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1 ED Management of Recent Onset tat Atrial Fibrillation and Flutter (RAFF) Canadian Cardiovascular Society Guidelines 2010 CAEP St John s 2011

2 Ian Stiell MD MSc FRCPC Professor and Chair, Dept of Emergency Medicine, U of Ottawa Distinguished Professor and University Health Research Chair, U of Ottawa Senior Scientist, Ottawa Hospital Research Institute Disclosures Site PI Vernakalant studies funded by Astellas Unrestricted grant Boehringer Ingelheim (Dabigatran) Peer reviewed grants NIH, CIHR, HSFC

3 RAFF Recent Onset taf or AFL Symptomatic, recent onset episodes of AF/AFL where cardioversion is an option First detected or recurrent episode (paroxysmal) not permanent (chronic) Onset is less than 48 hours (or less than 7 days if anticoagulated) 2 schools of thought for treatment: Conservative rate control: control rate, anticoagulate, t delayed or no cardioversion Aggressive rhythm hth control: convert with drugs or electricity

4 RAFF in the ED: Overview Case Study, Quizzes What are we Doing in Canadian EDs? 2011 Guidelines Take home Messages Feel free to ask questions

5 Atrial Fibrillation Case Study

6 Atrial Fibrillation Case Study 52 yr oldmale presents with sudden onset of palpitations 6 hours before Feels slightly weak but no chest pain or dyspnea No prior history of arrhythmia or other cardiac disease Generally well, no meds HR 140, BP 160/95, T 37, O2 Sat 97%

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8 Atrial Fibrillation How would you manage this case in your ED? Case Study a) control rate and send home on coumadin b) control rate and refer to cardiology c) attempt cardioversion with drugs but not with DC shock d) attempt cardioversion i with ihdrugs first and with DC shock, if necessary e) attempt cardioversion with DC shock first

9 Quiz: RAFF in the ED Atrial flutter with 2 : 1 conduction and isolated premature ventricular contraction

10 Quiz: RAFF in the ED Atrial flutter with 2 : 1 conduction Lead II helps identify flutter waves

11 Quiz: RAFF in the ED Atrial flutter with 1 : 1 conduction Rare and can be mistaken for ventricular tachycardia

12 Quiz: RAFF in the ED Atrial fibrillation with classical Ashman phenomenon series of beats N t l h t l bf b tl d t d Note long short cycle before aberrantly conducted impulses

13 Quiz: RAFF in the ED Multifocal atrial tachycardia Note that although the rhythm is irregular, at least three distinct t P wave morphologies are present

14 RAFF in the ED: Overview Case Study, Quizzes What are we Doing in Canadian EDs? 2011 Guidelines Take home Messages Feel free to ask questions

15 Annals of Emerg Med January 2011

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17 ED Treatment and Inter hospital Variation

18 ED Treatment and Inter hospital Variation

19 % Attempted Cardioversion by Hospital

20 ED Treatment and Inter hospital Variation

21 RAFF Management in the ED: Rhythm or Rate Control? Annals Emerg Med Jan 2011

22 References/Guidelines for RAFF AHA/ACC/ESC Guidelines JACC 2006/2011 ED only mentioned once in 98 pages AFFIRM Trial New Engl J Med 2002 Does not apply to RAFF in the ED AF CHF Trial New Engl J Med 2008 Not tfor RAFF patients t in the ED Rosen 7 th Edition 2009 RAFF < 72 hours, rate control first is recommended d Cardioversion may be undertaken, often in consultation with a cardiologist CCS Guidelines Can J Card Feb 2011 Best tfrom ED perspective

23 Can J Emerg Med 2010

24 Patient Characteristics (N = 660) Atrial Fibrillation (N=628) Mean age Range Male (%) 55% Duration in hours 8.9 Presenting symptoms Palpitations 78% Chest Pain 12% Multiple visits 50% Heartrate rate onarrival arrival, mean 113 Range Previous cardioversion 68% Electrical 37% Procainamide 49% Atrial Flutter (N=32) 63 22% %

