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+ IMPROVING CARE THROUGH EVIDENCE GUIDELINES UPDATE | PRINT | SUBSCRIBE | WEBSITE Canadian CardiovascuPAGE Practice Guideline: 2 |2|Clinical PAGE lar Society Atrial FibrilBenign Paroxysmal lation Guidelines 2010: Positional Vertigo Management Of RecentOnset Atrial Fibrillation/ PAGE 3 | Practice Parameter: Flutter In the Emergency Therapies For Benign Department Paroxysmal Positional Canadian Journal of Vertigo (An Evidence-Based Cardiology Review): Report Of The Quality Standards Subcom2011OfACCF/AHA/HRS PAGE 6|mittee The American Focused Academy of Updates NeurologyIncor- CurrentParoxysmal Guidelines On Benign Positional Atrial Fibrillation The Externa Vertigo And AcuteInOtitis Emergency Department In The ED: Current Guidelines his issue of EM Practice Guidelines Update reviews 2 T I guidelines that focus on the management of atrial fibrilIn this issue(AF) of EM Guidelines Update, we(ED). review lation in Practice the emergency department AF2is the guidelines thatsustained address the diagnosis anddisturbance management of most common cardiac rhythm in adults. It paroxysmal positional vertigoand (BPPV) and 1 guideline on isbenign a risk factor for thromboembolism congestive heart failure the topicand of acute otitis symptoms externa (AOE). BPPV is the pain mostand common (CHF), it causes such as chest shortcause of vertigo, with a lifetime prevalence of 2.4%, and ness of breath. Prevalence increases with age, and itwhile is predicted porated Into The itthat is not per 5.6 se, itmillion is an important cause of patient bydangerous 2050, nearly people in the United States will ACC/AHA ESC 2006 discomfort and missed as well ascurrent falls, particularly the 1 PAGE 5 | Clinical Practice Guideline: be diagnosed with AF,work doubling the number ofincases. Guidelines For The elderly. The most common emergency department therapies Acute Otitis Externa Several key controversies exist in the management of AF,for includManagement Of Patients BPPV (antihistamines, anticholinergics, and sedatives) are not ing rhythm versus rate control, electric versus pharmacological With Atrial Fibrillation recommended byand specialists. rhythm control, if and when anticoagulation is indicated. Circulation Several key guidelines have been recently published to direct The second topic for review, AOE, is a prevalent and painful emergency clinicians in their care of patients with this most comcondition seen by emergency clinicians whose management can be mon arrhythmia. complicated by several common pitfalls. PAGE13 | Editorial Comment PAGE15 | References PAGE15 | CME Questions Editor’s Note: To read more about this publication and the background and methodologies for practice guideline development, go to: http://www.ebmedicine.net/introduction Practice Guideline Impact Practice Guideline Impact: • • Hemodynamically Vestibular suppressant medications the benzodiazepine, unstable patients of require immediate directanticholinergic, and antihistamine classes have a limited role current cardioversion. in the management of BPPV. • Hemodynamically stable patients with onset of AF < 48 hours undergo cardioversion withoutisanticoagulation. • may A particle repositioning maneuver the therapy of choice in • Ifthe AFmanagement duration is ≥ of 48BPPV hoursand or an unknown period ofintime, the should be performed the ED patient must from be assessed or arranged the ED. for the need for thromboembolism prophylaxis. • • The Systemic antibiotics should bemust avoided in most cases patient's risk of bleeding be assessed priorofto initiatdiffuse AOE. ing anticoagulation. • Only symptomatic patients or patients with insufficient rate control require hospital admission. November 2009 May 2012 Volume 1, Number Volume 4, Number 25 Editor-In-Chief Authors Reuben J. Strayer, MD Vishal Demla, MD Department of Emergency Medicine, Mount Sinai School of Medicine, New Assistant Professor of Emergency Medicine, York, NYSinai School of Medicine, New York, NY Mount Editor-In-Chief Editorial Reuben J. Board Strayer, MD Assistant Professor of Emergency Medicine, Mount Sinai School of Medicine, Andy Jagoda, MD, FACEP New York, NY Professor and Chair, Department of Emergency Medicine Mount Sinai School of Medicine, New York, NY Editorial Board Nicole C. Bouchard, MD, FRCPC Erik Kulstad, MD, MS Assistant Clinical Professor, Assistant SiteMedical Director; Center Director of Medical Research Director, Advocate Christ Toxicology, New York-Presbyterian Hospital, Columbia University Medical Department of Emergency Medicine, Oak Lawn, IL Center, New York, NY EddyJagoda, S. Lang, MDCM, Andy MD, FACEPCCFP (EM), CSPQ Professor and Chair, Department of Emergency Medicine, Mount Sinai School Associate Professor, McGill University, SMBD Jewish General of Medicine,Montreal, New York,Canada NY Hospital, Erik Kulstad, MD, MS Lewis S. Nelson, MD of Emergency Medicine, Advocate Christ Research Director, Department Director, Fellowship in Medical Toxicology, New York City Poison Medical Center, Oak Lawn, IL Control Associate Professor, Department of Emergency Eddy S.Center, Lang, MDCM, CCFP (EM), CSPQ Medicine, NYU Medical Center, New York, NY Professor, University of Senior Researcher, Alberta Health Services; Associate Gregory M. Press, MD, RDMS Calgary; Adjunct Professor, McGill University, Montreal, Quebec, Canada Lewis S. Nelson, MD Assistant Professor, Director of Emergency Ultrasound, Emergency Associate Professor of Emergency Medicine, New York University School of Ultrasound Fellowship Director, Department of Emergency Medicine, Medicine; Director, Fellowship in Medical Toxicology, New York City Poison University of Texas at Houston Medical School, Houston, TX Control Center, New York, NY Gregory Press, MD, Scott M.M.Silvers, MDRDMS Assistant Professor, Director of Emergency Ultrasound, Emergency Ultrasound Chair, Department of Emergency Medicine Fellowship Director, Department of Emergency Medicine, University of Texas at Mayo Clinic, Jacksonville, FL Houston Medical School, Houston, TX ScottS.Weingart, MD FACEP Maia Rutman, MD Assistant Professor, Department Emergency Medicine, Elmhurst Medical Director, Pediatric Emergency of Services, Dartmouth-Hitchcock Medical Center; Assistant of Pediatric Emergency Medicine, Hospital Center,Professor Mount Sinai School of Medicine, NewDartmouth York, NY Medical School, Lebanon, NH Scott Silvers,this MDactivity, see “Physician CME Information” on Prior toM. beginning Chair, Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL page 7. Scott Weingart, MD, FACEP Associate Professor, Director of the Division of Emergency Critical Care, Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY Editor’s Note: Introduction to a New Series EM Practice Guidelines Update is a new publication from EB Medicine that will help emergency department cliniResearch Editor cians G. stay current Phillip Blanc, MD, with MPH practice guidelines. To read more Department of Emergency Medicine, Mount Sinai School of Medicine, New about this publication and the background and methodYork, NY ologies for practice guideline development, http://www. ebmedicine.net/introduction Prior to beginning this activity, see “CME Information” on page 16. | print | SUBSCRIBE | WEBSITE Current Guidelines On Atrial Fibrillation In The Emergency Department Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Management Of Recent-Onset Atrial Fibrillation/Flutter In The Emergency Department2-5 Canadian Journal of Cardiology. 2011;27(1):38-46. Link: http://www.ccs.ca/guidelines/cc_library_e.aspx T had a connection with the presented content. Evidence and recommendations were classified according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.3 (http://www.onlinecjc.ca/article/S0828-282X(10)00004-8/fulltext) (See Tables 1 and 2.) This approach separates the quality of evidence from the strength of recommendations. Only recommendations pertinent to emergency clinicians are abstracted here. he Canadian Cardiovascular Society (CCS) convened a primary panel of experts to undertake a comprehensive review of current knowledge and management strategies in the field of AF and to develop an evidence-based set of recommendations on the diagnosis and management of patients with AF. The target is primary care physicians, emergency physicians, internists, and cardiologists. The working groups undertook a review of the English language literature, using Ovid MEDLINE® and Cochrane Library searches and a critical appraisal of the evidence, focusing predominantly on the results of randomized clinical trials and systematic reviews. In the absence of such data, recommendations were based on the results of large cohort studies or smaller clinical studies. Writing group disclosures were listed and revealed that most authors had an affiliation with a commercial organization that may have Table 2. GRADE