ACEP 2018 Atrial Fibrillation v13 - prd-medweb-cdn.s3 ... · • Careful if hx of CHF, COPD, WPW....

9/28/2018

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ACEP 2018

Atrial Fibrillation Update 2018

Don’t Miss a BeatCorey M. Slovis, M.D.

Vanderbilt University Medical CenterMetro Nashville Fire DepartmentNashville International Airport

Nashville, TN

Atrial Fibrillation is Common

• # 1 sustained cardiac arrhythmia

• > 3,000,000 patients

• 1% of US population

• 9% of all those ≥ 80 yo

• AFib ED visits

Atrial Fibrillation5 Epidemiologic Facts

• Incidence

• Mortality

• Stroke Risk

• Heart Failure Risk

• CHA2DS2-VASc Importance2014

411,406

ED Visits for Atrial FibrillationAre Dramatically Increasing

JAHA 2018;Online August

537,801

30.7%

2007

X100

600

500

400

300

200

100

0

JAMA 2001;285:2370-75

Incidence of Atrial Fibrillation by Age Atrial Fibrillation Heart Failure

JAMA Network Open 2018;1:e180941

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Atrial Fibrillation Ischemic Strokes


Stroke in AFib and AflutterBy CHA2DS2-VASc


Atrial Fibrillation All Cause Mortality


There Are 5 Causes of Atrial Fibrillation

• Pericardium

• Myocardium

• Endocardium

• Pulmonary

• Hypersympathetic

Pericarditis

LVH, Myocarditis

Endocarditis, Valvular

PE, pulmonary hypertension

Cocaine, amphetamines, hyperthyroid, ETOH withdrawal, caffeine, beta agonists, fever, dehydration

What are the 5 steps in the treatment of ED patients who

present with either new AFib/Flutter or AFib with RVR?

Secure ABCs

5 Step ED Dx - Rx

Determine etiology

Beta Blocker vs Diltiazem for RVR

Establish stroke risk (CHA2DS2-VASc)

Cardiovert, Admit or D/C on meds

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Why is Atrial Fibrillation so dangerous?

Stroke Is The Biggest AF Risk

• 5% year if no anticoagulation

• 10% year if prior CVA or TIA

• Anticoagulation decreases CVA risk by at least 2/3

AFib = Stroke Risk

Atrial Fibrillation Equals an Increased Stroke Rate

• About 0.5-1% per year but can be higher

• 5% if no anticoagulation

• CHA2DS2-VASc – important determinant

• Silent cerebral ischemia by CT/MRI is 20-40%

• AF doubles risk of death from age 55 onward

You need to calculate another score:

CHA2DS2-VASc

Always Calculate the Patient’s ScoreCHA2DS2-VASc

• CHF (1)

• Hypertension (1)

• Age ≥ 75 (2)

• Age 65 – 74 (1)

• Diabetes Mellitus (1)

• Stroke/ TIA/Thromboembolic (2)

• Vascular (AMI, PVD, Aortic Plaques) (1)

• Sex Female (1)

Chest 2010;137:263-272

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0123456789

10111213141516

0

1.3

0 1 2 3 4 5 6 7 8 9

3.2 4.0

Stroke Risk and CHADS2 Score

9.8

6.7

15.2

2.2

6.7

9.6

JAMA 2001;285:2370-75

Which is best for patients: Rate or Rhythm Control

• Classic article, 4,060 pts, multicenter

• Average age 70 yo ± 9

• Rate controlled patients had less hospitalizations

• More adverse effects in the rhythm group

• Slightly more deaths too (p = ns; 0.08)

NEJM 2002;347:1825-37

In General: Rate Control is Superior to Rhythm Control

Annals of Emerg Med 2015;65:540-2

• Meta-analysis of 4 ED relevant studies

• 1,438 patients with new onset AF

• Rate control if older, chronic AF

• Rhythm > rate control if < 65 yo and healthy

ED Rate vs. Rhythm Control

Younger, healthier patients do better with therapy directed at keeping them

in sinus rhythm

Older, sicker patients do better with their AF rate controlled

Rhythm Control

Rate Control

Secure ABCs

5 Step ED Dx - Rx

Determine etiology




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There Are 5 Routine Tests for All New AF Patients

• CBC

• BMP

• Thyroid

• CXR

• Echocardiogram (sooner or later)

Consider Additional Tests

• BNP

• Troponin

• Exercise Testing

• TEE

R/O HF

R/O ACS

WPW, Inducible, ACS

Pre cardioversion ifAF > 48 hrs duration

A 67 year old woman presents with atrial fibrillation with rapid ventricular

response, HR between 140-160.

