1. Atrial Fibrillation A Strategic Update Paul Calle, Ghent Stephen Bohan, Boston

2. Atrial Fibrillation/Strategy Stephen Bohan Setting the Stage Basic Approach Paul Calle Common Clinical Decisions Special Situations

3. Emergency physicians need strategies with regard to recognition clinical evaluation search for precipitating factors heart rate control vs. conversion to sinus rhythm prevention of thromboembolism management in particular subgroups admission versus discharge Atrial Fibrillation/Strategy

4. Strategies are plans to accomplish a goal. Goal for atrial fibrillation should be to treat each patient efficiently and safely based on evidence. Such a strategy should allow for treatment to be standardized.

5. Atrial Fibrillation/Strategy Why should treatment be standardized? Standardization reduces variability and variability is the enemy of efficiency and safety Atrial fibrillation will become an extremely common presentation to the Emergency Department

6. Atrial Fibrillation/ Strategy Atrial Fibrillation/ Prevalence < 55 years-----1/1000 > 79 years-----9/100 Atrial Fibrillation/Importance 1.5 to 1.9 increase in mortality

7. Atrial Fibrillation/Strategy Before we can develop a goal/strategy we need better taxonomy: (Is this an anglophone problem?) Lone Paroxysmal Persistent Recurrent Chronic

8. Atrial Fibrillation/Strategy Lexicon/Definitions (ACC/AHA/ESC) First Detected Episode Recurrent (2 or more episodes) If episode stops spontaneously = PAROXYMAL If episode is sustained = PERSISTENT Conversion does not change designation Permanent Lone Patient younger than 60yrs and no disease clinically or by echo

9. Atrial Fibrillation All of the above terms refer to episodes that are: 1) at least 30 sec in duration and 2) do not have a secondary cause such as surgery or thyroid disease

10. The many faces of atrial fibrillation in ED... Tachycardia-related symptoms (palpitations, chest pain, lightheadedness, pulmonary edema,...) bradycardia-related symptoms (cardiogenic shock, [convulsive] syncope,...) Trauma Stroke and systemic embolism Symptoms mainly related to precipitating medical condition (alcoholism, hyperthyreodism, pneumonia,...) Asymptomatic Atrial Fibrillation/Strategy

11. Emergency Department Approach: Unstable patient: hypotension angina hyoxemia wide irregular (hard to tell at high rate) tachycardia ELECTRICITY (BIPHASIC) IS YOUR FRIEND (CIRCULATION 2000;101:1282)

12. Atrial Fibrillation/Strategy Emergency Department Approach Careful history: time of onset medications recent surgery symptoms of chest discomfort (patients often have ‘sensation” that is not like angina) symptoms of thyroid disease

13. Atrial Fibrillation/Strategy Emergency Department approach Stable patient Physical Examination Evidence of CHF Evidence of pneumonia (fever) Evidence of thyroid disease Careful auscultation (after rate control) Record/EKG review

14. Atrial Fibrillation/Strategy Emergency Department approach Laboratory examination EKG (prior BBB, prior MI, active ischemia) Chest X ray (heart size, effusion, pneumonia) Metabolic screen including TSH on first episode Anti coagulation Aspirin Low Molecular Weight Heparin Coumadin (start in ED)

15. Atrial Fibrillation/Strategy What agent should be used for rate control? calcium channel blockers and beta blockers equally effective at start of treatment Digoxin slower to take effect beta blockers render better control on exercise beta blockers reduce mortality in CHF beta blockers reduce mortality post MI

16. Atrial Fibrillation/Strategy Conversion Two kinds of conversion conversion of rhythm conversion of physicians to new mode of treatment Why convert? (common wisdom) “Improved hemodynamics, less CHF, fewer emboli”

17. Atrial Fibrillation Who should be converted? 50% of patients convert on their own in 24 hours Young (<55yrs), first episode clearly identified cause (cardiac surgery, catecholamine, medications) no history of/evidence of valvular heart disease

18. Atrial Fibrillation/Strategy Conversion >59 years--16% reversion rate at 30 days and 30% at one year--- even with antidysrhythmic, worse if structural heart disease BUT---MOST IMPORTANTLY---- Conversion probably does not make any difference.

19. Atrial Fibrillation/Strategy AFFIRM and RACE two studies, two continents, 4,500 patients all patients had had at least one prior episode mostly age 60+ rate control vs rhythm control NO DIFFERENCE IN DEATH OR STROKE

20. Atrial Fibrillation/Strategy Stroke occurred even when in sinus rhythm Stroke occurred when off anticoagulants or with subtherapeutic INR

21. Atrial Fibrillation/Strategy How should AFFIRM and RACE change my practice in the Emergency Department? If patient is stable: control rate and initiate anticoagulation, observe for conversion if young, first episode, onset within 48 hrs and no spontaneous conversion consider propafenone 600 mg po or electrical cardioversion--continue anticoagulation.