25 IV Medications Used in ED IV Rate Control Metoprolol Diltiazem Atrial Atrial Fibrillation Flutter (N=628) (N=32) 39% 26% 15% 47% IV Rhythm Control Procainamide id Attempted 100% 100% Successful 60% 28%

26 Electrical Cardioversion and Discharge Atrial Fibrillation ill i (n=628) Atrial Flutter (n=32) Electrical Cardioversion Attempted Successful 36% 91% 63% 100% Disposition Discharged Home 97% 94% Discharged Home in NSR 94% 88%

27 Adverse Events for 660 Patient Visits (%) Adverse events (%) Hypotension (SBP < 100) Bradycardia (HR < 60) AV block Ventricular tachycardia Atrial tachycardia Syncope Torsades de Pointes Stroke Death Admitted (%) Relapse within 7 days (%) A Fib (N=628) A Flutter (N=32)

28 Median Lengths of Time in Hours from ED Arrival to Discharge Hou urs All Patients (N=660) Chemical Electrical l Conversion Conversion (N=385) (N=243)

29 Chemical Conversion Rates: Rate Control vs No Rate Control 100 P 0.01 Conve ersion Rate (%) % 64.1% 0 Rate Control (N=246) No Rate Control (N=382)

30 Ottawa Aggressive Protocol Large cohort of patients High rate of discharging patients in NSR: 94% of AAF 88% of AAFL Low rate of adverse events, none serious Rapid disposition especially if converted with medication and if rate control not used Limitations: Retrospective review No prospective follow up Patients selected by attending physicians

31 RAFF in the ED: Overview Case Study, Quizzes What are we Doing in Canadian EDs? 2011 CCS Guidelines Take home Messages Feel free to ask questions

32 Atrial Fibrillation Guidelines Update Leadership. Knowledge. Community.

33 Atrial Fibrillation Guidelines

34 RAFF Management in the ED: Rhythm or Rate Control? Atrial Fibrillation Guidelines

35 RAFF Management in the ED: Assessment Stable? Ischemia Hypotension CHF Onset clear? < 48 hours < 48 hours Severity of symptoms Previous episodes? A i l Anticoagulated? INR

36 RAFF Management in the ED: Unstable Patients Rare for RAFF to present as unstable patient Beware of patients with ih CHF, ischemia, hypotension who actually have permanent AF Atrial Fibrillation Guidelines

37 Strategy of rhythm-control for recent-onset AF/AFL Known duration < 48 h (and not high risk patients 1 ) Duration > 48 h or unknown or high risk patients 1 Hemodynamically unstable Hemodynamically stable Failed CV Rate control Urgent electrical cardioversion 2 Pharmacological or electrical cardioversion 2 Therapeutic OAC for 3 weeks before cardioversion TEE guided cardioversion (OAC initiated with heparin bridging) 3 Successful CV Antithrombotic therapy Antithrombotic therapy In general, no prior or subsequent anticoagulation is required. OAC continued for 4 consecutive weeks. If AF/AFL persists or recurs or if AF/AFL has been recurrent, If AF/AFL persists or recurs or if AF/AFL has been recurrent, antithrombotic therapy as appropriate (per CHADS 2 score) antithrombotic therapy as appropriate (CHADS 2 score) should be continued indefinitely. should be initiated and continued indefinitely. Early follow up should be arrange to review ongoing Early follow up should be arranged to review antithrombotic strategy. antithrombotic strategy. 1 Patients at particularly high risk of stroke (e.g. mechanical valve, rheumatic heart disease, recent stroke/tia) J biphasic waveform preferred 3 Heparin must be initiated and continued until a therapeutic level of oral anticoagulation has been established.