Classifications, Factors Determining Strength of Evidence3 Factors Description Quality of evidence The higher the quality of evidence, the greater the probability that a strong recommendation is indicated; eg, strong recommendation that patients with AF at moderate to high risk of stroke be treated with oral anticoagulants. Difference between desirable and undesirable effects The greater the difference between desirable and undesirable effects, the greater the probability that a strong recommendation is indicated; eg, strong recommendation that patients with AF ≥ 48-hour duration receive oral anticoagulation therapy for at least 3 weeks prior to planned cardioversion and 4 weeks following. Table 1. GRADE Classifications, Quality Of Evidence3 Classification Evidence High Future research unlikely to change confidence in estimate of effect; eg, multiple well-designed, well-conducted clinical trials. Multiple populations evaluated. Data derived from multiple randomized controlled trials or meta-analyses. Moderate Further research likely to have an important impact on confidence in estimate of effect and may change the estimate; eg, limited clinical trials, inconsistency of results, or study limitations. Low Further research very likely to have a significant impact on the estimate of effect and is likely to change the estimate; eg, small number of clinical studies or cohort observations. Very low Values and preferences The greater the variation or uncertainty in values and preferences, the higher the probability that a conditional recommendation is indicated; eg, aspirin may be a reasonable alternative to oral anticoagulant therapy in patients at low risk of stroke. Cost The higher the cost, the lower the likelihood that a strong recommendation is indicated; eg, conditional recommendation for catheter ablation as first-line therapy for AF. Abbreviation: AF, atrial fibrillation. The estimate of effect is very uncertain; eg, case studies, consensus opinion. EM Practice Guidelines Update © 2012 2 www.ebmedicine.net • May 2012 | print | SUBSCRIBE | WEBSITE Current Guidelines On Atrial Fibrillation In The Emergency Department 3. Atrioventricular (AV) nodal blocking agents (digoxin, calcium channel blockers, beta-blockers, adenosine) are contraindicated (Strong Recommendation, Low-Quality Evidence). Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Management Of Recent-Onset Atrial Fibrillation And Flutter In The Emergency Department2 Link: http://www.onlinecjc.ca/article/S0828-282X(10)00015-2/fulltext Overall Approach 1. We recommend that in stable patients with recent-onset AF/ atrial flutter (AFL), a strategy of rate control or rhythm control could be selected (Strong Recommendation, High-Quality Evidence). 2. We recommend for patients with acute hemodynamic instability secondary to rapid recent-onset AF/AFL, immediate electrical conversion to sinus rhythm (Strong Recommendation, Low-Quality Evidence). Prevention Of Thromboembolism We recommend that hemodynamically stable patients with AF/AFL of ≥ 48 hours' or uncertain duration for whom a strategy of rhythm control has been selected should have rate control optimized and receive therapeutic oral anticoagulant (OAC) therapy (warfarin [international normalized ratio (INR) 2-3] or dabigatran) for 3 weeks before and at least 4 weeks postcardioversion. Following attempted cardioversion: 1. If AF/AFL persists or recurs or if symptoms suggest that the presenting AF/AFL has been recurrent, the patient should have antithrombotic therapy continued indefinitely (using either OAC or aspirin as appropriate). 2. If sinus rhythm is achieved and sustained for 4 weeks, the need for ongoing antithrombotic therapy should be determined based on the risk of stroke, and, in selected cases, expert consultation may be required (Strong Recommendation, Moderate-Quality Evidence). 3. We recommend that hemodynamically stable patients with AF/AFL of known duration < 48 hours for whom a strategy of rhythm control has been selected may generally undergo cardioversion without prior or subsequent anticoagulation. However, if the patient is at particularly high risk of stroke (eg, mechanical valve, rheumatic heart disease, recent stroke, or transient ischemic attack [TIA]), cardioversion should be delayed and the patient should receive OAC for 3 weeks before and at least 4 weeks postcardioversion. Rhythm Control In hemodynamically stable patients with AF/AFL of known duration < 48 hours in whom a strategy of rhythm control has been selected: 1. We recommend that rate-slowing agents alone are acceptable while awaiting spontaneous conversion (Strong Recommendation, Moderate-Quality Evidence). 2. We recommend that synchronized electrical cardioversion or pharmacologic cardioversion may be used when a decision is made to cardiovert patients in the ED (Strong Recommendation, ModerateQuality Evidence). 3. We suggest that antiarrhythmic drugs may be used to pretreat patients before electrical cardioversion in the ED in order to decrease early recurrence of AF and to enhance cardioversion efficacy (Conditional Recommendation, Low-Quality Evidence). Electrical Cardioversion 1. We recommend that electrical cardioversion may be conducted in the ED with 150-200 joules biphasic waveform as the initial energy setting (Strong Recommendation, Low-Quality Evidence). Disposition And Follow-Up 1. We recommend hospital admission for highly symptomatic patients with decompensated heart failure or myocardial ischemia (Strong Recommendation, Low-Quality Evidence). 2. We suggest limiting hospital admission to highly symptomatic patients in whom adequate rate control cannot be achieved (Conditional Recommendation, Low-Quality Evidence). 3. We suggest that after conversion to sinus rhythm has been achieved, whether antiarrhythmic drug therapy is indicated should be based on the estimated probability of recurrence and the symptoms during AF. Long-term therapy will need to be determined by Rapid Pre-excitation During Atrial Fibrillation We recommend, in patients with rapid ventricular pre-excitation during AF (Wolff-Parkinson-White syndrome): 1. Urgent electrical cardioversion if the patient is hemodynamically unstable (Strong Recommendation, Low-Quality Evidence). 2. Intravenous (IV) antiarrhythmic agents procainamide or ibutilide in stable patients (Strong Recommendation, Low-Quality Evidence). EM Practice Guidelines Update © 2012 3 www.ebmedicine.net • May 2012 | print | SUBSCRIBE | WEBSITE Current Guidelines On Atrial Fibrillation In The Emergency Department an appropriate outpatient consultation (Conditional Recommendation, Low-Quality Evidence). 3. We recommend that the goal of rhythm control therapy should be improvement in patient symptoms and clinical outcomes and not necessarily the elimination of all AF (Strong Recommendation, Moderate-Quality Evidence). Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Rate And Rhythm Management4 Link: http://www.onlinecjc.ca/article/S0828-282X(10)00002-4/fulltext Drugs For Heart Rate Control 1. We recommend beta-blockers or nondihydropyridine calcium channel blockers as initial therapy for rate control of AF or AFL in most patients without a past history of myocardial infarction or left ventricular dysfunction (Strong Recommendation, Moderate-Quality Evidence). 2. We suggest that digoxin not be used as initial therapy for active patients and be reserved for rate control in patients who are sedentary or who have left ventricular systolic dysfunction (Conditional Recommendation, Moderate-Quality Evidence). 3. We suggest that digoxin be added to therapy with beta-blockers or calcium channel blockers in patients whose heart rate remains uncontrolled (Conditional Recommendation, Moderate-Quality Evidence). 4. We suggest that dronedarone may be added for additional rate control in patients with uncontrolled ventricular rates despite therapy with beta-blockers, calcium channel blockers, or digoxin (Conditional Recommendation, Moderate-Quality Evidence). 5. We suggest that amiodarone for rate control should be reserved for exceptional cases in which other means are not feasible or are insufficient (Conditional Recommendation, Low-Quality Evidence). 6. We recommend beta-blockers as initial therapy for rate control of AF or AFL in patients with myocardial infarction or left ventricular systolic dysfunction (Strong Recommendation, High-Quality Evidence). Antiarrhythmic Drug Therapy To Maintain Sinus Rhythm 1. We recommend use of maintenance oral antiarrhythmic therapy as first-line therapy for patients with recurrent AF in whom long-term rhythm control is desired (Strong Recommendation, ModerateQuality Evidence). 2. We recommend that oral antiarrhythmic drug therapy should be avoided in patients with AF or AFL and advanced sinus or AV nodal disease unless the patient has a pacemaker or implantable defibrillator (Strong Recommendation, Low-Quality Evidence). 