She has a history of HF, is very SOB, and sounds wet.

BP is 160/100


Is rate control for atrial fibrillation with RVR always the best strategy?

• 416 patients with AF

• All patients had “complex” AF

• Complex = an acute underlying illness

• 2 Canadian University affiliated EDs


• Shock requiring vasopressors

• Intubation or NIPPV

• Bradycardia requiring pacing or meds

• Stroke or embolic complication

• CPR or death

Major Complications

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0%

10%

20%

30%

40%

50% 40.7%

7.1%

Rate or Rhythm Control

Attempted

Major Adverse Complications Annals of Emerg Med 2015;65:511-22

33.6% absolute differenceRR=5.7

82% relative decrease

No rate or Rhythm Control

0%

10%

20%

30%

40%

50%

19.0%

44.5%

Effective Rate Control (> 20 BPM)Annals of Emerg Med 2015;65:511-22

Control Attempted(Elec, Dilt, BB)

No Attempt at Control(Crystalloid, Bronchodilator)

25.5% absolute differenceRR=2.3

Electrical cardioversion was only effective in 13.3 % of

these sick patients

AF Rate or Rhythm Control in Sick Patients

Take Homes

• Rarely effective

• Dangerous

• Focus on underlying disease before attempting to control rate or rhythm

Be aggressive with fluids, oxygenation, correcting electrolyte abnormalities before using antiarrhythmics

Beta blockers first line if spontaneous conversion does not occur

Mortality from 26.1% to 61.3% if pts stay in AFib

Crit Care Med 2016;20:373-82

Study is not about acute AFib in ED septic patients….do not try to convert septic pts in ED

A patient presents with likely PSVT –is 6 mg or 12 mg adenosine better ?

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Adenosine can kill patients with bypass tracks if: Wide and Irregular

Adenosine increases rapid bypass tract conduction and can result in very fast

refractory VFib

Wide complex Afib and Adenosine =

A rapid Vfib death

Don’t Use Adenosine

• Never give if wide and irregular

• Never give if rate < 150

• Never if only slows during vagal stim

• Careful if hx of AFib, Aflutter, MAT

• Careful if hx of CHF, COPD, WPW

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Rate Control in Stable PatientsAFib/AFlutter

Rate Control in AF with RVR• Calcium Channel Blockers

- Diltiazem 25 mg over 1-2 minMay to 35 mg over1-2 min if inadequate response after 5 min

• Beta Blockers- Metoprolol 5 mg IV q 5 min

up to 3 doses

- Esmolol 0.5 mg/kg over 1 min0.05 – 0.1 mg/kg/mintitrate to effect

European Heart 2013;34:1481-88; 1489-97

• The role of Digoxin in Atrial Fibrillation is controversial – it may increase mortality or be a marker for those who will do poorly regardless of its use

• In general – don’t be the one to start it

Acad Emerg Med 2018;in press August

• 450 pts, double-blind, placebo controlled

• 3 groups of pts from 3 Tunisian hospitals

• High dose vs Low dose vs Placebo

• MgSO4 9 grams vs 4.5 grams vs Placebo

• Given over 30 minutes

Is Magnesium effective for rate control in “Rapid” Atrial Fibrillation?

Measured effectiveness as HR < 90or rate lowering by > 20%


0%

10%

20%

30%

40%

50%

60%

70% 59.5%64.2%

EffectivenessHR < 90 or HR > 20%

9 Grams 4.5 Grams

43.6%

--


High Dose Mg Low Dose Mg Placebo

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This paper is not what it seems


• Essentially all patients got other rate control agents

• 45-50% received Digoxin

• 30% received Diltiazem

• 20% received Beta Blockade

Magnesium for Rate Control in AFTake Homes

• Adjunct? – maybe; Primary – NO

• 2.5 grams or 4.5 grams?

• 9 grams = lots of flushing (10-15%)

• Was very safe, < 1% hypotension

• Read this paper carefully

A 47 year old man presents with new onset atrial fibrillation.

He has well controlled hypertension and no history of AFib.

He felt his heart start to beat “funny” a few hours ago after running?

Can you safely convert rate stable Atrial Fibrillation and Flutter with medication

and/or cardioversion?