38 RAFF Management in the ED: Onset < 48 Hours Atrial Fibrillation Guidelines

39 RAFF Management in the ED: Rate Control Drugs Heart rate targets prior to discharge: 100 BPM at rest 110 BPM during walk test Atrial Fibrillation Guidelines

40 RAFF Management in the ED: Rhythm Control Drugs Atrial Fibrillation Guidelines

41 AcadEmerg Md Med 2007

42 Conversion Rates with Procainamide 340 consecutive RAFF patients treated with procainamide, 1 gram IV infusion over 60 minutes rsion Rate Conve 100% 50% 0% 50.4% 52.2% 28.0% All Visitsit (N=341) Atrial Fibrillationill (N=316) Atrial Flutter (N=25)

43 Procainamide: Adverse Events Adverse events Hypotension (SBP < 100) Bradycardia (HR < 60) Atrioventricular block Ventricular tachyarrhythmia Atrial tachyarrhythmia Syncope Torsades de Pointes Admitted Relapse within 7 days Atrial Fib (N=316) 10% 9% 0.6% 0.6% 0.3% 0.3% 0% 0% 5% 3%

44 Acad Emerg Med 2010 Novel, relatively l atrial selective, il l i antiarrhythmic h i that prolongs atrial refractoriness to rapidly convert AF to SR Approved in Europe but still investigational in Canada and U.S. Roy et al Circulation 2008

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46 RAFF Management in the ED: Electrical Cardioversion Most patients say YES Propofol and Fentanyl given by EP Start at 200 joules Consider AP pads Usually no heparin or OAC Atrial Fibrillation Guidelines

47 Quiz: RAFF in the ED Rapid ventricular pre excitation (Wolff Parkinson White syndrome) during atrial fibrillation Note very rapid (up to 300 bpm) irregular wide QRS complexes

48 RAFF Management in the ED: Rapid Ventricular Pre excitation excitation in AF Atrial Fibrillation Guidelines

49 RAFF Management in the ED: Prevention of Thromboembolism b

50 RAFF Management in the ED: Prevention of Thromboembolism > 48 hr Atrial Fibrillation Guidelines

51 Dabigatran (Pradax) Approved for stroke prevention in AF in Oct 2010 Oral anticoagulant from the class of direct thrombin inhibitors Does not require INR monitoring RE LY study for AF (NEJM 2009): Dabigatran 110 mg BID non inferior to warfarin, less bleeding Dabigatran 150 mg BID more effective than warfarin, same bleeding Bleeding: Call Transfusion medicine, transfuse, Octaplex (prothrombin complex concentrate), Factor VIIa

52 RAFF Management in the ED: Prevention of Thromboembolism b CCS G id li CCS Guidelines: CHADS 2 = 0 ASA recommended CHADS 2 = 1 OAC preferred CHADS 2 > 2 OAC strongly recommended

53 RAFF Management in the ED: Prevention of Thromboembolism < 48 hr Atrial Fibrillation Guidelines

54 RAFF Management in the ED: Transesophageal Echocardiography Low risk but highly symptomatic Onset uncertain Onset >48 hours Partially anticoagulated Use LMWH then OAC Klein, New Engl J Med 2001 Atrial Fibrillation Guidelines

55 RAFF Management in the ED: Hospital Admission Where is this hospital? St. Anthony NL Headquarters of the Grenfell Mission Atrial Fibrillation Guidelines

56 RAFF Management in the ED: Follow up after Discharge Cardiologist or Internist Transthoracic echo Thromboembolism prevention INR monitoring Long term anti arrhythmicsarrhythmics Atrial Fibrillation Guidelines

57 RAFF Management in the ED: Take Tk Home Messages First, do no harm! Priority is stroke prevention CHADS 2 score consider OAC or ASA Rate or rhythm h control ok Chemical cardioversion = IV procainamide Electrical ca cardioversion= o 200 j WPW = electrical or procainamide Arrange follow up

58 Yes!

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