Who Needs Admission and Who can go home?

Transcription

1 Who Needs Admission and Who can go home?

2

3 Where is the presentation (clinic or ER)? Time of onset/duration Can symptoms be relieved? Stroke risk reduction Can adequate heart rate control be achieved? Is cardioversion necessary? Post- cardioversion management

4 Treatment options may be more limited in Clinic setting Rural ER settings may also not offer full treatment options Tertiary Care ER may allow aggressive treatment options that may allow outpatient treatment of the majority of AF patients

5 How reliable is the history of onset? Duration < 48 hours Duration > 48 hours

6 Patients will be very sure of onset if symptoms are severe. Asymptomatic patients should not be considered reliable regarding onset/duration.

7 < 48 hours Cardioversion is feasible without TEE Anticoagulation still recommended prior to cardioverison and for at least 4 weeks afterwards. > 48 hours TEE is required to exclude intra-cardiac thrombus if restoration of NSR is planned and the patients has not been previoulsy adequately anticoagulated

8 Palpitations Rapid heart beat Increased dyspnea on exertion Presyncope (rarely frank syncope unless Preexcitation present) Rarely chest pain

9 Number one Priority CHA2DS2-VASc score NOACS preferable to Coumadin for Initial treatment Consider NOACs as a bridge to Coumadin in patients not covered for the newer agents Everyone post Cardioversion gets anticoagulation for 4 weeks regardless of CHA2DS2-VASc score or TEE results

10 Lip Y, et al. Chest 2010, 137(2):263

11 IV Diltiazem 5-20mg IV, then 5-20mg/hr Metoprolol 5mg IV Q5min x 3 Esmolol gtt, if in ICU PO Diltiazem 30-60mg Q6H Diltiazem CD mg Q24H Verapamil mg Q24H Metoprolol 25mg Q6-8H Metoprolol XL 25-50mg Q12-24H Atenolol mg Q24H Digoxin?

12 For Acute control of Ventricular response IV Cardizem is drug of choice For chronic heart rate control Beta Blockers should be first consideration Oral Cardizem is an acceptable alternative if beta blockers cannot be tolerated. Digoxin should only be used if rate control unable to be achieved with first line drugs

13 Determine need for long term anticoagulation using CHA2DS2-VASc score Are antiarrhythic drugs indicated and can these be initiated in the outpatient setting?

14 Not everyone needs an Antiarrhythmic Meds that can be started without admission No structural Heart disease: First line Class IC Rythmol, Flecainide Second line Class III Amiodarone Structural Heart Disease (CAD, CHF, cardiomyopathy) only choice is Amiodarone

15 Recurrent AF High risk of recurrence Severe symptoms Low risk for adverse effects of the drug

16 Adequate Symptom control Adequate Heart rate control Initial Stroke prevention strategy defined and implemented Appropriate follow up arranged

17 The vast majority of AF patients can be treated in the outpatient setting Exceptions are those that are hemodynamically compromised or have refractory symptoms Patient that require inpatient monitoring for initiation of Class III agents (Betapace or Tikosyn)

18 56 yom presents to outpatient clinic for routine check. He has no complaints and no previous PMH. He takes no meds. He is employed as Diesel mechanic. EKG demonstrates atrial fibrillation with heart rate of 110 bpm.

19 67yof with no past medical history present for yearly Gyn exam and the nurse notes an irregular pulse. She takes no meds. EKG atrial fibrillation at 85 bpm

20 72 yom presents to ER in small but quaint MS town in NE Mississippi with complaints of increase dyspnea and mild chest pain He has a history of CAD, Prior MI Telemetry monitor demonstrates atrial fibrillation at 170 bpm EKG confirms AF and shows 1mm lateral ST depression.

21 He is given 1mg/kg of LMWH and 20mg of IV cardizem followed by 5mg/hr in fusion. His symptoms have resolved and repeat EKG demonstrates resolution of ST depression. Initial cardiac enzymes are negative. What now??

22 72 yom with a h/o HTN and Type II DM present to NMMC ER with symptoms of palpitations and increased dyspnea for the last 3-4 days. He had a cardiac catheterization done 3 months ago that showed normal coronaries and recent echo showed preserved LV function and mild MR

23 He is given 1mg/kg SC of LMWH and given 20 mg of IV cardizem followed by 5mg/hr of IV cardizem His heart rate is now 120 bpm and his BP is 92/54 with slight improvement of symptoms

24 He undergoes TEE which shows no intracardiac thrombus and cardioversion is performed successfully. What now?