EmergencyKT: Atrial Fibrillation

Transcription

1 EmergencyKT: Atrial Fibrillation A fib 1 on ECG: Work up Consider: CBC, EPI, Troponin, BNP, ETOH, TSH/Free T4, Ca, Mg, Phos, LFTs, Urine toxicology, CXR, NPO except medications If ICD or pacer: call Device rep for interrogation & continue pathway: ensure EP fellow on call Is contacted, either by device rep or by paging: 2513 weekdays 8am-5pm or pm-8am and weekends/holidays If patient non-compliant with home meds restart home PO regimen Device Reps: Medtronic St Jude Boston Medical/Guidant Biotronik Outpatient Electrophysiology Follow-up Established UC EP Clinic patients: Call Terri Back at leave message about patient s visit to ED Patient needs new outpatient EP follow-up: Call Lee Chao at & leave message to establish new appointment Clinically or Hemodynamically stable? -Synchronized Cardioversion 2 CCU Service -Consider push dose pressors if patient SBP< Observe for 3-6 hours then discharge home on 81 mg ASA PO daily Established diagnosis of A fib with recent ablation for A fib within last 3 months? Therapeutic on Coumadin 8 (See definition Page 4) -Start Diltiazem 0.25mg/kg IV, max 20 mg over 2 min, then 5-15 mg/hr IV -Procedural sedation 6 & Synchronized Cardioversion 2 -Page 1111 to inform fellow of patient in ED -If EP clinic patient, call Terri Back at in EP clinic to inform about patient visit to ED or call Lee Chao at to establish new EP follow-up Patient converts to sinus rhythm? Age < 65 AND CHADS 2 Score 19 0 AND Cardiac disease ruled out on stress test, cath or echo Within 2 years? Duration of A fib 9 absolutely known to be less than h by history? -Rate control with Diltiazem 0.25mg/kg IV, max 20 mg over 2 min, then 5-15 mg/ hr IV A Page 2 Duration possibly between hours? -M F 8am-4pm: Page 6000 Cardiology Fellow to request TEE with Cardioversion -If after hours, or test unavailable, follow arrow below Patient converts to sinus rhythm? B Page 2 -Observe for 3-6 hours then discharge home -If EP clinic patient, call Terri Back at in EP clinic to inform about patient visit to ED or call Lee Chao at to establish new EP follow-up

2 EmergencyKT: Atrial Fibrillation Page 2 A B Patient safe for discharge home with Cardiology follow up unless patient requires work up for alternative chief complaint Age > 65 AND CHADS 2 Score 19 0 AND Cardiac disease ruled out on stress test, cath or echo within 2 years? Therapeutic on coumadin 8 (See definition page 4) Rate Controlled 10? (Either with meds or at baseline) -Amiodarone 150 mg IV over 10 min. -Then 1 mg/min IV for work up of secondary causes and further rate control -Start Diltiazem 0.25mg/kg IV, max 20 mg over 2 min, then 5-15 mg/hr IV Rate Controlled 10? (Either with meds or at baseline) for work up of secondary causes History Of CHF 12? C Page 3 -If clinical concern for acute decompensated heart failure: PND, orthopnea, crackles, JVD, peripheral or pre-sacral edema, then also treat for Acute decompensated heart failure: (See CPQE CHF guideline) and -Page fellow at 6000 if 8 am 5pm to facilitate consideration of early TEE Therapeutic on coumadin 8 (See definition page 4) Rate > 100 bpm? -Amiodarone 150 mg IV over 10 min; then 1 mg/ min IV Patient in acute decompensated heart failure? -Digoxin 0.25 mg IV Q2h up to max 1.5 mg total (Use with caution in acute or chronic renal failure) 13 -Digoxin 0.25 mg IV Q2h up to max 1.5 mg total or If Digoxin contraindicated may consider: -Metoprolol 2.5-5mg IV over 2 min repeat up to 3 doses Q 5 min (Hold metoprolol if Systolic BP <90)

