1. Atrial Fibrillation: Update in ED Management Susan P Torrey, MD, FAAEM, FACEP Associate Professor of Emergency Medicine Tufts University School of Medicine

2. I have no financial disclosures but… www.TorreyEKG.com @STorreyMD

3. Atrial fibrillation Epidemiology Most common arrhythmia in ED 0.4% in general population (10X  > 60 years) Substantial morbidity and mortality Cardiovascular and overall survival 5-fold risk stroke Diminished quality of life Significant health care costs

4. Etiology of atrial fibrillation Enlargement of atria Ischemic cardiomyopathy Hypertensive cardiomyopathy Valvular disease (mitral stenosis) Excess stimulation Hyperthyroid Cocaine Embolism

5. Natural history of atrial fib Cellular and electrophysiologic remodeling Apoptosis, necrosis, and fibrosis Occur as early as 1 month “Atrial fib begets atrial fib” Paroxysmal  Persistent  Permanent

6. What’s the hurry? Anter Circ 2009

7. HATCH score HTN1 Age > 751 CVA or TIA2 COPD1 CHF2 de Vos JACC 2010 Predicting progression from paroxysmal to persistent atrial fib

8. HATCH score

9. Natural history of atrial fib Relapse rate – up to 25% in few weeks Spontaneous conversion – 25 - 50% Thromboembolic risk 5%/year – 1.5% (age 50-59) to 23% (age >80) As diverse as the variety of patients Progressive over time

10. ED Management of A Fib Unstable vs. stable presentation Rhythm vs. rate control Anticoagulation?

11. Algorithm for hypotensive A. Fib

12. Unstable? Hypotensive, conscious pt with atrial fib Amiodarone – for rate control May cardiovert within 4-6 hours Heparin advisable Digoxin Slow in onset, but may help Diltiazem Small doses

13. Algorithm for hypotensive A. Fib Atzema CL. Managing Atrial Fibrillation. Ann Emerg Med, 2015

14. The stable patient with A fib Rate or Rhythm Control < 48 hours since onset – cardioversion? ≥ 65 years old – no difference in outcome Sinus rhythm is preferable to A fib Rate control β-blockers or Ca-channel blockers ? worse exercise tolerance with β-blockers β-blockers with hx CAD

15. The stable patient with A fib Rhythm Control Electrical cardioversion – 90% effective Chemical cardioversion – 60% effective procainamide, propafenone, flecainide, amiodarone Questions to consider Time from onset of arrhythmia Risk of thromboembolic event

16. Stable patients with clear onset < 48 hours Without ischemia, hypotension or CHF Pharmacologic cardioversion Procainamide 1 gm over 60 min Electrical cardioversion 150-200 J biphasic synchronized Association of the Ottawa Aggressive Protocol with rapid discharge of ED patients with recent-onset atrial fibrillation or flutter Stiell IG, et al. CJEM 12:181, 2010.

17. Ottawa Aggressive Protocol 660 patients IV procainamide  58% converted 243 underwent EC  92% converted Adverse events – 7.6% (minor) Median LOS – 4.9 hours 7-day relapse – 8.6%

18. #ECsuccessd/c Michael 1999 80 89%100% Burton 2004 388 86 91 Jacoby 2005 30 97 - Stiell 2010 243 92 97 Scheuermeyer 2010 141 96 96 882 92%96% Is Discharge to Home after ED Cardioversion Safe For the Treatment of Recent-Onset Atrial Fibrillation? von Besser K. Ann Emerg Med 58:517, 2011

19. Prospective, randomized trial from Italy 247 patients with AF < 48 hours Excluded comorbid disease and CHADS 2 ≥ 2 108/121 EC (89%) vs 93/125 PC (74%) ED LOS – 180 min EC vs 420 PC Relapse 2 month – 26% EC vs 28% PC Cardioversion of atrial fibrillation in ED: a prospective randomized trial. Bellone A, et al. Emerg Med J 29:188. 2012

20. ED cardioversion of atrial fib ED cardioversion is effective and safe With identification of appropriate patient, and With attention to thromboembolic risk Saves time, money and resources Patient satisfaction Spare admission and unnecessary meds

21. CHADS 2 CHF1 Hypertension1 Age ≥ 751 Diabetes1 Stroke/TIA2

22. CHA 2 DS 2 -VASc CHF1 Hypertension1 Age ≥ 752 Diabetes1 Stroke/TIA2 Vascular dz1 (MI, CABG, PVD) Age 65-74 y1 Sex (female)1

23. To anticoagulate or not 2012 European Society (ESC) 2014 Canadian Cardiovasc Society (CCS) 2014 American Coll Card (ACC/AHA) All groups recommend anticoagulation for: Age > 65 years Mechanical heart valves Rheumatic valvular disease

25. HAS-BLED HHypertension1 AAbnl renal or liver fx1 or 2 SStroke1 BBleeding hx1 LLabile INRs1 EElderly1 DDrugs or alcohol1 or 2 ≥ 3 = high risk of bleeding

28. Atrial fibrillation in Sub-Saharan Africa Stambler BS. Internat J Gen Med 8:231, 2015

29. Atrial fibrillation in Sub-Saharan Africa Stambler BS. Internat J Gen Med 8:231, 2015

30. Thomboembolic Complications after Cardioversion of Acute Atrial Fibrillation Airaksinen KE, et. Al. J Am Coll Card 62;1187, 2013 Thomboembolic Complications after Cardioversion of Acute Atrial Fibrillation Airaksinen KE, et. Al. J Am Coll Card 62;1187, 2013 5,116 cardioversions in 2,481 patients No peri-procedural anticoagulation Embolic events within 30 days 38 embolic events (31 strokes) – 0.7% Occurred median 2 days / mean 4.6 days FinVC (Finnish CardioVersion) Study