3. We recommend that an AV blocking agent should be used in patients with AF or AFL being treated with a class I antiarrhythmic drug (eg, propafenone or flecainide) in the absence of advanced AV nodal disease (Strong Recommendation, Low-Quality Evidence). Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Prevention Of Stroke And Systemic Thromboembolism In Atrial Fibrillation And Flutter5 Link: http://www.onlinecjc.ca/article/S0828-282X(10)00008-5/fulltext Assessing Risk 1. We recommend that all patients with AF or AFL (paroxysmal, persistent, or permanent) should be stratified using a predictive index for stroke (eg, CHADS2) and for the risk of bleeding (eg, HAS-BLED) and that most patients should receive antithrombotic therapy (Strong Recommendation, High-Quality Evidence). 2. We recommend that patients at very low risk of stroke (CHADS2 = 0) should receive aspirin (75-325 mg/day) (Strong Recommendation, High-Quality Evidence). 3. We recommend that patients at low risk of stroke (CHADS2 = 1) should receive OAC therapy (either warfarin [INR 2-3] or dabigatran) (Strong Recommendation, High-Quality Evidence). 4. We suggest, based on individual risk benefit considerations, that aspirin is a reasonable alternative for some (Conditional Recommendation, Moderate-Quality Evidence). Rhythm Control 1. We recommend the optimal treatment of precipitating or reversible predisposing conditions of AF prior to attempts to restore or maintain sinus rhythm (Strong Recommendation, Low-Quality Evidence). 2. We recommend a rhythm control strategy for patients with AF or AFL who remain symptomatic with rate-control therapy or in whom rate-control therapy is unlikely to control symptoms (Strong Recommendation, Moderate-Quality Evidence). EM Practice Guidelines Update © 2012 4 www.ebmedicine.net • May 2012 | print | SUBSCRIBE | WEBSITE Current Guidelines On Atrial Fibrillation In The Emergency Department mechanical valve, rheumatic heart disease, recent stroke, or TIA), the patient should receive IV unfractionated heparin (UFH) or lowmolecular-weight heparin (LMWH) before cardioversion, if possible, or immediately thereafter if even a brief delay is unacceptable, and then be converted to OAC for at least 4 weeks postcardioversion. 2. If the AF or AFL is ≥ 48 hours' or of uncertain duration, we suggest the patient receive IV UFH or LMWH before cardioversion if possible, or immediately thereafter if even a brief delay is unacceptable. Such a patient should then be converted to OAC for at least 4 weeks postcardioversion. 3. Following attempted cardioversion, the guidelines for subsequent antithrombotic therapy are identical to those for the management of hemodynamically stable patients undergoing cardioversion (Conditional Recommendation, Low-Quality Evidence). ■ Emergency Cardioversion We recommend that hemodynamically stable patients with AF or AFL of ≥ 48 hours' or uncertain duration for whom electrical or pharmacologic cardioversion is planned should receive therapeutic OAC therapy (warfarin [INR 2-3] or dabigatran) for 3 weeks before and at least 4 weeks postcardioversion. Following attempted cardioversion: 1. If AF or AFL persists or recurs or if symptoms suggest that the presenting AF or AFL has been recurrent, the patient should have antithrombotic therapy continued indefinitely (using either OAC or aspirin, as appropriate). 2. If sinus rhythm is achieved and sustained for 4 weeks, the need for ongoing antithrombotic therapy should be determined on the basis of the risk of stroke, and, in selected cases, expert consultation may be required (Strong Recommendation, Moderate-Quality Evidence). We recommend that hemodynamically stable patients with AF or AFL of known duration < 48 hours may undergo cardioversion without prior or subsequent anticoagulation. However, if the patient is at particularly high risk of stroke (eg, mechanical valve, rheumatic heart disease, recent stroke, or TIA), cardioversion should be delayed, and the patient should receive OAC for 3 weeks before and at least 4 weeks postcardioversion. Following attempted cardioversion, 1. If AF or AFL persists or recurs or if symptoms suggest that the presenting AF or AFL has been recurrent, antithrombotic therapy (OAC or aspirin, as appropriate) should be commenced and continued indefinitely. 2. If normal sinus rhythm is achieved and sustained for 4 weeks, the need for ongoing antithrombotic therapy should be determined on the basis of the risk of stroke according to CHADS2 score, and in selected cases expert consultation may be required (Strong Recommendation, Moderate-Quality Evidence). We suggest that hemodynamically unstable patients with AF or AFL who require emergency cardioversion be managed as follows: 1. If the AF or AFL is of known duration < 48 hours, the patient may generally undergo cardioversion without prior anticoagulation. However, if the patient is at particularly high risk of stroke (eg, EM Practice Guidelines Update © 2012 5 www.ebmedicine.net • May 2012 | print | SUBSCRIBE | WEBSITE Current Guidelines On Atrial Fibrillation In The Emergency Department 2011 ACCF/AHA/HRS Focused Updates Incorporated Into The ACC/AHA/ESC 2006 Guidelines For The Management Of Patients With Atrial Fibrillation: A Report Of The ACCF/AHA Task Force On Practice Guidelines6 Circulation. 2011;123:e269-e367. Link: http://circ.ahajournals.org/content/123/10/e269.full.pdf T were recused from voting on recommendations for which they had a relevant conflict. his is a focused update to the 2006 guidelines.6-9 The guidelines were created by a committee composed of members representing the American College of Cardiology (ACC), the American Heart Association (AHA), the European Society of Cardiology (ESC), the European Heart Rhythm Association (EHRA), and the Heart Rhythm Society (HRS). This document was reviewed by 2 official reviewers nominated by the ACC, 2 official reviewers nominated by the AHA, and 2 official reviewers nominated by the ESC, as well as by the American College of Cardiology Foundation (ACCF) Clinical Electrophysiology Committee, the AHA ECG and Arrhythmias Committee, the AHA Stroke Review Committee, the EHRA, the HRS, and numerous additional content reviewers nominated by the writing committee. The document was approved for publication by the governing bodies of the ACC, AHA, and ESC and officially endorsed by the EHRA and the HRS. The ACC/AHA/ESC Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation conducted a comprehensive review of the relevant literature from 2001 to 2006. Recommendations were sorted into 4 classes based on predefined categories representing their benefit-to-risk ratios (I, IIa, IIb, III). In addition, the level of evidence for each of these recommendations was evaluated for quality and graded based on predefined criteria (A, B, C). (See Table 3.) Only recommendations pertinent to emergency medicine are excerpted here. Section numbering has been retained from the original guidelines. Table 3. American Heart Association Classification Of Levels And Classes Of Evidence6 Levels of Evidence Literature searches were conducted in the PubMed/MEDLINE® database and the Cochrane Library (including the Cochrane Database of Systematic Reviews and the Cochrane Controlled Trials Registry). In an effort to respond promptly to new evidence, the ACCF/AHA Task Force on Practice Guidelines has created a “focused update” process to revise the existing guideline recommendations that are affected by evolving data or opinion. Evidence will be reviewed at least twice per year, and updates will be initiated on an as-needed basis. All authors disclosed conflicts of interest and relationships with industry; authors EM Practice Guidelines Update © 2012 Level A Multiple populations evaluated. Data derived from multiple randomized controlled trials or meta-analyses. Level B Limited populations evaluated. Data derived from a single randomized trial or nonrandomized studies. Level C Very limited populations evaluated; only consensus opinion of experts, case studies, or standard of care Classes of Evidence 6 Class I Benefit >>> Risk; procedure SHOULD be performed/administered Class IIa Benefit >> Risk; IT IS REASONABLE to perform procedure/administer treatment Class IIb Benefit ≥ Risk; procedure/treatment MAY BE CONSIDERED Class III No proven benefit/harmful to patients www.ebmedicine.net • May 2012 | print | SUBSCRIBE | WEBSITE Current Guidelines On Atrial Fibrillation In The Emergency Department Class III 1. Digitalis should not be used as the sole agent to control the rate of ventricular response in patients with paroxysmal AF. (Level of evidence: B) 3. In patients with decompensated HF and AF, IV administration of a nondihydropyridine calcium channel antagonist may exacerbate hemodynamic compromise and is not recommended. (Level of evidence: C) 4. IV administration of digitalis glycosides or nondihydropyridine calcium channel antagonists to patients with AF and pre-excitation syndrome may paradoxically accelerate the ventricular response and is not recommended. (Level of evidence: C) [Editor’s note: beta-blockers should also be avoided in this setting.] 