3 EmergencyKT: Atrial Fibrillation Page 3 C -Metroprolol 2.5-5mg IV over 2 min repeat up to 3 doses Q 5 min (Avoid metoprolol with active exacerbation of asthma or COPD) CAD or Rate> 100 Valvular Disease 3 Bpm? unless therapeutic on coumadin 8 unless therapeutic on coumadin 8 - Avoid metoprolol with active exacerbation of asthma or COPD: alternative rate control: Diltiazem 0.25 mg/kg/iv, max 20 mg over 2 min, then 5-15 mg/hr IV Consider other underlying causes of A fib such as stress from: -ETOH -Thyroid disease -Post-operative Acute Asthma or COPD 15 Exacerbation? -Diltiazem 0.25 mg/kg IV, max 20 mg over 2 min, then 5-15 mg/hr IV -Diltiazem 0.25 mg/kg/iv max 20 mg over 2 min then 5-15 mg/hr IV or -Metroprolol 2.5-5mg IV over 2 min repeat up to 3 doses Q 5 min (Metoprolol preferred if any concern for hyperthyroidism as underlying cause for A fib) if not therapeutic on coumadin

4 Discharge Instructions Emergency Department Atrial Fibrillation You were treated in the Emergency Department at University Hospital for Atrial Fibrillation. Atrial fibrillation is an abnormal heart rhythm, where the upper chambers of the heart are beating too quickly and are creating an irregular heart rhythm. If untreated, the side effects of this irregular heart beat can be life threatening. Because blood is not being pumped normally through the heart, blood clots can form and can cause a stroke, which is a blood clot in your brain. This abnormal heart beat can also weaken the muscles of your heart, and lead to heart failure. Symptoms you may experience during this irregular heart rhythm include chest pain, shortness of breath or heart pounding quickly in the chest. 1. You will need to follow up with a Cardiologist as soon as possible. 2. You have been given a Cardiology Appointment on:, 20 at at this location:. 3. Return to the Emergency Department, or call you Cardiologist or Primary Care Doctor if you experience any chest pain, shortness of breath, or if you feel your heart pounding in your chest or beating too quickly. 4. You will need to take 81 mg Aspirin daily to protect your heart make sure you do not miss any doses.

5 EmergencyKT: Atrial Fibrillation Algorithm: Definitions 1 Atrial fibrillation: Replacement of P waves by rapid oscillations or fibrillatory waves that vary in amplitude, shape, and timing, associated with an irregular, frequently rapid ventricular response when atrioventricular (AV) conduction is intact 2 Synchronized Cardioversion: Patient is pre-treated with analgesia, such as fentanyl, & sedation, such as versed or propofol; Defibrillator is placed in synchronized mode shock with J initially with pads placed antero-posteriorly and at least 10cm from pacer/aicd device location 3 Cardiac disease: Patient has cardiac diagnosis such as: CAD, ischemic heart disease, inflammatory heart disease, cardiomyopathy, valvular disease or hypertensive heart disease 4 Pulmonary disease: Patient has pulmonary diagnosis such as: inflammatory, obstructive or restrictive disease, cancer, pleural cavity disease or pulmonary vascular abnormality 5 Thyroid disease: Patient has known thyroid abnormality such as hyper- or hypo-function, cancer or goiter 6 Procedural sedation: Consider use of Versed 0.1 mg/kg Q 5 minutes to effect + Fentanyl 1-3 mcg/kg to effect or Propofol mg/ kg to effect. If performing TEE/cardioversion, ED attending to run sedation while Cardiology fellow/attending/echo tech team runs TEE in SRU. 7 Longstanding or permanent A fib: Patient in Atrial fibrillation for > 1 year with history of contraindicated or failed cardioversion 8 Therapeutic on coumadin: Patient on coumadin with INR > 2 in ED and once monthly INR>2 as outpatient for last 3 months or once weekly INR>2 as outpatient for last 4 weeks; if patient on Pradaxa/dabigatran, TEE recommended before cardioversion as therapeutic monitoring guidelines not yet established. 9 Duration of A fib: If unknown, assume duration is > 24 hours 10 Rate controlled: Patient HR is between , either naturally or due to rate-control medication 11 Cards f/u: See separate CPQE tab regarding outpatient resources for follow up and EP lab referral 12 History of CHF: known diagnosis or noted systolic or diastolic dysfuntion on documented echocardiogram 13 Acute or chronic renal failure: Patient with known chronic renal failure or with Cr>1.2 in ED note patients in acute or chronic renal failure may still be loaded with digoxin, but patient will need monitoring of Creatinine and digoxin levels for medication adjustment during admission. 14 ETOH abuse: patient with reported or previously documented history of alcohol dependence or abuse 15 Acute asthma or COPD exacerbation: patient with reported or previously documented history of obstructive lung disease, asthma, COPD, emphysema or chronic bronchitis, now presenting with acute respiratory symptoms such as wheezing, cough or shortness of breath. 16 Thyrotoxicosis: patient with elevated T4 or low TSH in ED or symptoms concerning for thyroid storm such as hypertension, tachycardia, fever, diaphoresis, vomiting or diarrhea 17 Patient is discharged home with follow up appointment with Hoxworth Cardiology Clinic which is made by Emergency Physician prior to discharge by calling Patient must fill out appropriate Financial Aid paperwork prior to that appointment. 18 Push Dose Pressor: Phenylephrine Mix 1 ml of phenylephrine (10mg/ml) in 100ml bag of normal saline to form solution of 100mcg/ml. Dose 0.5-2ml every 2-5 minutes as needed. Onset 1 minute, duration 20 minutes. 19 CHADS 2 Score: History of Prior AIS/TIA 2 points; Age > 75 1 point; Diabetes 1 point; Hypertension 1 point; Heart failure 1 point.

