thyroid, electrolyte, toxins, HF Establish stroke risk (CHA 2 DS 2 VAS c ) Cardiovert, admit or D/C on meds Rate Control in AF Calcium Channel Blocker - Diltizem 25 mg over 1-2 min May to 35 mg over 1-2 min if inadequate response after 5 min Beta Blocker - Metoprolol 5 mg IV q 5 min up to 3 doses - Esmolol 0.5 mg/kg over 1 min mg/kg/min titrate to effect J Emerg Med 2015;49: Is Diltiazem or Labetalol superior in rate control Atrial Fibrillation and Flutter with RVR Double blind study of 52 pts with AF ( ) Measured HR < 100 within 30 min 0.25 mg/kg Diltiazem vs 0.15 mg/kg Metoprolol Maximum 30 mg Diltiazem vs 10 mg Metoprolol Escalated at 15 min to 0.35 mg/kg vs 0.25 mg/kg % Heart Rate Less than M Blue Box = Metoprolol Red Box = Diltiazem D M Min 15 Min D J Emerg Med 2015;49: M 95.8 D 30 Min J Emerg Med 2015;49:

7 Rate Control for AF with RVR Take Homes IV Diltiazem appears to be better and faster at rate control for AF with RVR than Metoprolol Although cardiologists seem to prefer Metoprolol, Diltiazem is as good or better for AF with RVR No increased toxicity Be careful with dosing Older, frailer patients should get less European Heart 2013;34: ; The role of Digoxin in Atrial Fibrillation is controversial it may increase mortality or be a marker for those who will do badly regardless of its use In general don t be the one to start it ED Conversion of Atrial Fibrillation Medical followed by electrical Annals Emerg Med 2011;58: Procainamide is effective in about 50% Electricity is 86%-90% effective No significant underlying diseases (HF, pneumonia, ACS, etc.) Must be less than 48 hrs of AFib Safety of ED Cardioversion JAMA 2014;312:647-8 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 Risk of CVA S/P Cardioversion without anticoagulants 0-48 hrs onset = 0.7% JAMA 2014;312: % < % OR=4.0 7

8 Cardioversion for Fib/Flutter AHA recommends J biphasic Neither A-P nor A-L Pad Placement is Superior J for flutter Use highest recommended AP or AL your choice Switch portions if unsuccessful Acad Of EM 2014; 21: Meta-analysis 13 studies 836 AP pts vs 856 AL pts Trend toward AL > AP if biphasic Anticoagulation Pre Cardioversion If CHA 2 DS 2 VAS c = 0 not needed pre or post Others, if no TEE 3 weeks pre cardioversion Who Needs an Echo in AF 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 Annals Emerg Med 2011;58: We conclude that it would be within the standard of care to discharge home stable patients with AFib after cardioversion with adequate follow-up... The return rate for relapsed AFib is 3%-17% Anticoagulation and Atrial Fibrillation Even if Converted 8

9 JACC 2015;65:643-4 Always DC on anticoagulation if CHA 2 DS 2 VAS c score 2 or greater None needed if score = 0 CHA 2 DS 2 VAS c of 1 is controversial no antithrombotic or oral anticoagulant or ASH therapy should be individualized based on shared decision making after discussion of absolute and RR of stroke and bleeding CHA 2 DS 2 VAS c JAMA 2015; 314:291-2 Agent 0 NOAC or discuss NOAC or Warfarin JACC 2015;65:643-4 Increasing evidence for anticoagulation if CHA 2 DS 2 VAS c =1 Yearly strokes = 2.75% (m), 2.55% (f) Incremental risk if age Do not D/C unless you, patient and cardiologist have all agreed on plan NOACs now endorsed in ACC/AHA guidelines. Check carefully for use/dosage in CRF, valvular disease, obese, fluid and s/p cardioversion Apixaban Dabigatran Edoxaban NOACs, DOACs Novel Oral Anticoagulants Direct Oral Anticoagulants Eliquis Pradaxa Rivaroxaban Xaralto anti-xa Savaysa anti-xa direct antithrombin anti-xa Warfarin use is decreasing and is becoming relegated to mainly those patients with: Mechanical Heart Valves Mitral Stenosis Chronic Renal Failure Lancet 2014;383:

10 Anticoagulation for AFib Warfarin: Apixaban: Edoxiban: Dabigatran: Rivaroxaban: INR 2-3; not < 2 5 mg BID 2.5 mg BID < 60 kg, > 80 y, Cr > mg QD > 60 kg 30 mg QD > 30 kg Not for pts CrCl > mg BID if CrCl > mg / d 15 mg / d if CrCl Anticoagulation and ED Discharge Annals Emerg Med 2013;62: Annals Emerg Med 2013;62:566-8 Annals Emerg Med 2015;65:1-12 Annals Emerg Med 2015;66: EM MDs need to pay close attention to CHA 2 DS 2 VAS c scores Anticoagulants started in ED increase compliance and decrease stroke risk JACC 2015;65:643-4 Always DC on anticoagulation if CHA 2 DS 2 VAS c score 2 or greater None needed if score = 0 CHA 2 DS 2 VAS c of 1 is controversial no antithrombotic or oral anticoagulant or ASH therapy should be individualized based on shared decision making after discussion of absolute and RR of stroke and bleeding Atrial Fibrillation What s New or Different? Is rate control for atrial fibrillation always the best strategy? 416 patients with AF All patients had complex AF Complex = an acute underlying illness 2 Canadian University affiliated EDs 10

11 Sepsis (35.6% HF (32%) ARF (6.7%) COPD (4.4%) CVA (3.7%) GI Bleed (3%) PE (2.2%) Acute Concomitant Illnesses Major Complications Shock requiring vasopressors Intubation or NIPPV Bradycardia requiring pacing or meds Stroke or embolic complication CPR or death Major Adverse Complications 50% 40% 30% 40.7% 33.6% absolute difference RR=5.7 Minor Complications Fluid bolus 20% 7.1% O 2 by bag valve mask 10% 0% Rate or Rhythm Control Attempted No Rate or Rhythm Control Total Adverse Events Effective Rate Control (> 20 BPM) 15% 14% 13% 12% 11% 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% 14.1% 19/135 Rate or Rhythm Control Attempted 1.1% 3/281 No Rate or Rhythm Control 13% absolute difference RR= % 40% 30% 20% 10% 0% 19.0% Control Attempted (Elec, D;1+, BB) 44.5% No Attempt at Control (Crystalloid, Bronchodilator) 25.5% absolute difference RR=2.3 11

12 Complication Rate vs. Effectiveness 60% (9/15) had cardiovascular complications 26.7% (4/15) had medication complications 19.0% had pulse reduction of 20 BPM with medical control 20% (3/5) had successful electrical conversion Trying to Control AF in Sick Patients Take Homes Rarely effective Dangerous Focus on underlying disease before attempting to control rate or rhythm Rate control is rarely effective in complex AF with RVR patients and can be very dangerous AF Rate Control in Complex Patients Take Homes Treat the underlying disease(s) It s dangerous to try to control rate immediately Beware underlying sepsis, dehydration, HF Beta blockade + HF = ETI Older pts and higher CHADs scores often denote who has an underlying cause of AF with RVR The Best Single Current Cardiology Reference The Best Single Current EM Reference Annals of Emerg Med 2015;65:532-9 JACC 2014;64: Definitive recommendations from AHA- ACC 201 references, up to 2014 Every possible table & resource Authoritative review ED focused 48 references including from

13 There Are 5 Causes of Atrial Fibrillation Pericardium Myocardium Endocardium Pulmonary Hypersympathetic Pericarditis LVH, Myocarditis JAMA 2001;285: Endocarditis, valvular heart disease PE, pulmonary hypertension Cocaine, amphetamines, hyperthyroid, ETOH withdrawal, caffeine, beta agonists, fever, dehydration Always Calculate the Patient s Score CHA 2 DS 2 VAS c CHF(1) Hypertension (1) Age 75 (2) Age (1) Diabetes Mellitus (1) Stroke/ TIA/Thromboembolic (2) Vascular DSX (AMI, PVD, Aortic Plaques (1) Sex Female (1) Chest 2010;137: Step ED Dx - Rx Secure ABCs with rate control, if needed Beta blocker vs Diltiazem Determine etiology R/O ischemia, thyroid, electrolyte, toxins, HF Establish stroke risk (CHA 2 DS 2 VAS c ) Cardiovert, admit or D/C on meds Summary Atrial Fibrillation is common Stroke is high risk Always calculate CHA 2 DS 2 VAS c score Anticoagulate if indicated 2 = yes, 0 = no, 1 = consult Summary Treat underlying conditions Dilt or BB for rate control Cardioversion can be safe < hrs Procainamide works 50-60% 200 Joules biphasic works 90% VanderbiltEM.com 13