8.1.3.1 Pharmacological Rate Control During Atrial Fibrillation Recommendations: Class I 2. In the absence of pre-excitation, IV administration of beta-blockers (esmolol, metoprolol, or propranolol) or nondihydropyridine calcium channel antagonists (verapamil, diltiazem) is recommended to slow the ventricular response to AF in the acute setting, exercising caution in patients with hypotension or heart failure (HF). (Level of evidence: B) 3. IV administration of digoxin or amiodarone is recommended to control the heart rate in patients with AF and HF who do not have an accessory pathway. (Level of evidence: B) 5. Digoxin is effective following oral administration to control the heart rate at rest in patients with AF and is indicated for patients with HF, LV dysfunction, or for sedentary individuals. (Level of evidence: C) 8.1.4 Preventing Thromboembolism Recommendations: Class I 1. Antithrombotic therapy to prevent thromboembolism is recommended for all patients with AF, except those with lone AF or contraindications. (Level of Evidence: A) 2. The selection of the antithrombotic agent should be based upon the absolute risks of stroke and bleeding and the relative risk and benefit for a given patient. (Level of Evidence: A) 3. For patients without mechanical heart valves at high risk of stroke, chronic oral anticoagulant therapy with a vitamin K antagonist is recommended in a dose adjusted to achieve the target intensity INR of 2.0 to 3.0, unless contraindicated. Factors associated with highest risk for stroke in patients with AF are prior thromboembolism (stroke, TIA, or systemic embolism) and rheumatic mitral stenosis. (Level of Evidence: A) 4. Anticoagulation with a vitamin K antagonist is recommended for patients with more than 1 moderate risk factor. Such factors include age 75 years or greater, hypertension, HF, impaired left ventricle systolic function (ejection fraction 35% or less or fractional shortening less than 25%), and diabetes mellitus. (Level of Evidence: A) 6. Aspirin, 81 to 325 mg daily, is recommended as an alternative to vitamin K antagonists in low-risk patients or in those with contraindications to oral anticoagulation. (Level of Evidence: A) Class IIa 1. A combination of digoxin and either a beta-blocker or a nondihydropyridine calcium channel antagonist is reasonable to control the heart rate both at rest and during exercise in patients with AF. The choice of medication should be individualized and the dose modulated to avoid bradycardia. (Level of evidence: B) 3. IV amiodarone can be useful to control the heart rate in patients with AF when other measures are unsuccessful or contraindicated. (Level of evidence: C) 4. When electrical cardioversion is not necessary in patients with AF and an accessory pathway, IV procainamide or ibutilide is a reasonable alternative. (Level of evidence: C) Class IIb 1. When the ventricular rate cannot be adequately controlled both at rest and during exercise in patients with AF using a beta-blocker, nondihydropyridine calcium channel antagonist, or digoxin, alone or in combination, amiodarone may be administered to control the heart rate. (Level of evidence: C) 2. IV procainamide, disopyramide, ibutilide, or amiodarone may be considered for hemodynamically stable patients with AF involving conduction over an accessory pathway. (Level of evidence: B) EM Practice Guidelines Update © 2012 7 www.ebmedicine.net • May 2012 | print | SUBSCRIBE | WEBSITE Current Guidelines On Atrial Fibrillation In The Emergency Department 2. When surgical procedures require interruption of oral anticoagulant therapy for longer than 1 week in high-risk patients, UFH may be administered or LMWH given by subcutaneous injection, although the efficacy of these alternatives in this situation is uncertain. (Level of Evidence: C) 4. In patients undergoing percutaneous coronary intervention, anticoagulation may be interrupted to prevent bleeding at the site of peripheral arterial puncture, but the vitamin K antagonist should be resumed as soon as possible after the procedure and the dose adjusted to achieve an INR in the therapeutic range. Aspirin may be given temporarily during the hiatus, but the maintenance regimen should then consist of the combination of clopidogrel, 75 mg daily, plus warfarin (INR 2.0 to 3.0). Clopidogrel should be given for a minimum of 1 month after implantation of a bare metal stent, at least 3 months for a sirolimus-eluting stent, at least 6 months for a paclitaxel-eluting stent, and 12 months or longer in selected patients, following which warfarin may be continued as monotherapy in the absence of a subsequent coronary event. When warfarin is given in combination with clopidogrel or low-dose aspirin, the dose intensity must be carefully regulated. (Level of Evidence: C) 7. For patients with AF who have mechanical heart valves, the target intensity of anticoagulation should be based on the type of prosthesis, maintaining an INR of at least 2.5. (Level of Evidence: B) 8. Antithrombotic therapy is recommended for patients with AFL as for those with AF. (Level of Evidence: C) Class IIa 1. For primary prevention of thromboembolism in patients with nonvalvular AF who have just 1 of the following validated risk factors, antithrombotic therapy with either aspirin or a vitamin K antagonist is reasonable, based upon an assessment of the risk of bleeding complications, ability to safely sustain adjusted chronic anticoagulation, and patient preferences: age ≥ 75 years (especially in female patients), hypertension, HF, impaired left ventricular function, or diabetes mellitus. (Level of Evidence: A) 2. For patients with nonvalvular AF who have 1 or more of the following less well-validated risk factors, antithrombotic therapy with either aspirin or a vitamin K antagonist is reasonable for prevention of thromboembolism: age 65 to 74 years, female gender, or coronary artery disease (CAD). The choice of agent should be based upon the risk of bleeding complications, ability to safely sustain adjusted chronic anticoagulation, and patient preferences. (Level of Evidence: B) 3. It is reasonable to select antithrombotic therapy using the same criteria irrespective of the pattern (ie, paroxysmal, persistent, or permanent) of AF. (Level of Evidence: B) 4. In patients with AF who do not have mechanical prosthetic heart valves, it is reasonable to interrupt anticoagulation for up to 1 week without substituting heparin for surgical or diagnostic procedures that carry a risk of bleeding. (Level of Evidence: C) Class III Long-term anticoagulation with a vitamin K antagonist is not recommended for primary prevention of stroke in patients below the age of 60 years without heart disease (lone AF) or any risk factors for thromboembolism. (Level of Evidence: C) 8.1.5 Cardioversion Of Atrial Fibrillation Recommendations For Pharmacological Cardioversion Of Atrial Fibrillation: Class I Administration of flecainide, dofetilide, propafenone, or ibutilide is recommended for pharmacological cardioversion of AF. (Level of Evidence: A) Class IIb 1. In patients 75 years of age and older at increased risk of bleeding but without frank contraindications to oral anticoagulant therapy, and in other patients with moderate risk factors for thromboembolism who are unable to safely tolerate anticoagulation at the standard intensity of INR 2.0 to 3.0, a lower INR target of 2.0 (range 1.6 to 2.5) may be considered for primary prevention of ischemic stroke and systemic embolism. (Level of Evidence: C) EM Practice Guidelines Update © 2012 Class IIa 1. Administration of amiodarone is a reasonable option for pharmacological cardioversion of AF. (Level of Evidence: A) 8 www.ebmedicine.net • May 2012 | print | SUBSCRIBE | WEBSITE Current Guidelines On Atrial Fibrillation In The Emergency Department 2. Patient preference is a reasonable consideration in the selection of infrequently repeated cardioversions for the management of symptomatic or recurrent AF. (Level of Evidence: C) 3. Administration of amiodarone can be beneficial on an outpatient basis in patients with paroxysmal or persistent AF when rapid restoration of sinus rhythm is not deemed necessary. (Level of Evidence: C) Class III 1. Frequent repetition of direct-current cardioversion is not recommended for patients who have relatively short periods of sinus rhythm between relapses of AF after multiple cardioversion procedures despite prophylactic antiarrhythmic drug therapy. (Level of Evidence: C) 2. Electrical cardioversion is contraindicated in patients with digitalis toxicity or hypokalemia. (Level of Evidence: C) Class IIb Administration of quinidine or procainamide might be