22. Anticoagulation strategy : ACC/AHA/ESC guidelines Recommendations to prevent ischemic stroke and systemic embolism Recommendations to prevent ischemic stroke and systemic embolism related to cardioversion Atrial Fibrillation/Strategy

23. Class I: Conditions for which there is evidence for and/or general agreement that the procedure or treatment is useful and effective Class II:Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment Atrial Fibrillation/Strategy

24. Class IIa:The weight of evidence or opinion is in favor of the procedure or treatment Class IIb: Usefulness/efficacy is less well established by evidence or opinion Class III:Conditions for which there is evidence and/or general agreement that the procedure or treatment is not useful/effective and in some cases can be harmful Atrial Fibrillation/Strategy

25. Recommendations for antithrombotic therapy in patients with AF Class I 1.Administer antithrombotic therapy (oral anti- coagulation or aspirin) to all patients with AF except those with lone AF, to prevent thrombo- embolism. (Level of evidence: A) 2.Individualize the selection of the antithrombotic agent based on assessment of the absolute risks of stroke and bleeding and the relative risk and benefit for a particular patient. (Level of evidence:A)

26. Recommendations for antithrombotic therapy in patients with AF based on thromboembolic risk stratification Patient featuresAntithrombotic therapy Grade of recommendation Age < 60 yrs No heart disease (lone AF) Age < 60 yrs Heart disease but no risk factors* Age  60 yrs, no risk factors* Age  60 yrs With diabetes mellitus or coronary artery disease Aspirin (325 mg daily) or no therapy Aspirin (325 mg daily) Oral anticoagulation (INR 2.0 - 3.0) Addition of aspirin, 81-162 mg daily is optional I IIb *Risk factors for thromboembolism include heart failure, LV ejection fraction < 0.35, and history of hypertension.

27. Patient featuresAntithrombotic therapy Grade of recommendation Age  75 yrs especially women Heart failure LV ejection fraction  0.35 Thyrotoxicosis Hypertension Rheumatic heart disease (mitral stenosis) Prosthetic heart valves Prior thromboembolism Persistent atrial thrombus on TEE Oral anticoagulation (INR  2.0) Oral anticoagulation (INR 2.0 - 3.0) Oral anticoagulation (INR 2.5 - 3.5 or higher may be appropriate) I

28. Class IIa 1.Target a lower INR of 2 (range 1.6 to 2.5) for primary prevention of ischemic stroke and systemic embolism in patients over 75 years old considered at increased risk of bleeding complications but without frank contra- indications to oral anticoagulation. (Level of evidence: C)

29. Class IIa 2.Manage antithrombotic therapy for patients with atrial flutter, in general, as for those with AF. (Level of evidence: C) 3.Select antithrombotic therapy by the same criteria irrespective of the pattern of AF (i.e., for patients with paroxysmal, persistent, or permanent AF). (Level of evidence: B)

30. Class IIb 1.Interrupt anticoagulation for a period of up to 1 week for surgical or diagnostic procedures that carry a risk of bleeding, without substituting heparin in patients with AF who do not have mechanical prosthetic heart valves. (Level of evidence: C)

31. Class IIb 2.Administer heparin (i.v. or s.c.) respecti- vely in selected high-risk patients or when a series of procedures requires inter- ruption of oral anticoagulant therapy for a period longer than 1 week. (Level of evidence: C)

32. Recommendations in patients with AF undergoing cardioversion Class I 1.Administer anticoagulation therapy regardless of the method (electrical or pharmacological) used to restore sinus rhythm. (Level of evidence: B) 2.Anticoagulate patients with AF lasting more than 48h or of unknown duration for at least 3 to 4 weeks before and after cardioversion (INR 2 to 3). Level of evidence: B)

33. 3. Perform immediate cardioversion in patients with acute (recent-onset) AF accompanied by symptoms or signs of hemodynamic instability without waiting for prior anticoagulation. (Level of evidence: C) a.If not contraindicated, administer heparin intravenously concurrently. b.Next, provide oral anticoagulation for a period of at least 3 to 4 weeks. c.Limited data from recent studies support low molecular-weight heparin. Recommendations in patients with AF undergoing cardioversion

34. 4.Screening for thrombus in LA or LA appendage by TEE is an alternative to routine preantico- agulation. (Level of evidence: B) a.Anticoagulate patients in whom no thrombus is identified with intravenous unfractionated heparin before cardioversion. b.Next, provide oral anticoagulation (INR 2 to 3) for a period of 3 to 4 weeks. c.Limited data support low-molecular-weight heparin. (Level of evidence: C) d.Treat patients whit thrombus on TEE with oral anticoagulation (INR 2 to 3). Recommendations in patients with AF undergoing cardioversion

35. Atrial Fibrillation/Strategy Algorithm for management : newly discovered AF Newly discovered AF ParoxysmalPersistent No therapy needed unless severe symptoms (eg, hypotension, HF, angina pectoris) Anticoagulation as needed Accept permanent AF Anticoagulation and rate control as needed Rate control and anti- coagulation as needed Consider antiarrhythmic drug therapy Cardioversion Long-term antiarrhythmic drug therapy unnecessary

36. Atrial Fibrillation/Strategy Algorithm for management : recurrent paroxysmal AF Recurrent paroxysmal AF Minimal or no symptoms Anticoagulation and rate control as needed No drug for prevention of AF Disabling symptoms in AF Antiarrhythmic drug therapy Anticoagulation and rate control as needed