31. Thomboembolic Complications after Cardioversion of Acute Atrial Fibrillation Airaksinen KE, et. Al. J Am Coll Card 62;1187, 2013 Thomboembolic Complications after Cardioversion of Acute Atrial Fibrillation Airaksinen KE, et. Al. J Am Coll Card 62;1187, 2013 Independent predictors Age > 60 years Heart failure Female sex Diabetes Highest risk (CHF and DM)9.8% Lowest risk (no CHF, < 60)0.2%

32. Time to Cardioversion for Acute Atrial Fibrillation and Thromboembolic Complications. Nuotio I, et. al. JAMA 312:647, 2014 Time to Cardioversion for Acute Atrial Fibrillation and Thromboembolic Complications. Nuotio I, et. al. JAMA 312:647, 2014 Time to cardioversion < 12 hours > 12 hours Incidence emboli 0.3% 1.1% Risk of stroke with anticoag – 0.3-0.8% Risk without anticoag < 48 hrs – 0.7%

33. Should Atrial Fib Patients with 1 Risk Factor (Beyond Sex) Receive Oral Anticoagulation? Chao TF, et al. J Am Coll Card 65:635, 2015 Should Atrial Fib Patients with 1 Risk Factor (Beyond Sex) Receive Oral Anticoagulation? Chao TF, et al. J Am Coll Card 65:635, 2015 12,935 males (score 1) – 2.75%/yr stroke rate 1.96% with vascular disease 3.50% those 65-74 years old 7,900 females (score 2) – 2.55%/yr 1.91% with HTN 3.34% those 65-74 years old

34. Should Atrial Fib Patients with 1 Risk Factor (Beyond Sex) Receive Oral Anticoagulation? Chao TF, et al. J Am Coll Card 65:635, 2015 Should Atrial Fib Patients with 1 Risk Factor (Beyond Sex) Receive Oral Anticoagulation? Chao TF, et al. J Am Coll Card 65:635, 2015 CHA 2 DS 2 -VAS C risk factors are not equal Age 65 – 74 associated with highest risk Anticoagulation for 1 additional risk factor

35. Anticoagulation, CHA 2 DS 2 VAS C score, and thromboembolic risk of cardioversion of acute A fib. Gronberg T, et al. Am J Cardiol 117:1294-98, 2016 Anticoagulation, CHA 2 DS 2 VAS C score, and thromboembolic risk of cardioversion of acute A fib. Gronberg T, et al. Am J Cardiol 117:1294-98, 2016 CHA 2 DS 2 VAS C was significant predictor of thromboembolic complications in cardioversion of acute atrial fib Periprocedural anticoagulation reduced risk 82% High CHA 2 DS 2 VAS C score had high rate of failed cardioversion or early recurrence of A fib  ? rationality of rhythm control

36. NOACs Novel Oral Anticoagulants Dabigatran (Pradaxa ® ) – inhibits thrombin Rivaroxaban (Xarelto ® ) – blocks factor Xa Apixaban (Eliquis ® ) compared to warfarin, NOACs cause significant reduction in strokes, intracranial hemorrhage, major bleeding events and mortality Ruff CT, et al. Comparison efficacy and safety NOACs with warfarin in atrial fib – meta-analysis. Lancet 2014

37. Comparison of Efficacy and Safety of new Oral Anticoagulants with Warfarin in Atrial Fib Ruff CT, et al. Lancet 383; 955, 2014

38. NOACs Novel Oral Anticoagulants Fewer interactions with medications Fewer restrictions of foods No lab monitoring Rapid onset action – peak 3 hours Contraindicated: Mechanical heart valves Mitral stenosis

39. Impact on outcomes of changing treatment guideline recommendations for stroke prevention Chao TF, et al. Mayo Clin Proc 91:567-574, 2016. Impact on outcomes of changing treatment guideline recommendations for stroke prevention Chao TF, et al. Mayo Clin Proc 91:567-574, 2016. Patients with atrial fib recommended OAC 2011 guidelines- 69% 2014 guidelines- 86% Most woman with a fib (94%) Most patients > 65 years (97%) New guidelines =  risk adverse outcomes Hazard ratio – 0.89

41. In conclusion… Respect atrial fibrillation Not exactly a benign arrhythmia For ED management consider… Rhythm control Rate control Anticoagulation

42. 30-day Death after ED Visit for A. Fib – The AFTER Study Atzema CL, et al. Ann Emerg Med 66:658, 2015 1. Troponin positive 2. Other acute ED dx 3. COPD 4. Bleeding risk 5. Age ≥ 75 Age 65 – 74 6. CHF

43. 30-day Death after ED Visit for Atrial Fibrillation - the AFTER Study Atzema CL, et al. Ann Emerg Med 66:658, 2015

44. CaCl before IV diltiazem in management of atrial fibrillation. Kolkebeck T, et al. JEM 26:395-400, 2004. CaCl before IV diltiazem in management of atrial fibrillation. Kolkebeck T, et al. JEM 26:395-400, 2004. Prospective, double-blind, placebo-control 75 pts with a fib > 120/min ½ received CaCl / ½ placebo Rate control same between groups No significant side-effects noted No benefit to maintaining BP