Safety of ED Cardioversion

• Safe if AF is acute

• Very safe if no thrombus

• Risk of CVA increases over time

• TEE required if onset unknown or > 48 hrs

• New evidence suggests maybe > 12 hrs

JAMA 2014;312:647-8

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0.00.10.20.30.40.50.60.70.80.91.01.11.2

< 12 12-24

0.3%

1.1%

OR=4.0

Risk of CVA S/P Cardioversion without anticoagulants0-48 hrs onset = 0.7% JAMA 2014;312:647-8

• 1,091 pts, mean age 63.9 years, 2010-2012

• 6 academic centers, 84.7% AFib, 15.3%Aflutter

• Clear history of onset ≤ 48 hrs

• Clear 7d history and no thrombus by TEE

Ann Emerg Med 2017;69:562-71

Is Canadian “aggressive care” with cardioversion effective and safe?

• Study excludes patients with other primary diagnoses or complaints including:

- ACS- CHF- Pneumonia- PE- Sepsis and/or SIRS criteria

Ann Emerg Med 2017;69:562-71

Rapid ED CardioversionInitial Therapy

• Rhythm control in 72.8%

- 39.1% electrocardioversion first

- 33.7% rhythm converting drug first

• Just rate control in 17.8%

- Metoprolol 65.1%

- Diltiazem 32.2%

Ann Emerg Med 2017;69:562-71

PharmacologicRhythm Control

• Procainamide used in 85%

• Converted 52.2% of patients

• Use 35-50 mg/min (up to 20 mg/kg)

• Can go faster - but careful!

Synchronized Cardioversion Effectiveness

• 90.0% successful electrical conversion

- Mean max energy 148 joules

- 1.4 mean shocks required

Ann Emerg Med 2017;69:562-71

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Electrical Conversion

• AHA recommends 120-200J biphasic

• 50-100J for flutter

• My bias: Use highest recommended: 200 or more

• AP or AL – your choice

• Switch positions if unsuccessful

Cardioversion for Fib/Flutter

Acad Emerg Med 2014; 21:717-26

• Meta-analysis 13 studies

• 836 AP pts vs 856 AL pts

• Trend toward AL > AP if biphasic

Neither A-P nor A-L Pad Placement is Superior

• 80.1% conversion to sinus rhythm

• 1 stroke and no deaths at 30 days(89 yo F on coumadin who had spontaneously converted in ED)

Ann Emerg Med 2017;69:562-71

Is Canadian “aggressive care” with cardioversion effective and safe?

Acad Emerg Med 2018;25:641-9

Can a simple to follow protocol allow more discharges in AFib/AFlut patients?

• 1,108 patients

• Retrospective before-after trial

• Academic community hospital

• Evaluated percent of pts admitted in 1 year

• Also 3 and 30 day returns

Study Assumptions and Hypothesis

• 20 yr AFib admits 60% in US

• No defined AHA/ACC discharge pathway

• Great care variations US vs Canada

• Future stroke is greatest risk

• AFib/AFlut rarely acutely life-threatening


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• Arranged follow up within 3d

• Seen then in cardiology clinic

• Anticoagulation held until then

• Discharged on BB or Calcium Blocker

• Metoprolol 50 BID

• Diltiazem 120-180 ext release


Current Common AFib PathwayMost EDs

• H/P, CXR, ECG, basic labs, thyroid

• IV rate control meds

• Cardiology consult

• Echo

• Admit

St. Joseph Murphy AlgorithmExclusions and Admit

• Underlying Acute Illness(sepsis, PE, etc.)

• Acute Coronary Syndrome

• Acute Heart Failure

• Syncope

• Hemodynamic instability


• 3,510 patients, 24 Canadian EDs

• 2,343 pts for derivation, 1,167 in validation

• 11 variables predict patients at higher risk

• Provides guidance on admission to hospital

Am Heart J 2018;203:85-92

Which Atrial Fibrillation patients are at highest risk for a poor outcome

High Risk AF Patients

“Major” “Minor”Cr > 2.26 COPD

+ Troponin Dementia

Furosemide required Cancer

HF Age

Not on anticoagulation HAS-BLED > 3

INR > 3

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• Synchronized cardioversion not focus

• Rate-control IV meds discouraged

• Not specifically stated by patientsalmost all < 48 hr onset of AFib/AFlut

• About ½ “low morbidity”