6 EmergencyKT Atrial Fibrillation Algorithm: References 2011 ACCF/AHA/HRS Focused Updates Incorporated in the ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation. Journal of American College of Cardiology. 2011; 57(11). Wyse DG et al. A comparison of rate control and rhythm control in patients with atrial fibrillation (AFFIRM). N Engl J Med Dec 5; 347(23): Payne RM. Management of arrhythmias in patients with severe lung disease. Clin Pulm Med. 1994;1:232. Bahn et al. Hyperthyroidism and other causes of thyrotoxicosis: Management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists Kuhlkamp V, Schirdewan A, Stangl K, et al. Use of metoprolol CR/XL to maintain sinus rhythm after conversion from persistent atrial fibrillation: a randomized, double-blind, placebo-controlled study. J Am Coll Cardiol. 2000;36: Segal JB, McNamara RL, Miller MR, et al. The evidence regarding the drugs used for ventricular rate control. J Fam Pract. 2000;49: Roberts SA, Diaz C, lan PE, et al. Effectiveness and costs of digoxin treatment for atrial fibrillation and flutter. Am J Cardiol. 1993;72: Intravenous diltiazem for the treatment of patients with atrial fibrillation or flutter and moderate to severe congestive heart failure Tamariz LJ, Bass EB. Pharmacological rate control of atrial fibrillation. Cardiol Clin. 2004;22: Van Gelder et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibirllation. N Engl J Medicine 2002 Dec 5;347(23): Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD; Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. N Engl J Med Dec 5;347(23): Kister JP et al. The Effect of Low-Dose Warfarin on the Risk of Stroke in Patients with nrheumatic Atrial Fibrillation: The Boston Area Anticoagulation Trial for Atrial Fibrillation. N Engl J Med 1990; 323: Khan IA, Mehta NJ, Gowda RM. Amiodarone for pharmacological cardioversion of recent-onset atrial fibrillation. Int J Cardiol. 2003;89: Barrett et al. A cllinical prediction model to estimate risk for 30-day adverse events in Emergency Department patients with symptomatic Atrial fibrillation. Ann Emerg Med 2011 Jan;57(1):1-12 Scheuermeyer FX, Grafstein E, Stenstrom R, et al. Thirty-day outcome of emergency department patients undergoing electrical cardioverison for atrial fibrillation or flutter. Acad Emerg Med 2010;17: Stiell IG, Clement CM, Perry JJ, et al. Association of the Ottowa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CJEM 2010;12: Jacoby et al. Synchronized emergency department cardioversion of atrial dysrhythmias saves time, money and resources. The Journal of Emergency Medicine 2005;28,1:27-30 Burton et al. Electrical cardioversion of emergency department patients with atrial fibrillation. Annals of Emergency Medicine 2004; 44(1):20-30 Michael et al. Cardioversion of Paroxysmal Atrial Fibrillation in the Emergency Department. Annals of Emergency Medicine 1999; 33(4): Wozakowska-Kaplon B, Janion M, et al. Efficacy of biphasic shock for transthoracic cardioversion of persistent atrial fibrillation: can we predict energy requirements? Pacing Clin Electrophysiol. 2004;27:764 8.