37. Atrial Fibrillation/Strategy Algorithm for management : recurrent persistent or permanent AF Recurrent persistent AFPermanent AF Minimal or no symptoms Disabling symptoms in AF Anticoagulation and rate control as needed Anticoagulation and rate control Continue anticoagulation as needed and therapy to maintain sinus rhythm Anticoagulation and rate control as needed Antiarrhythmic drug therapy Electrical cardio- version as needed

38. Guidelines for management in special situations (ACC/AHA/ESC) Acute myocardial infarction Ventricular preexcitation (WPW-syndrome) Hyperthyroidism During pregnancy Pulmonary diseases Atrial Fibrillation/Strategy

39. Acute myocardial infarction Class I 1. Electrical cardioversion for patients with severe hemodynamic compromise or intractable ischemia. (Level of evidence: C) 2. Intravenous administration of digitalis or amiodarone to slow a rapid ventricular response and improve LV function. (Level of evidence: C)

40. Acute myocardial infarction 3.Intravenous ß-blockers to slow a rapid ventricular response in patients without clinical LV dysfunction, bronchospastic disease, or AV block. (Level of evidence: C) 4.Heparin for patients with AF and acute MI, unless contraindications to anticoagulation are present. (Level of evidence: C)

41. Class III Administer type IC antiarrhythmic drugs in patients with AF in the setting of acute myo- cardial infarction. (Level of evidence: C) Acute myocardial infarction

42. Ventricular preexcitation Class III Intravenous administration of ß-blocking agents, digitalis glycosides, diltiazem, or verapamil. (Level of evidence: B) Kent bundel

43. Class I 1.Immediate electrical cardioversion in case of hemodynamic instability. (Level of evidence: B) 2. Intravenous procainamide or ibutilide in patients without hemodynamic instability in association with a wide QRS-complex. (Level of evidence: C) 3.Refer for catheter ablation of the accessory pathway in symptomatic patients. (Level of evidence: B) Ventricular preexcitation

44. Class IIb Administer intravenous quinidine, procainamide, disopyramide, ibutilide, or amiodarone to hemodynamically stable patients. (Level of evidence: B) Ventricular preexcitation

45. Class I 1.Administer a ß-blocker as necessary to control heart rate, unless contraindicated. (Level of evidence: B) 2.In circumstances when a ß-blocker cannot be used,administer diltiazem or verapamil to control the ventricular rate. (Level of evidence: B) 3.Use oral anticoagulation (INR 2 to 3) (Level of evidence: C); once euthyroid, recommen- dations as for patients without hyper- thyroidism. (Level of evidence: C) Hyperthyroidism

46. Class I 1.Control the rate of ventricular response with digoxin, a ß-blocker, or a calcium channel antagonist. (Level of evidence: C) 2.Electrical cardioversion in hemodynamically unstable patients. (Level of evidence: C) 3.Administer antithrombotic therapy (anticoagulant or aspirin) throughout pregnancy. (Level of evidence: C) Pregnancy

47. Class IIb 1.Attempt pharmacological cardioversion by administration of quinidine, procainamide, or sotalol in hemodynamically stable patients. (Level of evidence: C) 2.Administer heparin (i.v. or s.c.) to patients with risk factors during the first trimester and last month of pregnancy. (Level of evidence: B) 3.Administer an oral anticoagulant during the second trimester to patients at high thrombo- embolic risk. (Level of evidence: C) Pregnancy

48. Class I 1.Correction of hypoxemia and acidosis are the primary therapeutic measures. (Level of evidence: C) 2.In patients with obstructive pulmonary disease who develop AF, a calcium channel antagonist agent (diltiazem or verapamil) is preferred for ventricular rate control. (Level of evidence: C) 3.Attempt electrical cardioversion in hemo- dynamically unstable patients. (Level of evidence: C) Pulmonary diseases

49. Class III 1.Use of theophylline and ß-adrenergic agonist agents. (Level of evidence: C) 2.Use of ß-blockers, sotalol, propafenone, and adenosine. (Level of evidence: C) Pulmonary diseases

50. Management of bradycardia-related symptoms Increase ventricular rate (atropin, dopamine, epinephrine, pacemaker,...) Stop all agents slowing the ventricular response Continuous ECG-monitoring Beware of torsade de pointes Atrial Fibrillation/Strategy

51. Management of flutter Atrial Fibrillation/Strategy Rule of thumb for emergency physicians : atrial flutter = atrial fibrillation

52. Criteria for hospital admission Highly symptomatic patients Structural heart disease Embolic event or high risk of thromboembolism Failure to control heart rate in ED Start of oral antiarrhythmic therapy with high proarrhythmia potential after cardioversion Need for admission for appropriate management of underlying disease Atrial Fibrillation/Strategy

53. Criteria for discharge from ED No structural heart disease No need for in-hospital management of underlying disease No or minimal symptoms (after rate control or cardioversion) No need for proarrhythmic drugs Appropriate follow-up as out-patient possible Atrial Fibrillation/Strategy

54. Questions ??