• ¼ HF Hx, ¼ CAD, 1/8 DM0

10

20

30

40

50

60

70

80 63.6%

BLS

Hospital Admit Rates

All Patients Low Acuity

80%

Pre Post Pre Post


16.1%P < 0.001

31.3%P < 0.001

67.4%

43.7%

NOTE

• Pharmacological conversions not attempted

• IV rate control discouraged

• 50 mg PO Metoprolol

• 120-180 mg PO Diltiazem ER

• D/C cardioversion not increased


Additional Findings

• Cardioversion rates pre : post:- 21.2% vs 17.2%

• 3 day ED return for any reason:- 1.19 vs 1.0%

• 30 day ED returns- 3.8% vs 3.0%

• 90% followed up in AFib clinic

• 10% went outside system


Simplified AFib Discharge PathwaysTake Homes

• Single center trial

• Very simple, very impressive

• < 48 hr not specifically cited

• stroke risk ?

• This protocol will be used

Do patients you see in new AFib need to be anticoagulated…?

How about if you can convert them?

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• 0

• 1

• 2

• 0

• NOAC or discuss

• NOAC or Warfarin

JAMA 2015; 314:291-2

CHA2DS2-VASc AgentNon-vitamin K anticoagulants now endorsed in ACC/AHA guidelines.

Check carefully for use/dosage in CRF, valvular disease, obese, and

s/p cardioversion

Non-Vitamin K AnticoagulantsNovel Oral AnticoagulantsDirect Oral Anticoagulants

• Apixaban

• Dabigatran

• Edoxaban

• Rivaroxaban

Eliquis anti-xa

Pradaxa direct antithrombin

Savaysa anti-xa

Xarelto anti-xa

Apixaban

Dabigatran

Edoxaban

Rivaroxaban

Eliquis anti-xa


Xarelto anti-xa

Savaysa anti-xa

Non-Vitamin K AnticoagulantsNovel Oral AnticoagulantsDirect Oral Anticoagulants

• Apixaban

• Dabigatran

• Edoxaban

• Rivaroxaban

Eliquis anti-xa


Savaysa anti-xa

Xarelto anti-xa

JACC 2018;72:471-2

• 110,636 Medicare database AF pts

• 9,147 developed new AF in ED

• 25% new AFib diagnosed in ED

• Average age 77, 63% female

How often do ED physicians prescribe anticoagulants for stroke prophylaxis in newly

diagnosed Atrial Fibrillation?

Results

• High stroke risk and low/int bleed risk not correlation with increase likelihood of Rx

• Almost 2/3 of Rxs: Warfarin

JACC 2018;72:471-2

Less than 1 in 5 prescribed anticoagulation

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• 76,354 pts

• Compared each non-vit K drug to Warfarin

• Apixaban lowered stroke risk 33% vs Warfarin

• Apixaban and dabigatran lowered GI bleed risk

• All decreased risk of intracranial bleeding

J Am Heart Assoc 2016;5:e003725

Are the non-vitamin K oral anticoagulants safer than Warfarin?

Warfarin use is decreasing and is becoming relegated to mainly those

patients with:

Mechanical Heart Valves

Mitral Stenosis

Chronic Renal FailureLancet 2014;383:955-62

Anticoagulation and ED Discharge

Annals Emerg Med 2013;62:557-65 Annals Emerg Med 2013;62:566-8

Annals Emerg Med 2015;65:1-12 Annals Emerg Med 2015;66:347-54

If you don’t discharge a patient on a non-vitamin K antagonist when

indicated, it can take weeks-months for it to be started…and allow a

preventable stroke to occur

• Two populations: CHADS2 ≥ 2 and CHA2DS2VASc ≥ 2

• 38.2% of 210,380 CHADS2 ≥ 2 got only ASA

• 40.2% of 294,642 CHA2DS2VASc ≥ 2 got only ASA

JACC 2016;67:2913-23

How often do we not follow current recommended anticoagulation guidelines for

high risk AFib patients?

• More than 1 in 3 high risk for stroke AF pts treated below the standard of care!