considered for pharmacological cardioversion of AF, but the usefulness of these agents is not well established. (Level of Evidence: C) [Editor’s note: there are high-quality data attesting to the safety and efficacy of procainamide for pharmacologic cardioversion of AF.2] Class III 1. Digoxin and sotalol may be harmful when used for pharmacological cardioversion of AF and are not recommended. (Level of Evidence: A) 8.2.6 Pharmacological Enhancement Of Direct-Current Cardioversion Recommendations: Class IIa 1. Pretreatment with amiodarone, flecainide, ibutilide, propafenone, or sotalol can be useful to enhance the success of direct-current cardioversion and prevent recurrent AF. (Level of Evidence: B) 2. In patients who relapse to AF after successful cardioversion, it can be useful to repeat the procedure following prophylactic administration of antiarrhythmic medication. (Level of Evidence: C) 8.2 Direct-Current Cardioversion Of Atrial Fibrillation And Flutter Recommendations: Class I 1. When a rapid ventricular response does not respond promptly to pharmacological measures for patients with AF with ongoing myocardial ischemia, symptomatic hypotension, angina, or HF, immediate R-wave synchronized direct-current cardioversion is recommended. (Level of Evidence: C) 2. Immediate direct-current cardioversion is recommended for patients with AF involving pre-excitation when very rapid tachycardia or hemodynamic instability occurs. (Level of Evidence: B) 3. Cardioversion is recommended in patients without hemodynamic instability when symptoms of AF are unacceptable to the patient. In case of early relapse of AF after cardioversion, repeated direct-current cardioversion attempts may be made following administration of antiarrhythmic medication. (Level of Evidence: C) Class IIb 1. For patients with persistent AF, administration of beta-blockers, disopyramide, diltiazem, dofetilide, procainamide, or verapamil may be considered, although the efficacy of these agents to enhance the success of direct-current cardioversion or to prevent early recurrence of AF is uncertain. (Level of Evidence: C) 8.2.7 Prevention Of Thromboembolism In Patients With Atrial Fibrillation Undergoing Cardioversion Recommendations: Class I 1. For patients with AF of 48-hour duration or longer, or when the duration of AF is unknown, anticoagulation (INR 2.0 to 3.0) is recommended for at least 3 weeks prior to and 4 weeks after cardiover- Class IIa 1. Direct-current cardioversion can be useful to restore sinus rhythm as part of a long-term management strategy for patients with AF. (Level of Evidence: B) EM Practice Guidelines Update © 2012 9 www.ebmedicine.net • May 2012 | print | SUBSCRIBE | WEBSITE Current Guidelines On Atrial Fibrillation In The Emergency Department b. For patients in whom thrombus is identified by TEE, oral anticoagulation (INR 2.0 to 3.0) is reasonable for at least 3 weeks prior to and 4 weeks after restoration of sinus rhythm, and a longer period of anticoagulation may be appropriate even after apparently successful cardioversion, because the risk of thromboembolism often remains elevated in such cases. (Level of Evidence: C) 3. For patients with AFL undergoing cardioversion, anticoagulation can be beneficial according to the recommendations as for patients with AF. (Level of Evidence: C) sion, regardless of the method (electrical or pharmacological) used to restore sinus rhythm. (Level of Evidence: B) 2. For patients with AF of more than 48-hours' duration requiring immediate cardioversion because of hemodynamic instability, heparin should be administered concurrently (unless contraindicated) by an initial IV bolus injection followed by a continuous infusion in a dose adjusted to prolong the activated partial thromboplastin time to 1.5 to 2 times the reference control value. Thereafter, oral anticoagulation (INR 2.0 to 3.0) should be provided for at least 4 weeks, as for patients undergoing elective cardioversion. Limited data support subcutaneous administration of LMWH in this indication. (Level of Evidence: C) 3. For patients with AF of less than 48 hours' duration associated with hemodynamic instability (angina pectoris, myocardial infarction, shock, or pulmonary edema) cardioversion should be performed immediately without delay for prior initiation of anticoagulation. (Level of Evidence: C) 8.3 Maintenance Of Sinus Rhythm Recommendations: Class I Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended. (Level of Evidence: C) Class IIa 1. Pharmacological therapy can be useful in patients with AF to maintain sinus rhythm and prevent tachycardia-induced cardiomyopathy. (Level of Evidence: C) 2. Infrequent, well-tolerated recurrence of AF is reasonable as a successful outcome of antiarrhythmic drug therapy. (Level of Evidence: C) Class IIa 1. During the first 48 hours after onset of AF, the need for anticoagulation before and after cardioversion may be based on the patient’s risk of thromboembolism. (Level of Evidence: C) 2. As an alternative to anticoagulation prior to cardioversion of AF, it is reasonable to perform transesophageal echocardiography (TEE) in search of thrombus in the left atrium or left atrium appendage. (Level of Evidence: B) a. For patients with no identifiable thrombus, cardioversion is reasonable immediately after anticoagulation with UFH (eg, initiate by IV bolus injection and an infusion continued at a dose adjusted to prolong the activated partial thromboplastin time to 1.5 to 2 times the control value until oral anticoagulation has been established with a vitamin K antagonist (eg, warfarin), as evidenced by an INR ≥ 2.0). (Level of Evidence: B) Thereafter, oral anticoagulation (INR 2.0 to 3.0) is reasonable for a total anticoagulation period of at least 4 weeks, as for patients undergoing elective cardioversion. (Level of Evidence: B) Limited data are available to support the subcutaneous administration of a LMWH in this indication. (Level of Evidence: C) EM Practice Guidelines Update © 2012 Class III 1. Antiarrhythmic therapy with a particular drug is not recommended for maintenance of sinus rhythm in patients with AF who have welldefined risk factors for proarrhythmia with that agent. (Level of Evidence: A) 2. Pharmacological therapy is not recommended for maintenance of sinus rhythm in patients with advanced sinus node disease or AV node dysfunction unless they have a functioning electronic cardiac pacemaker. (Level of Evidence: C) 10 www.ebmedicine.net • May 2012 | print | SUBSCRIBE | WEBSITE Current Guidelines On Atrial Fibrillation In The Emergency Department 8.4.3 Wolff-Parkinson-White Pre-excitation Syndromes Recommendations: Class I 2. Immediate direct-current cardioversion is recommended to prevent ventricular fibrillation in patients with a short anterograde bypass tract refractory period in whom AF occurs with a rapid ventricular response associated with hemodynamic instability. (Level of Evidence: B) 3. IV procainamide or ibutilide is recommended to restore sinus rhythm in patients with Wolff-Parkinson-White (WPW) syndromes in whom AF occurs without hemodynamic instability in association with a wide QRS complex on the electrocardiogram (ECG) (greater than or equal to 120-ms duration) or with a rapid pre-excited ventricular response. (Level of Evidence: C) 8.4.2 Acute Myocardial Infarction Recommendations: Class I 1. Direct-current cardioversion is recommended for patients with severe hemodynamic compromise or intractable ischemia or when adequate rate control cannot be achieved with pharmacological agents in patients with acute myocardial infarction and AF. (Level of Evidence: C) 2. IV administration of amiodarone is recommended to slow a rapid ventricular response to AF and improve left ventricular (LV) function in patients with acute myocardial infarction. (Level of Evidence: C) 3. IV beta-blockers and nondihydropyridine calcium antagonists are recommended to slow a rapid ventricular response to AF in patients with acute myocardial infarction who do not display clinical LV dysfunction, bronchospasm, or atrioventricular block. (Level of Evidence: C) 4. For patients with AF and acute myocardial infarction, administration of UFH by either continuous IV infusion or intermittent subcutaneous injection is recommended in a dose sufficient to prolong the activated partial thromboplastin time to 1.5 to 2.0 times the control value, unless contraindications to anticoagulation exist. (Level of Evidence: C) Class IIa IV flecainide or direct-current cardioversion is reasonable when very rapid ventricular rates occur in patients with AF involving conduction over an accessory pathway. (Level of Evidence: B) Class IIb It may be reasonable to administer IV quinidine, procainamide, disopyramide, ibutilide, or amiodarone to hemodynamically stable patients with AF involving conduction over an accessory pathway. (Level of Evidence: B) Class IIa IV administration