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ATRIAL FIBRILLATION An overview by: Matt Hall Preceptor: Dr Lester Mercuur Acute Management of AF: A three-part approach to the acute management of AF should be considered: • Appropriate control of the ventricular rate. • The need for, proper timing of, and the appropriate method for the restoration of sinus rhythm. • The need for anticoagulation to prevent thromboembolism. Order of Algorithm: Haemodynamic stability Assess state of hydration Ventricular Rate Control Clinical category of AF Risk-stratifying the cardioversion decision Anticoagulation considerations Disposition decisions Introduction Most common sustained arrhythmia More prevalent in men and with increasing age Overall prevalence of AF is 1%. 70% are at least 65 years old and 45% are over 75 Prevalence ranges from 0.1% in adults <55 to 9%in those >80 AF uncommon in infants and children, almost always occurring with structural heart disease Accounts for >5% cardiac admissions Classification LONE AF:AF without structural heart disease PAROXYSMAL AF: Self terminating AF in which the episodes of AF last <7 days (usually <24hrs) and may be recurrent PERSISTENT AF: Not self terminating and last >7 days PERMANENT AF: AF lasting >1 year and cardioversion has failed or not been attempted Etiology: Cardiac Hypertension (1.5x) Coronary heart disease (6-10%) Rheumatic heart disease (16-70%) CHF (10-30%) Cardiomyopathy (10-28%) Myocarditis Post cardiac sx (30-60%) Pericarditis Congenital heart disease Etiology: Non Cardiac Hyperthyroidism (20-25%) Pulmonary embolism (10-14%) Obstructive sleep apnea Noncardiac surgery (4.1%) Alcohol (60% binge drinkers-”holiday heart”) Caffeine Hypothermia Medications (theophylline) Symptoms and Signs Palpitations Fatigue Presyncope/syncope Dyspnea/Chest Pain Neurologic Deficit Irregularly irregular HR Absent a wave in JVP Variable S1 Murmur Evaluation History and Physical: Define symptoms Clinical type Onset of discovery of AF Frequency/duration of AF episodes Precipitating Causes Modes of termination Response to drug therapy Presence of heart disease/reversible cause Evaluation con’t ECG: Verify presence of AF Identify LVH Pre-excitation BBB Prior MI P wave duration and morphology Measure intervals RR,QRS, QT AF with pre-excitation AF with pre-excitation AF with pre-existing BBB Differences: Pre-excitation: – Varying QRS width and morphology Existing BBB: – Identical QRS morphology Evaluation con’t Laboratory:CBC INR/PTT Electrolytes Creatinine TSH CXR Echocardiogram Additional: TEE, Holter, Stress test, Cardiac Catheterization, EPS Acute Management of AF: A three-part approach to the acute management of AF should be considered: • Appropriate control of the ventricular rate. • The need for, proper timing of, and the appropriate method for the restoration of sinus rhythm. • The need for anticoagulation to prevent thromboembolism. RATE VS RHYTHM CONTROL Favours rate control Persistent AF Recurrent AF Less Symptomatic >65 years old Hypertension No Hx CHF Previous antiarrythmic drug failure Patient preference Favours Rhythm Control Paroxysmal AF First episode AF More symptomatic <65 years old No hypertension Hx of CHF No previous failure of antiarrythmic drugs Patient preference Order of Algorithm: Haemodynamic stability Assess state of hydration Ventricular Rate Control Clinical category of AF Risk-stratifying the cardioversion decision Anticoagulation considerations Disposition decisions ATRIAL FIBRILLATION Unstable primarily due to the arrhythmia. Ø Hemodynamic instability Ø Unstable angina/Acute MI Ø Pulmonary edema Ø Pre-excited AF (WPW) Hemodynamically stable Exclude WPW. Intravenous AV-blocking agents are contraindicated Ø UF heparin IV bolus and infusion OR LMWH Immediate electrical cardioversion Admit Warfarin x 4/52 Ø Ø Ø Rate Control (See Table 1) PERMANENT AF NEW ONSET AF OR RECURRENT PAROXYSMAL AF Assumes hemodynamically stable and rate controlled Therapeutic INR Sub therapeutic INR