1. Treatment of Atrial Fibrillation M Samson – PGY-2 Riverside Campus July 17, 2015 Academic Day

2. Outline Definitions A Fib in the acute setting o Electrical Cardioversion o Chemical Cardioversion Chronic Treatments o Rate Control o Rhythm Control Stroke Prophylaxis o Risk stratification o VKA o NOACs

3. Definitions Paroxysmal AF – AF that terminates spontaneously or with treatment within 7 days of onset. Episodes may recur with variable frequency. Persistent AF – Lasting more than 7 days Long-Standing Persistent – more than 12 months Permanent – When the patient and clinician make a joint decision to stop further attempts of restoring sinus rhythm Non-Valvular A fib – AF in the absence of rheumatic valve disease, prosthetic valve, or mitral valve repair.

4. A Fib in the ED Treatment depends on several factors. The 2 most important ones are: o 1) hemodynamic compromise o 2) time of onset

5. Acute Onset A Fib Hemodynamic Instability Electrical Cardioversion.150 J synchronized. Anticoagulate for 4 weeks Electrical Cardioversion.150 J synchronized. Anticoagulate for 4 weeks Yes No Onset <48hrs Rate Control. Anticoagulate for 3 weeks before rhythm control. Offer rate or rhythm control. Electrical Cardioversion is appropriate. YesNo

6. Acute Onset A Fib - ?anticoagulation If onset is greater than 48 hrs offer heparin for anticoagulation for subtherapeutic anticoagulation or no anticoagulation. Continue heparin based on risk stratification. Continue for at least 4 weeks. If onset is less than 48 hrs offer anticoagulation if 1) stable sinus rhythm not restored within 48hrs, 2) there is a high risk of recurrence 3) it is recommended based on risk stratification.

7. Chronic Treatment Rate Control Rhythm Control Stroke Prophylaxis

8. Risk Stratification – Stroke Vs Major Bleeding CHA 2 DS 2 -VASc – determines risk of stroke HAS-BLED – determines risk of major bleed

9. CHA 2 DS 2 -VASc C – (C)HF H – hypertension A – Age, 2 points if greater than 75, 1 if greater than 65 D – diabetes S – 2 points for previous stroke or TIA V – peripheral vascular disease Sc – Sex category, 1 for female

10. Case 1 – Mr Couminda Mr. Couminda is a 60 y/o gentleman. He has been to the ED on 3 occasions over the past yr and treated for atrial fibrillation with cardioversion. Today, he denies any palpitations, chest pains, orthopnea, PND, headaches, visual disturbances, claudication, erectile dysfunction or signs of neuropathy. He has had no previous stroke or TIA You have been treating him for T2DM and HTN. His current medications are o Perindopril 4 mg daily o Amlodipine 10 mg daily o Metformin 500 mg BID

11. Exam: o BP 124/78, HR 66, O 2 sat – 99% on RA o CVS – S1/S2 normal, regular rhythm, no murmur, no JVP, no carotid bruits o Resp – GAEB, no crackles o Abdomen – no masses, no abdominal bruits o Extremity – sensation intact to light touch, well perfused, edema present Investigations: o ECG – normal sinus rhythm o Bloodwork – CBC – WNL, Electrolytes – WNL, Creat 74, LDL 1.9, TSH 1.43, A1c 6.0% o ECHO – EF 60%. No valvular anomalies.

12. What is his CHA 2 DS 2 -VASc? A) 0 B) 1 C) 2 D) 3 E) 4

13. What is his CHA 2 DS 2 -VASc? A) 0 B) 1 C) 2 – CHF-0, H-1, A-0, D-1, S-0, VASc-0, Male D) 3 E) 4

15. HAS-BLED H – hypertension A – abnormal renal or hepatic function S - stroke B – bleeding L – labile INRs E – elderly D – drugs (antiplatelet, NSAIDs) or ETOH Do not withhold anticoagulation based on fall risk!

16. CHA 2 DS 2 -VASc If 0 – do not offer anticoagulation If 1 – consider offering ASA or anticoagulation If 2 or greater and non-valvular AF – offer anticoagulation with VKA or NOAC If 2 or greater and valvular AF – offer VKA

17. VKA - Warfarin Target is INR of 2.0 - 3.0 with non-valvular AF and 2.0 – 3.0 or 2.5 – 3.5 with prosthetic valves depending on type of prosthesis and which valve INR should be checked weekly after initiation and at least monthly when stable If INR is very labile and GFR >15, consider changing to NOAC

18. NOACs Dabigatran, Rivaroxaban, and Apixaban currently indicated for stroke prevention in AF No INRs or monitoring except yearly renal function Need to be titrated in moderate renal impairment and should not be used in severe renal impairment Should not be used in valvular AF Ne reversible agent available Yearly creatinine should be monitored

19. Cost – from Rx files Warfarin – $15/month Dabigatran - $110/month Rivaroxaban - $100/month Apixaban - $140/month

20. NOACs and Renal Impairment

21. Rate Vs Rhythm Rate ControlRhythm Control Persistent AF Less symptomatic Age >65 HTN No history of HF Past failure of antiarrhythmics Paroxysmal or new AF More Symptomatic Age <65 No HTN HF exacerbated by AF No past failure of antiarrhythmic drugs

22. Rate Control Offer for patients with all types of AF unless: There is a reversible cause They have heart failure caused by AF (rhythm control may be more appropriate) New onset AF A flutter and ablation is suitable Can use o 1) standard beta-blocker (not sotalol), o 2) Non-DHP Ca channel blocker. o Consider 3) digoxin if they are sedentary. If decompensated heart failure – start with beta- blocker then add digoxin if beta blocker not controlling rate adequately.

23. Goals of Rate Control Asymptomatic patients with preserved LV function - <110 bpm. Symptomatic patients or LV dysfunction <80 bpm.

24. FYI - Dosages

25. Rhythm Control If greater than 48 hrs AF – anticoagulate for 3 weeks before rhythm control Electrical Cardioversion is reasonable Pharmacological – propafenone, dofetilide, flecainide, ibutilide are appropriate “Pill in a pocket” with propafenone or or flecainide if they have used these drugs in a supervised setting. Need to use in addition to beta-blocker or Ca Channel blocker. For paroxysmal AF. Consider cardiology referral for ablation if symptomatic and refractory to pharmacological options.

26. Resources Rx Files – 9 th Edition