of digitalis is reasonable to slow a rapid ventricular response and improve LV function in patients with acute myocardial infarction and AF associated with severe LV dysfunction and heart failure. (Level of Evidence: C) Class III IV administration of digitalis glycosides or nondihydropyridine calcium channel antagonists is not recommended in patients with WPW syndromes who have pre-excited ventricular activation during AF. (Level of Evidence: B) Class III The administration of class IC antiarrhythmic drugs is not recommended in patients with AF in the setting of acute myocardial infarction. (Level of Evidence: C) EM Practice Guidelines Update © 2012 11 www.ebmedicine.net • May 2012 | print | SUBSCRIBE | WEBSITE Current Guidelines On Atrial Fibrillation In The Emergency Department 8.4.4 Hyperthyroidism Recommendations: Class I 1. Administration of a beta-blocker is recommended to control the rate of ventricular response in patients with AF complicating thyrotoxicosis, unless contraindicated. (Level of Evidence: B) 2. In circumstances when a beta-blocker cannot be used, administration of a nondihydropyridine calcium channel antagonist (diltiazem or verapamil) is recommended to control the ventricular rate in patients with AF and thyrotoxicosis. (Level of Evidence: B) 3. In patients with AF associated with thyrotoxicosis, oral anticoagulation (INR 2.0 to 3.0) is recommended to prevent thromboembolism, as recommended for AF patients with other risk factors for stroke. (Level of Evidence: C) 4. Once a euthyroid state is restored, recommendations for antithrombotic prophylaxis are the same as for patients without hyperthyroidism. (Level of Evidence: C) 8.4.7 Pulmonary Diseases Recommendations: Class I 1. Correction of hypoxemia and acidosis is the recommended primary therapeutic measure for patients who develop AF during an acute pulmonary illness or exacerbation of chronic pulmonary disease. (Level of Evidence: C) 2. A nondihydropyridine calcium channel antagonist (diltiazem or verapamil) is recommended to control the ventricular rate in patients with obstructive pulmonary disease who develop AF. (Level of Evidence: C) 3. Direct-current cardioversion should be attempted in patients with pulmonary disease who become hemodynamically unstable as a consequence of AF. (Level of Evidence: C) Class III 1. Theophylline and beta-adrenergic agonist agents are not recommended in patients with bronchospastic lung disease who develop AF. (Level of Evidence: C) 2. Beta-blockers, sotalol, propafenone, and adenosine are not recommended in patients with obstructive lung disease who develop AF. (Level of Evidence: C) ■ 8.4.5 Pregnancy Recommendations: Class I 1. Digoxin, a beta-blocker, or a nondihydropyridine calcium channel antagonist is recommended to control the rate of ventricular response in pregnant patients with AF. (Level of Evidence: C) 2. Direct-current cardioversion is recommended in pregnant patients who become hemodynamically unstable due to AF. (Level of Evidence: C) 3. Protection against thromboembolism is recommended throughout pregnancy for all patients with AF (except those with lone AF and/ or low thromboembolic risk). Therapy (anticoagulant or aspirin) should be chosen according to the stage of pregnancy. (Level of Evidence: C) EM Practice Guidelines Update © 2012 12 www.ebmedicine.net • May 2012 | print | SUBSCRIBE | WEBSITE Current Guidelines On Atrial Fibrillation In The Emergency Department Editorial Comment Unstable Patients According to AHA/CCS/ESC/JCS, unstable patients (hypotension, heart failure, ischemic chest pain, altered mentation) not responding to pharmacotherapy should receive immediate R-wave synchronized direct-current cardioversion. Biphasic waveform is preferred for its lower energy requirement and greater success rates. Initial electrical doses should be 150 to 200 J for biphasic devices in order to increase likelihood of initial success and limit the cumulative dose from multiple attempts. These recommendations also apply to patients who are pregnant or have pulmonary disease, cardiomyopathy, or thyrotoxicosis. Both the AHA and CCS recommend that in unstable patients with AF of > 48 hours' (or unknown) duration requiring prompt cardioversion, heparin should be administered concurrently with bolus followed by infusion to achieve prothrombin time (PTT) 2x reference control, with OAC started thereafter. Pharmacological Rate Control Of Atrial Fibrillation In The Absence Of Pre-excitation Syndrome Rate-slowing agents such as beta-blockers or nondihydropyridine calcium channel antagonists are recommended for rate control of stable patients with AF or AFL. The CCS recommends beta-blockers as the initial agent in patient with myocardial infarction. If the patient has concomitant HF, digoxin or amiodarone is recommended. Digoxin can be given in combination with a calcium channel antagonist or betablocker; digoxin monotherapy is not recommended. If these agents fail to adequately control rate, amiodarone can be administered. This recommendation is similar across all societies except CCS, which recommends dronedarone instead of amiodarone when additional rate control is needed due to the ATHENA trial, which demonstrated that drondedarone was associated with reduced hospitalizations and cardiac mortality. Electrical cardioversion is not as effective at converting AF to normal sinus rhythm as it is with other arrhythmias. Although electrical cardioversion is the recommended first-line therapy in the unstable patient, emergency clinicians should be prepared for failure of this modality and be prepared with other strategies, which may include vasopressors in combination with AV nodal blocking agents, calcium in combination with calcium channel blockers, amiodarone, and magnesium. Preventing Thromboembolism For patients with AF/AFL of an unknown period of time or > 48 hours, antithrombotic therapy to prevent thromboembolism is recommended. The selection of antithrombotic agent is based on risk of stroke using CHADS2 (cardiac failure, hypertension, age, diabetes, and prior stroke); the ESC/CCS recommends an expanded acronym CHA2DS2VASc (congestive heart failure, hypertension, age > 75 years, diabetes, stroke, vascular disease, age 65-74, and female sex). Scoring is similar to CHADS2. Anticoagulation should be continued at least 3 weeks before and at least 4 weeks postcardioversion. Rate Versus Rhythm Control The decision regarding rate versus rhythm control is controversial. There is no evidence showing mortality benefit or decreased risk of thromboembolism using rhythm control over rate control.4 The decision should be based on onset of symptoms, severity of symptoms, comorbidities, results of past treatments (if applicable), and physician comfort and preference. The more confidently the onset of symptoms can be established to be < 48 hours, and the younger and more active the patient, the stronger is the indication for primary rhythm control over rate control. EM Practice Guidelines Update © 2012 For patients with AF duration < 48 hours, CCS generally recommends cardioversion without prior or subsequent anticoagulation unless at significant risk, ie, mechanical valve, rheumatic heart disease, recent stroke, or TIA. The AHA has similar recommendations. Editorial Comment continued on page 14 >> 13 www.ebmedicine.net • May 2012 | print | SUBSCRIBE | WEBSITE Current Guidelines On Atrial Fibrillation In The Emergency Department Agents For Thromboembolism Based on risk score, either a Vitamin K antagonist or aspirin can be used. CCS and ESC describe the use of newer agents for OAC, including dabigatran. CCS updated its guideline, giving dabigatran a Class I recommendation as an alternative to warfarin in patients who do not have a prosthetic heart valve, hemodynamically significant valve disease, severe renal failure (creatinine clearance < 15 mL/min), or advanced liver disease (impaired baseline clotting function). Wolf-Parkinson-White Pre-excitation Syndromes If hemodynamically unstable, direct-current cardioversion is recommended. IV procainamide or ibutilide is recommended for cardioversion in patients with WPW syndromes who have AF without hemodynamic instability, associated with wide QRS complex (> 120 ms) or rapid ventricular response. AV nodal blocking agents such as digoxin, beta-blockers, adenosine, or calcium channel antagonists are contraindicated, as these agents will increase atrial conduction through the accessory pathway, which, without the dromotropic effect of the AV node, will conduct to ventricles at unstainably high rates and potentially cause degeneration into ventricular fibrillation. Risk Of Bleeding An assessment of bleeding risk should be made prior to starting anticoagulation. ESC/CCS discussed a newly derived risk score using a cohort of European patients with AF called HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly (> 65 years