Non-vitamin K oral anticoagulants are here

Become expert in using one

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• 5,738 pts from the ORBIT-AF II Registry

• Routine lab evaluation not required with NOACs

• Considered safer than Warfarin

• Some patients require dosing modifications

JACC 2016;68:2597-604

Are we dosing non-vitamin K antagonists correctly?• 87% being dosed correctly

• 9.4% underdosed

• 3.4% overdosed

• Renal disease was # 1 cause of dosing errors

• More strokes, bleeds, AMIs & hospitalizations

Results JACC 2016;68:2597-604

Take HomesNon Vitamin K Oral Anticoagulants

NOACs

• 1 in 8 AF patients are dosed incorrectly

• Under and over dosing increases morbidity and mortality

• Do not discharge patients with renal impairment on a NOAC without working with an ED or hospital pharmacist and/or an AFib focused cardiologist


• EM, Card, EP, IM, APP, RN, Pharm D

• Provides Flow Chart

• Includes med and/or DC Cardioversion if possible

• Recommends use of Ibutilide or Flecainide

• D/C on NOAC if no contraindication

Clear onset < 48 hrsor

Adequately anticoagulated ≥ 4 weeksAcad Emerg Med 2018;25:1065-75

Cardioversion Recommendations

CHADS2VASc score ≥ 2


Anticoagulation Recommendations

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200 J A-P pad placement


Electrical ConversionAcad Emerg Med 2018;25:1065-75

Pharmacological Conversion• Pretreat with 2 grams MgSO4 over 30 min

• 1 gram Ibutilide over 10 min

• May repeat 10 min after 1st dose

• Monitor for Torsades x 4 hrs

• Do not use if:QTC > 450 msec; Hypo K; EF < 30%

Annal Emerg Med 2018;71:96-108

How effective and safe is Ibutilide for ED conversion of Atrial Fibrillation and Atrial Flutter?

• 361 pts, 21 community EDs, 2009-2015

• Recent onset AFib/Flutter

• 61 yo median age (53-71 IQR); QTc > 480: 30%

• Evaluated conversion rate and complications

Ibutilide

• Class III antiarrhythmic, K channel blockade

• Slowed repolarization with QTc

• Usual dose: 1 mg x 2, 10 minute interval

• VTACH and/or Torsade's up to 5% each

• Almost always within 45 min – 1 hr


ECG monitoring s/p Ibutilide is 4 hours


Highest Risk for Ibutilide(% in this study)

• Heart Failure patients (5%)

• Prolonged QTc (29.4% > 480 mg)

• Hypokalemia (3.1% < 3.5 meq)

• Hypomagnesemia (0.9% < 1.6 meq/L)


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Methods

• 69% received rate reducing meds

• Most received Diltiazem

• Half also received 1-2 grams MgSO4

• 2/3 pre-Ibutilide Cardiology consult


Results

• 44% conversion to NSR at 90 min

• 54.8% to NSR at 4 hrs

• 75% conversion for Atrial Flutter

• 91.8% electrical cardioversion s/p Ibutilide

• 0.6% VTach incidence – both s/p 2nd dose


IbutilideTake Homes

• Great pre cardioversion

• Not impressive alone

• Similar to procainamide

• Requires 4 hrs of monitoring

• Can be used if hypoK/hypomag **But give 2 grams MgSO4 pre-drug!

Summary

Secure ABCs

5 Step ED Dx - Rx

Determine etiology




Atrial Fibrillation is common

Summary

Stroke is high risk

Always calculate CHA2DS2-VASc score

Anticoagulate if indicated

2 = yes, 0 = no, 1 = yes or discuss

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Treat underlying conditions

Summary

Dilt or BB for rate control

Cardioversion can be safe < 12-48 hrs

Antiarrhythmics convert half

200 Joules biphasic works 90%

30 Day Mortality

Discharging Atrial FibrillationTake Homes

• As risks for mortality , we should be more cautious

• Although authors provide score, I recommend looking at patients and how many increased risk factors they have

• If any major risk factor present: Admit or ask Cardiology to discharge

• 49,737 pts ages 0-17, retrospective study

• Pediatric Health Information System Database

• 43,841 NSS vs 1,762 (4%) LR

• Most DKA “mild to moderate”

• Evaluated LOS and incidence of cerebral edema

Ped Emerg Care 2018 Aug;ePub ahead of print

Is LR superior to NSS in Pediatric DKA?

0%

1%

2%

3%

4%

5%

0.8%

Cerebral Edema

LR

3.6%

NSS


Study shows more than a 4x increase incidence of cerebral edema with NSS

vs LR (3.6% vs 0.8%)


However 5.9% of NSS had “severe” or “extreme” DKA vs only 1.6% treated

with LR or about 4x as many seriously ill patients at risk for cerebral edema

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ACEP 2018 Atrial Fibrillation v13 - prd-medweb-cdn.s3 ... · • Careful if hx of CHF, COPD, WPW....

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