Discharge * LMWH and titrate warfarin dose * AF PRECIPITATED BY AN IDENTIFIABLE CONDITION: - ethanol intoxication - hyperthyroidism - sepsis - acute MI/PE - other Treat underlying condition Consider heparin or LMWH NO TO ALL (and AF < 48 hours) Consider single dose LMWH x 24 hours Cardioversion: Electrical : - procedural sedation - 100J/200J Pharmacologic: (See Table 2 ) Ÿ Ÿ Ÿ Ÿ Ÿ Is ANY ONE of the following present? Duration of AF>48 hours Duration of AF unknown Severe LV dysfunction: LVEF <40% Mitral valve disease Previous arterial embolism (CVA/TIA/peripheral arterial embolism) YES TO ANY # Use either TEE -GUIDED STRATEGY OR CONVENTIONAL STRATEGY if cardioversion is indicated; TEE-GUIDED STRATEGY: Unfractionated heparin or LMWH and obtain TEE * Clot CONVENTIONAL STRATEGY: LMWH + Warfarin initiation. Anticoag x 3/52 * No Clot Consider oral anticoagulation in high risk pts * New-onset AF may need further investigation * Cardioversion: Electrical: - procedural sedation -200J/360J Pharmacologic: (See table 2 ) Elective electrical or pharmacologic cardioversion in 3/52 Consider repeat TEE prior to cardioversion Warfarin x 1 month Warfarin x 1 month Consider long-term warfarin in selected patients (See table 3 ) Consider long-term warfarin in selected patients ( See table 3 ) # Patients who fall into this group AND who have had a therapeutic INR for at least the preceding three weeks deviate from the algorithm at this point; and the physician may proceed with cardioversion if it is indicated. Ensure continued anticoagulation. * denotes points in the algorithm where referral to an outpatient clinc may be indicated Ventricular rate control: Beta-Blockers Calcium Channel Blockers Digoxin (Amiodarone) WHICH ONE?? Beta Blockers High adrenergic tone (eg post-op AF) Good choice if ventricular response increases excessively during exercise Exercise induced angina Setting of acute MI or Heart Failure Thyrotoxicosis Calcium Channel Blockers No structural heart disease COPD Which One?? Digoxin Usually ineffective alone (NOT 1st Line) Synergistic with other drugs LV Dysfunction +/- CHF Amiodarone Effective for rate and maintenance of sinus rhythm after cardioversion (but at what cost) Acute Management of AF: A three-part approach to the acute management of AF should be considered: • Appropriate control of the ventricular rate. • The need for, proper timing of, and the appropriate method for the restoration of sinus rhythm. • The need for anticoagulation to prevent thromboembolism. The need for cardioversion: - Clinical category A wide clinical spectrum exists: - Asymptomatic to life-threatening - Paroxysmal vs. chronic/permanent AF - Normal heart vs. Diseased heart - Risk of stroke The need for cardioversion: - Considerations The frequency of the paroxysms of AF; the severity of the associated symptoms, and the degree of underlying heart disease all need to be considered when determining the need to restore and maintain sinus rhythm. The need for cardioversion: AF Spectrum Normal heart Infrequent episodes with severe symptoms Paroxysmal Diseased heart with poor LV function Frequent asymptomatic paroxysms Persistent/Permanent The need for cardioversion: An attempt at cardioversion is reasonable with: • lone AF (< 65 years with structurally normal hearts) • first episode/ new onset AF • patients who are very symptomatic during AF despite adequate ventricular rate control • patients with infrequent symptomatic paroxysmal atrial fibrillation. The need for cardioversion: Patients with minimal symptoms; and in whom factors have been identified which make cardioversion and maintenance of sinus rhythm less likely, may benefit from ventricular rate control and anticoagulation alone. Need for Urgent Cardioversion Ischemic Chest Pain Acute MI Hypotension Pulmonary Edema Syncope The timing of cardioversion: Key to the timing of cardioversion is the risk of thromboembolism. The timing of cardioversion: Factors associated with increased thromboembolic risk: • AF > 48 hours in duration or unknown duration. • Valvular heart disease – particularly mitral valve disease • Significant LV dysfunction (LVEF < 40%) or clinical heart failure • Previous CVA/TIA/peripheral arterial embolism • Hyperthyroidism • Atrial Septal Defect (even if repaired) NO TO ALL (and AF < 48 hours) Consider single dose LMWH x 24 hours Cardioversion: Electrical : - procedural sedation - 100J/200J Pharmacologic: (See Table 2 ) Ÿ Ÿ Ÿ Ÿ Ÿ Is ANY ONE of the following present? Duration of AF>48 hours Duration of AF unknown Severe LV dysfunction: LVEF <40% Mitral valve disease Previous arterial embolism (CVA/TIA/peripheral arterial embolism) YES TO ANY # Use either TEE -GUIDED STRATEGY OR CONVENTIONAL STRATEGY if cardioversion is indicated; TEE-GUIDED STRATEGY: Unfractionated heparin or LMWH and obtain TEE * Clot CONVENTIONAL STRATEGY: LMWH + Warfarin initiation. Anticoag x 3/52 * No Clot Consider oral anticoagulation in high risk pts * New-onset AF may need further investigation * Cardioversion: Electrical: - procedural sedation -200J/360J Pharmacologic: (See table 2 ) Elective electrical or pharmacologic cardioversion in 3/52 Consider repeat TEE prior to cardioversion Warfarin x 1 month Warfarin x 1 month Consider long-term warfarin in selected patients (See table 3 ) Consider long-term warfarin in selected patients ( See table 3 ) # Patients who fall into this group AND who have had a therapeutic INR for at least the preceding three weeks deviate from the algorithm at this point; and the physician may proceed with cardioversion if it is indicated. Ensure continued anticoagulation. * denotes points in the algorithm where referral to an outpatient clinc may be indicated The timing of cardioversion: Patients who have - any risk factors, - or when there is doubt about the risk need measures to ensure the absence of LA thrombus before cardioversion is attempted. For those with a sub-therapeutic INR, the TEE-guided strategy or the conventional strategy of delayed cardioversion is recommended. The timing of cardioversion: Patients who are already on warfarin; and who have had a therapeutic INR for at least the preceding three weeks, may undergo cardioversion in the emergency department if indicated. The timing of cardioversion: Patients who have no risk factors, and who have AF < 48 hours (preferably <24 hours) in duration, may undergo immediate cardioversion without the need exclude LA thrombus Electrical Cardioversion Have all supplies needed (Monitors ,IV, Intubation equipment, extra staff..etc) Premedicate Synchronized cardioversion (100,200,300,360J) Drugs For Conversion of AF CCS Consensus Ibutilide (Level of evidence A) Flecainide (A) Procainamide (B) Propafenone (A) Amiodarone (B) So what is the real danger? Acute Management of AF: A three-part approach to the acute management of AF should be considered: • Appropriate control of the ventricular rate. • The need for, proper timing of, and the appropriate method for the restoration of sinus rhythm. • The need for anticoagulation to prevent thromboembolism. Stroke and AF: Disabling stroke is the most devastating complication of AF Age, hypertension and previous stroke/TIA are the strongest predictors of ischemic stroke in patients with intermittent and sustained AF. Stroke and AF: The risk of stroke is the same in intermittent AF and permanent AF. The risk of thrombo-embolism does not differ between electrical or pharmacological cardioversion Spontaneous cardioversion is also associated with thrombo-embolic risks. Risk of stroke: AF Spectrum Normal heart Young No additional stroke risk factors Diseased heart with poor LV function Advanced age Numerous other additional stroke risk factors Recommendations for long-term antithrombotic therapy in AF: High risk criteria - age > 75 years - hypertension - previous stroke/TIA - previous systemic embolism - LVEF< 40% - Rheumatic mitral valve disease - Prosthetic valve Moderate risk criteria - age 65-75 years - diabetes mellitus - CAD with preserved LV function. Low risk criteria - age <65 years - no clinical or echocardiographic evidence of cardiovascular disease ANY High risk criterion - Warfarin therapy TWO or more Moderate criteria - Warfarin therapy ONE Moderate risk criterion - Warfarin therapy or Aspirin LOW risk criteria - Aspirin therapy 325mg Bottom line: Treatment should be carefully tailored to individual circumstance. Not all patients need cardioversion Defined role for attempting cardioversion When there is doubt about thrombo-embolic risk, cardioversion should be deferred Anticoagulation recommendations reduce the burden of ischemic stroke ATRIAL FIBRILLATION DISPOSITION PATHWAY Inpatient AFIB in the ED * Unstable * CHF * MI/ACS * PE/hyperthyroid/sepsis * Significant comorbid illness ADMIT Consult CCU Resident or IM Resident if AFIB precipitated by an identifiable condition Outpatient Needs initiation of outpatient anticoagulation Candidate for long term anticoagulation (see table 3) * Anticoagulation prior to delayed cardioversion And * Needs further investigation or treatment Or Yes * Rate Control Only * No known structural or ischemic heart disease No Yes * significant comorbid conditions Refer to Anticoagulation Management Services (AMS) Clinic AND/OR *: FAX: * ED Chart * AFIB Order Set & Discharge Summary * AMS Referral Form Discharge patient back to Primary Care MD COPY: * ED Chart *AFIB Order Set & Discharge Summary Refer to Urgent Assessment Clinic or to primary internist FAX: * ED Chart * AFIB Order Set & Discharge Summary * Urgent Assessment Form * Requires rhythm control * For delayed cardioversion * High risk AFIB (previousTIA/CVA, peripheral emboli) * Structural heart disease * Significant symptoms despite rate control Consult Cardiologist on Call or refer back to primary cardiologist FAX: * ED Chart * AFIB Order Set & Discharge Summary * THE AMS Clinic is designed for the management of heparin and coumadin. It is NOT intended for further investigation or treatment of AFIB. ALL AFIB patients MUST have follow-up arranged with the appropriate service. AF Order Set and Discharge Summary Order Set – Physician orders; Labs – – Nursing interventions Drugs and dosages Discharge Summary – Referral tool to Cardiology/ Internal Med/ Family Physician Cases 35 yo male with AF with rapid Ventricular response following an alcoholic binge. C/O palpitations x 3 hrs. Never before. 88 yo female with significant CHF hx/+HTN Presents with increased SOB. Hx AF….has been on many drugs and shocked few times in past. Coumadin in past. HR hasn’t been a problem for sometime. Denies CP/Palp. Current meds include Lasix, Carvediol, Ecasa, Digoxin, Altace. ECG shows AF rate 135, no ischemic changes. CXR looks wet. Cases 75 yo female with CAD Hx, DM, HTN presenting with cough/SOB. Denies CP. CXR shows RLL pneumonia and ECG shows AF rate 125. Meds: ECASA 81, Metoprolol 50 bid, Metformin 500 tid Cases 69 yo 100 kg male, sweaty, diaphoretic c/o chest pain. AF present at rate of 150. Cardioversion not successful. Patient is deteriorating…what now?? Cases 70 yo male c/o SOB, CP, diaphoresis. No CAD hx. Has had HTN x many years and hx AF with previous stroke. Meds include Atenolol, water pill, and coumadin. ECG shows AF with rate of 120 and ST elevation inf leads. INR 1.4 70 yo male presents with typical Anginal pain with CAD hx. Has had HTN, MI and AF. Meds include Bblocker, Ace, Ecasa 81, Coumadin, Statin. Ecg shows AF with rate of 145 but no ischemic changes. INR 1.3 Note In absence of a reversible cause, AF is usually recurrent(75% with no antiarrythmic drugs) AF begets AF (electrical remodeling) ? ACE A persistent rapid rate can result in tachycardia induced cardiomyopathy Rate control should be assessed at rest and with exercise In patients with rapid ventricular rate with preexcitation over an accessory bypass tract (WPWS) administer IV procainamide or ibutilide or perform DC cardioversion if unstable (avoid B blockers ,Ca Blockers, adenosine, digoxin) THE END