of age), and use of drugs/alcohol) where a score > 3 indicated high risk, and caution is needed when administering warfarin or aspirin. Disposition Disposition from the ED is only discussed in CCS guidelines. CCS recommends that only symptomatic patients or patients with insufficient rate control be admitted. Otherwise, patients can be discharged in 6 to 12 hours with urgent cardiology follow-up. While this recommendation is primarily informed by a single trial10 and must be adapted to individual practice environments, this practice has the potential to reduce resource utilization in many American centers which routinely admit all patients with new AF. ■ Pharmacological Conversion Of Atrial Fibrillation In Absence Of Pre-excitation Syndrome Propafenone or flecainide (Class I antiarrhythmic) are recommended for cardioversion in the absence of structural heart disease/AV nodal disease; as mentioned earlier, procainamide is also well-supported in this setting. Amiodarone should be considered if structural disease is present. This distinction is not discussed in AHA guidelines, but is recommended by the ESC/CCS. Direct-Current Cardioversion Antiarrythmic drugs may be used to pretreat patients in order to decrease recurrence of AF and enhance cardioversion efficacy. If normal sinus rhythm is achieved, the need for OAC should be determined using aforementioned risk scores for thromboembolism and early consultant follow-up should be arranged. Electrical cardioversion is contraindicated in patients with digoxin toxicity or hypokalemia. Refer to the previous section on unstable patients for further comments on direct-current cardioversion. EM Practice Guidelines Update © 2012 14 www.ebmedicine.net • May 2012 | print | SUBSCRIBE | WEBSITE Current Guidelines On Atrial Fibrillation In The Emergency Department References CME Questions 1. Khoo CW, Lip GY. Burden of atrial fibrillation. Curr Med Res Opin. 2009;25:1261-1263. (Editorial commentary) 2. Steill IG, Macle L, CCS Atrial Fibrillation Guidelines Committee. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: management of recent-onset atrial fibrillation and flutter in the emergency department. Can J Cardiol. 2011;27(1):38-46. (Clinical guidelines) To take the CME test, visit: www.ebmedicine.net/CME 1. Immediate electrical cardioversion is most appropriate for which of the following patients presenting with rapid AF? a. 91-year-old man with improved symptoms after IV diltiazem b. 42-year-old woman with spontaneous conversion to normal sinus rhythm c. 68-year-old woman with unstable vital signs d. 53-year-old man with rate control achieved after IV metoprolol 3. Gillis AM, Skanes AC, CCS Atrial Fibrillation Guidelines Committee. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: implementing GRADE and achieving consensus. Can J Cardiol. 2011;27(1):27-30. (Clinical guidelines) 4. Gillis AM, Verma A, Talajic M, et al. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: rate and rhythm management. Can J Cardiol. 2011;27(1):47-59. (Clinical guidelines) 2. Which of the following is indicated prior to initiating cardioversion in a hemodynamically stable patient with AF of > 48 hours’ duration? a. Rate control b. Anticoagulation for 3 weeks c. INR of 2 to 3 d. All of the above e. None of the above 5. Cairns JA, Connolly S, McMurtry S, et al. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: prevention of stroke and systemic thromboembolism in atrial fibrillation and flutter. Can J Cardiol. 2011;27:74-90. (Clinical guidelines) 6. Fuster V, Ryden LE, Cannom DS, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;123(10):e269-e367. (Clinical guidelines) 3. A 51-year-old man with no prior cardiac disease presents with rapid AF. His blood pressure is stable and he is asymptomatic. There is no accessory pathway indicated on ECG. Which of the following medications should be administered first in order to control the patient's rate? a. Amiodarone c. Procainamide b. Ibutilide d. Verapamil 7. European Heart Rhythm Association; European Association for Cardio-Thoracic Surgery, Camm AJ, et al. Guidelines for the management of atrial fibrillation. Eur Heart J. 2010;31(19):2369-2429. (Clinical guidelines) Erratum in Eur Heart J. 2011;32(9):1172. 8. JCS Joint Working Group. Guidelines for pharmacotherapy of atrial fibrillation (JCS 2008): digest version. Circ J. 2010;74(11): 2479-2500. (Clinical guidelines) 4. After multiple failed attempts at rate-controlling a patient's AF, a strategy to convert the patient's rhythm by pharmacological cardioversion is considered. Which of the following medications is most appropriate to administer in order to achieve conversion to sinus rhythm? a. Digoxin c. Dofetilide b. Diltiazem d. Dronedarone 9. 2011 Writing Group Members, Wann LS, Curtis AB, et al. 2011 ACCF/AHA/ HRS Focused Update on the management of patients with atrial fibrillation (updating the 2006 guideline): a report of the American College of Cardiology Foundation/American Association Task Force on Practice Guidelines. Circulation. 2011;123(1):104-123. (Clinical guidelines) 10. Stiell IG, Clement CM, Symington C, et al. Emergency department use of intravenous procainamide for patients with acute atrial fibrillation or flutter. Acad Emerg Med. 2007;14(12):1158-1164. (Cohort study, 341 patients) EM Practice Guidelines Update © 2012 15 www.ebmedicine.net • May 2012 | print | SUBSCRIBE | WEBSITE Current Guidelines On Atrial Fibrillation In The Emergency Department CME information for EM Practice Guidelines Update To take the CME test, visit: www.ebmedicine.net/cme To write a letter to the editor, email Reuben Strayer, MD, Editor-In-Chief, at: [email protected] Date of Original Release: May 1, 2012. Date of most recent review: April 10, 2012. Termination date: May 1, 2015. EM Practice Guidelines Update (ISSN Online: 1949-8314) is published monthly Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. (12 times per year) by EB Medicine Credit Designation: EB Medicine designates this enduring material for a maximum of 2 AMA PRA Category 1 Credits™. 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CEO and Publisher: Stephanie Williford Managing Editor: Dorothy Whisenhunt Goals: Upon completion of this article, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence, (2) cost-effectively diagnose and treat the most critical ED presentations, and (3) describe the most common medicolegal pitfalls for each topic covered. Managing Editor and CME Director: Jennifer Pai Director of Member Services: Liz Alvarez Objectives: Upon completion of this article, you should be able to: (1) decide when electrical cardioversion is appropriate in patients with AF, (2) choose appropriate medications for pharmacological cardioversion of AF, (3) chooose appropriate medications for rate control of AF, and (4) assess risk of thromboembolism and need for anticoagulation in AF. 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Years Subscribe Subscribe to to Emergency Emergency Medicine Medicine Practice Practice and and you’ll you’ll receive receive EM EM Practice Practice Guidelines Guidelines Update Update at at no no additional additional charge! charge! Plus, Plus, you you receive receive all all the the benefits benefits of of Emergency Emergency Medicine Medicine Practice: Practice: • • Achief-complaintfocus:Everyissuestartswithapatientcomplaint—justlikeyourdailypractice.You’reguidedstep-by-step A chief-complaint focus: Every issue starts with a patient complaint — just like your daily practice. You’re guided step-by-step inreachingthediagnosis—oftenthemostchallengingpartofyourjob. in reaching the diagnosis — often the most challenging part of your job. • • Anevidence-basedmedicineapproach:Thedegreeofacceptanceandscientificvalidityofeachrecommendationisassessed An evidence-based medicine approach: The degree of acceptance and scientific validity of each recommendation is assessed basedonstrengthofevidence. based on strength of evidence. • Diagnosisandtreatmentrecommendationssolidlybasedinthecurrentliterature. • Diagnosis and treatment recommendations solidly based in the current literature. 