Download The Management Of Atrial Fibrillation At The Front Door

The Management Of Atrial Fibrillation At The Front Door
Saxena AK, Iyer A
Acute Medicine Department, Accident and Emergency, St Thomas’ Hospital, London SE1 7EH
Introduction & Aims
Atrial Fibrillation is the commonest presenting
cardiac arrhythmia, with a prevalence of 9% in 80-90
year olds, and accounting for 3-6% of acute
admissions to hospital in the UK.
Fig.1 A&E Protocol based on 2006 NICE Guidelines [1].
Results
•Confirmed diagnosis of AF- on ECG
•General measures- O2, IV access, bloods (FBC, U+E, LFTs, Bone, Clotting,
Glucose, Mg, TFT’s)
•Treat pain, hypoxia, hypovolaemia, myocardial ischaemia
•Is patient haemodynamically unstable- if so is this due to AF?
Haemodynamic instability secondary to AF
Life threatening?
This is an audit which aims to review the
management of atrial fibrillation or flutter (AF) with
rapid ventricular response (FAF) in an Accident and
Emergency Department (A&E) where there is an
established Acute Medicine team. 2006 NICE
guidelines for AF were used as the standard [1].
It also reviews whether appropriate antithrombotic
therapy was administered using appropriate stroke
risk stratification.
Pt known to have
AF previously?
Emergency electrical
cardioversion under
sedation/GA
Yes
No
-iv beta-blockers or ca
antagonist
Emergency electrical
cardioversion under
sedation/GA
If delay in
organising electrical
cardioversion
-iv amiodarone if above
contraindicated
Anticoagulation
Emergency intervention should be performed as soon as possible. The
initiation of anticoagulation should NOT delay any emergency
treatment.
-iv amiodarone
In acute-onset AF- give heparin (if no contraindications), continue till a
full assessment has been made eg thrombo-embolic risk stratification
(see AF haemodynamically stable algorithm)
This is a re-audit. The previous audit in 2007 revealed
the inappropriate use of Digoxin in the management
of FAF. Beta-blockers and DC cardioversion were
underused.
Following this audit a protocol for the management of
FAF was instituted, based on the NICE guidance
(Fig.1). All doctors and nurses in A&E were made
aware of this protocol at departmental meetings.
Yes
No
If sure AF onset less than 48 hrs ago no need to anticoagulate unless:
Unable to restore sinus rhythm within 48 hrs
Anticoagulation recommended by thromboembolic risk
stratification
History of failed cardioversions/ recurrences
Structural heart disease
Confirmed AF- haemodynamically stable
Determine thromboembolic risk and anticoagulate appropriately:
High risk (anticoagulate with warfarin and clexane, if contraindicted-give aspirin)
Previous ischaemic stroke/TIA or thromboembolic event
Methods
Age ≥75 with hypertension, diabetes or vascular disease (CAD/PVD)
Clinical evidence of valve disease, heart failure
Moderate risk (consider each individual pt, warfarin or aspirin may be indicated)
The following standards were set:
Age ≥65 with no high risk factors
Age <75 with hypertension, diabetes or vascular disease (CAD/PVD)
1. All patients should receive treatment as per the
NICE 2006 Guidelines for AF.
Low risk (start aspirin- loading dose 300mg, continue with 75 mg OD)
•Age <65 with no moderate or high risk factors
2. Where Digoxin is prescribed first line, this is done
appropriately and the reasons for this documented.
3. All patients should receive appropriate
antithrombotic treatment as guided by an
appropriate risk stratifying system, e.g. CHADS2 [2].
Patients coded for ‘arrhythmia’ were identified from
the A&E computer database.
Starting in August 2009, 189 consecutive admission
electronic records were reviewed (both the scanned
A&E notes and the electronic discharge summary).
From these 50 patients (>18 years) were identified as
been admitted with AF or Atrial Flutter with a
ventricular rate > 100.
Data pertaining to the patient demographics, clinical
features, drugs/management used, antithrombotic
use, CHADS2 score and patient outcome were
recorded in a proforma.
Chart 1 shows the age distribution and 2 the % with
which presenting rhythm. The minimum ventricular
rate was 114 beats/min. 64% of patients were
managed in A&E Resus and 30% in Majors.
39/50 patients were previously not on any
antiarrhythmic, 61.5% of these were given 1st line
treatment with a beta – blocker (not Sotalol) as per
guidance (39% in 2007).
Rhythm or Rate?
•many instances both are options- the choice is
balance of various factors
•discuss options with patient
Consider Rhythm- control first if:
Symptomatic
Younger
Presenting for first time with
lone AF
AF secondary to
treated/corrected precipitant
With congestive heart failure
Consider Rate-control first if:
Over 65
With coronary artery disease
Mitral stenosis
Known large atrium
AF>12 months
Hx of failed attempts at cardioversion
Secondary to ongoing but reversible cause
of AF (eg thyrotoxicosis/sepsis)
Standard beta-blocker
21% of patients received digoxin as initial therapy
compared with 32% in 2007 (Chart 4). 38% of these
had a documented reason for its use, and 12.5%
received this as per NICE guidance.
Yes
Beta-blocker or ca antagonist
Structural heart disease?
Yes
Amiodarone
Class 1c (flecainide/propafenone)
Drug ineffective/ contraindicated. Previous relapse
while on beta-blocker/sotalol/class 1c
Only consider digoxin, as
adjunct if above not working,
or in sedentary elderly pts
Most of the patients received antithrombotic therapy,
however more could have been discharged on
warfarin. Documentation of risk stratification for stroke
needs to improve. CHADS2 scoring could be added to
the protocol.
References
1. NICE (2006) Atrial Fibrillation: The management of
atrial fibrillation. CG36. London: National Institute for
Health and Clinical Excellence.
Overall 78% of patients were judged to have had the
appropriate treatment (including DCCV) for AF as
per NICE algorithms.
2 Gage BF et al. Validation of clinical classification
schemes for predicting stroke: results from the National
Registry of Atrial Fibrillation. JAMA. 2001; 285:2864-2870
42% of patients were in AF on discharge, of these
95% were on antithrombotic therapy. 10 patients had
a CHADS2 score of >1. Of these 3 had risk
stratification documentation on admission and 6
were planned for warfarin on discharge.
Acknowledgements
No
Sotalol or
Following the previous Audit there has been an
improved compliance with the NICE guidelines. More
patients are being appropriately prescribed beta
blockers and having acute DCCV. Although the use of
digoxin is less it still continues to be overused.
Of 5 patients who had clinical features of being
‘unstable,’ 2 received DC cardioversion. In 2007 8
were ‘unstable’ but nil had DCCV.
Is rate control therapy needed?- aim for resting
rate less than 90bpm
Drug ineffective/ contraindicated. Previous
relapse while on beta-blocker
Conclusion
Thank you to Dr N Drake, Consultant in Emergency
Medicine for providing the data and protocol from the
previous 2007 A&E Audit.