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Medium (RBCs and you 1, 2012 tubewhich pondebeen ) from atic 1 to tube 4. Method shows4,some tap, tube Discussofgeneral ringathis, participation:: Print and online ting the diagnostic traum but how 1 to tube and you atic the clearin Print or online principle can you labtap, 4, and buttohow think g the ED. calls diagnthe s of acute answer you be sure? can osislab say calls think evaluati Prior SAH form be is of SAH. there to After Justitas sure? 5. Identifyto beginnin manageand on say there is may Just xanth youhave ment in common g this activity, as you After are ochrom should callingxanthochrom see “Physici Informapitfalls youcalling ponde You tion” oninthe do for ED urgicafor neuro the diagnos ia. You make ia.are ring make CME surgic back page. thethis, is ofan ED to treatin the neuros al consuthe diagno SAH. Date of original l consultation this patiento treat this sis ofelse patient? , what elseltation , what release: July Date of most SAH. t? 1, 2009 should recent you do in the Editor-in-Ch ief Andy Jagoda, Editor-in-Chie MD, FACEP f Professo Andy Jagoda, r and Chair,MD, Departm of Emergen FACEP Professor cy Medicine and Vice-Chaent Sinai School , Mount Academic ir of Affairs, Departme of Medicine Director,ofMount ; Medicalnt Emergency Sinai Medicine Sinai School York, NY Hospital,, Mount of Medicine New Director, Mount ; Medical Editorial Sinai Hospital, York, Chattano oga, TN Professor Michael , UT College A. Gibbs, of Medicine Charles V. Pollack, MD, Chief,Chattano , FACEP Jr., MA, MD, Departmoga, TN FACEP Charles V. Pollack, Jr., Michael A. ent of Emergen Medicine cy , Maine Chairma FACEP MA, MD, Gibbs, Medical MD,Center, n, Departm Chief, Portland FACEP Departme ent , ME Chairman Emergen nt of Emergen , Departme of cy Medicine Medicine Termination review: April 27, 2009 date: July 1, 2012 Medium: Prior to beginni Print and online ng this activity, see “Physic Information” ian CME on page 27. University Medical Center, University Nashville , TN Medical Center, Nashville Internationa Steven A. , Hospital, Jenny Walker, Godwin, University Pennsylv Board Center, NY International l Editors , Pennsylvania Hospital, ME MD, FACEP NewAssistan MD, Health William J. Universityof Pennsylv Assistan ania Jenny System, Walker, MD, MPH, MSW t Professo Peter Camero Editors Brady, MD Philadelp of Pennsylvania Steven Editori Health System, r and Emergen MPH, MSW Medicine Assistantt Professo A. Godwin, hia, n, MD al Board Professo Peter Family Residenc Professorr; Division Cameron Chair, r of Emergen Medicine MD, FACEPcy Michael S. Radeos,Philadelphia,PA ania Assistant Emergen William y Director, ; Division Chief, , MD Universit Michael S. Professor and Medicine J. Brady,cy Medicine ofFamily cy Medicine Chair, Medicine,, Departm MD, MPH PA Commun y of Florida Assistan entChief, Monash Emergen Radeos, and Emergen MD Medicine Departme t Professo Vice Chair Professor HSC, of Community and cy Medicine , Universit Jacksonv Assistant Residenc Preventiv Emergen cy Medicine nte Monash MPH Medicine r ofMD, of Emergen of ille, FL ity and Preventiv Emergen , Hospital, y Director, Professor Melbourn cy Medicine University y; Alfred University Medicine and cy Medicine , Weill Medicine,, Mount cy of Emergen ; Alfred Hospital, Medicine Sinai Medical of Florida Medical , Universit Melbourn e, Australia of Virginia e Center, Mount Sinai Gregory Cornell , Weill cy HSC, e, Australia Jacksonv y School of Vice Chair of MedicalCollege Emergen Universit L. Henry, Center, New York, NY Medical Amin Antoine Cornell ille, MD, Collegeof Medicine, cy Medicine Charlotte New York, FL FACEP y, New York, University Amin Antoine Kazzi, MD, NY , University CEO, of sville, Medical , New York,NY. of Ron Robert L. Virginia VASchool Gregory Associat Kazzi, Ron M. FAAEM NY. Rogers, MD, Robert L. M. Walls, Henry, MD, MD, FAAEM Assessment,L. Practice Associate e Professo of Medicine Walls, MD Risk Peter DeBlieux Charlotte Professo Rogers, FAAEM, FACP CEO, Medical Professor r and FACEP Chair, Departm , sville, VA Inc.; Clinical Professor andMD Vice , MD FAAEM, FACP MD,FACEP, FACEP, Chair, Departm Chair, Departme of Emergen PracticeProfesso r and Chair, Vice Professo ent and of Assessm of Emergen Assistan Risk Peter cyent, Medicine, r ofDeBlieux of Emergen Department Medicine nt of Emergen ent Emergency Medicine Clinical, Medicine Assistant t Professo Medicine of Michigan Inc.; , Universit r Universit LSU Health cy Medicine Brigham MD and Professo cy cy , University r of of Emergen Medicine Professo of California Irvine; American , AnncyArbor,Clinical Professor y and Women’s , r ofEmergen Science Medicine Women’s Hospital ,,Brigham ofy California Emergen Irvine; , The r of Clinical cy MI , Universit American Universit DirectorLSU Center; , The Hospital,,Harvard cy Medical of Michigan Medicine , , Universit Medical School, Lebanon y yofof of Emergen University y, Beirut, Harvard Health Science Medicine, John M. Maryland Howell, MD, Lebanon , Ann Arbor, University Maryland School School, Boston, , Beirut, Boston, cy Medicine School Services ofof Director Medicine Center; FACEPMI Clinical Baltimor MA John , Universi Scott Medicine Baltimore MA of Professo Scott M. e, , Weingar Emergen Hugo Peralta, MD Howell, , ty Hospital , MD Weingart, Hugo Orleans, r of MD, cy ,Medicine t, MD Services Peralta, MD Emergen Medicine MD FACEP Clinical New MD LA Assistan , Universit cy Alfred Assistantt Professo , George Professor Alfred Chairofof Emergen Chair Sacchet y Hospital, Sacchett Professo r of Washing of Emergen Emergency cy Medicine ti, MD, Wyatt W.Orleans, LA Medicine ton cy r of Emergen i, MD, NewUniversit Medicine, Emergen y, Washing Assistan FACEP , George Services, Assistant FACEP Hospital Italiano, Services, Decker, MD Hospital , Elmhurs cy Elmhurstt Hospital cy t Clinical ton,Washington Clinical of Academi Italiano, Buenos University Chair Wyatt Center, Hospital Center, Mount Professo Professor Buenos Departm , WashingtDC;Direc W. Decker, Departme and Associat c Affairs, tor Argentina Argentina Mount Sinai r, , Aires, Aires, ent nt Beston, Sinai School Inc, Inova of Academic MD of of DC;Director Thomas Emergency Emergen Practices Chair and e Professo Emergen Medicine Schoolofof Medicine Thomas Jefferson Fairfax Affairs, cy Medicine r of cy Medicine , Associate Medicine, ,, New New York, Hospital, Jefferson University Maarten Best Inc, Inova Maarten Church, York, NY Practices Philadelp , Resea , MayoProfessor CollegeEmergen Falls NY Simons, University, , Philadelp VA Simons, Fairfax Hospital, cy Medicine Clinic of , of Medicine Research MD, MD, Church, hia,hia, Emergen PhD rch Editor Emergen PhD , Mayo Clinic PAPA College Falls , Rocheste Editorss cycy Medicine of Medicine Medicine Francis M. r, MN Keith A. Marill,VA Scott Silvers, Scott Director, Residenc , Rocheste Director, Residenc Silvers, MD, MD Fesmire, Keith A. Marill, OLVG Nicholas y y MD, FACEP Francis OLVG Assistant Nicholas r, MN Hospital, MD, FACEP Director, Medical Director, Genes, MD, FACEP Hospital, M. Fesmire, Amsterda Medical Professor,MD Genes, Amsterdm, Heart-St Assistant Director, Departm MD, PhD Chief Resident, MD, FACEP Emergen The Department am, Departme roke Center, Chief Netherlan The Emergen Professor ErlangerDirector, Netherla Resident, MountPhD cy Medicine Emergen dsnds , Departmeof MedicalHeart-Str Emergenc Medicine, entntofof Emergency Mount Sinai cy cy Erlanger , Massach Center, General Medicine Center;oke nt Emergen y Jacksonv Mayo of Sinai Medicine Professo Medical Medicine Hospital, Assistant usetts Clinic, Jacksonv ille, FL , Mayo Clinic, cy Medicine Residenc r, UT College Center; General Hospital, New York, Harvard, Massach ille, FL Assistant School, Residency, New Medical usetts of Medicine NY Boston, MA Harvard York, NY y, School, Corey M. Medical Corey , Boston, MA Slovis, MD, Lisa Jacobso Accreditation: M. Slovis, Accredi FACP, FACEP Lisa Jacobso Professo n, MD tation: This This activity FACP, FACEP Mount Sinai n, Professor r andMD, (ACCME Chair, MD of Emergen Departme Chief Resident and Chair, activity has has been planned ) through (ACCME) of Medicine Emergency School cy Medicine of Emergen Departmentnt the sponsors been planned through , Mount and impleme , of , Vanderbi cy Medicine Sinai School Medicine,Medicine hip Thomas, Thomas, Dr. the sponsor Edlow, New implementednted in accordan Medicine Dr. York, NYEmergenResidenc , Vanderb lt Residenc and ship of EBof EB and y, ilt ce with the Medicin discussed Edlow, Dr. Bunney, their related in accorda y, New York, cy Medicine parties e. EB. EB Medicine is accredite Essentials Dr. Little, nce with in this educatio educatio Medicin NY nal presenta and their report no and Standard significa d by the e isntaccredit the Essentia nal presenta tion.related ACCME to financialed ls and Comme parties by the ACCME tion. Dr. Goldste Standardss of the Accredit interest provide rcial Support report no or other relations ofg the to provide continuin Council significa in has received : This Accreditation medical issuent hip with continui ation Councilfor Continuing of financia Emergen consulti the manufac ng medical educatio l interest n for physicia cy for Continu Medical Educatio or other turer(s) educatio Practice did ng fees from GenenteMedicine Practice ing Medical of any ncommer relations n for physicians. Faculty did not hip with the not receive ch ns. FacultyDisclosuEducatio re: any commer and CSL Behring. receive manufac cial product( any s) discusse Disclos Dr. n Commercial commerturer(s) cial support cial support. of any commer d inure: thisDr. Suppor . 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