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Learn how to Manage Afib Like a Boss in:
Manage Afib Like a Boss
Wieters
From @srrezaie
No Disclosures
J. Scott Wieters MD @EMedCoach
Wieters@gmail.com
Questions? 1. Treat Patient or Rhythm? 2. How LOW should we go? 3. Who to Cardiovert? 4.How to Cardiovert? 5. Who to Anticoagulate?
Whatugonnado?
?
Ashman's Phenomenon
Scheuermeyer FX, Pourvali R, Rowe BH, Grafstein E, Heslop C, MacPhee J, McGrath L, Ward J, Heilbron B, Christenson J. Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May NotBenefit From Attempts to Control Rate or Rhythm. Ann Emerg Med. 2015
May;65(5):511-522.e2. doi: 10.1016/j.annemergmed.2014.09.012. Epub 2014 Nov 6.PubMed PMID: 25441768.
HY P I M P
Scheuermeyer FX, Pourvali R, Rowe BH, Grafstein E, Heslop C, MacPhee J, McGrath L, Ward J, Heilbron B, Christenson J. Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May NotBenefit From Attempts to Control Rate or Rhythm. Ann Emerg Med. 2015
May;65(5):511-522.e2. doi: 10.1016/j.annemergmed.2014.09.012. Epub 2014 Nov 6.PubMed PMID: 25441768.
HYPER- Pericardial- Inside- Myocardial- Pulmonary-
Sepsis- 36% CHF- 32% ARF- 7% COPD- 4% CVA- 3% GIB- 3% PE- 2%
Scheuermeyer FX, Pourvali R, Rowe BH, Grafstein E, Heslop C, MacPhee J, McGrath L, Ward J, Heilbron B, Christenson J. Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May NotBenefit From Attempts to Control Rate or Rhythm. Ann Emerg Med. 2015
May;65(5):511-522.e2. doi: 10.1016/j.annemergmed.2014.09.012. Epub 2014 Nov 6.PubMed PMID: 25441768.
Trouble Trouble Trouble
0 0.125 0.25 0.375 0.5
Treat Rate 41%
Treat Patient
Complication Rate
7%
417 AF Pts
BB CCB-vs-
Dance with the one who Brought you…
Questions? 1. Treat Patient or Rhythm? 2. How LOW should we go? 3. Who to Cardiovert? 4.How to Cardiovert? 5. Who to Anticoagulate?
How Low Should you go?
RACE II 614 PtsProspective Multicenter Randomized Open-label Noninferiority trial Industry Funded
Van Gelder IC, RACE II Investigators. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010 Apr 15;362(15):1363-73. doi: 10.1056/
NEJMoa1001337. Epub 2010 Mar 15. PubMed PMID:20231232.
HR<110 -V- HR<80
RACE IIOutcome?
Van Gelder IC, RACE II Investigators. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010 Apr 15;362(15):1363-73. doi: 10.1056/
NEJMoa1001337. Epub 2010 Mar 15. PubMed PMID:20231232.
CV death
CHF Admit
Stroke
Embolism
Bleeding
LT Arrhythmia
LT side effect of drugs
Pacemaker or ICD
RACE II HR <110 HR <80Primary Outcome
12.9% 14.9%
Met HR Goal
98% 67%
Healthcare Visits
75 684
Van Gelder IC, RACE II Investigators. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010 Apr 15;362(15):1363-73. doi: 10.1056/
NEJMoa1001337. Epub 2010 Mar 15. PubMed PMID:20231232.
Van Gelder IC, RACE II Investigators. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010 Apr 15;362(15):1363-73. doi: 10.1056/
NEJMoa1001337. Epub 2010 Mar 15. PubMed PMID:20231232.
RACE IILess is More
Goal HR <110
Questions? 1. Treat Patient or Rhythm? 2. How LOW should we go? 3. Who to Cardiovert? 4.How to Cardiovert? 5. Who to Anticoagulate?
Is Rhythm Control Better Than Rate Control for New-Onset Atrial Fibrillation in the Emergency Department? Malya, Rohith R.Ganti, Latha et al. Annals of Emergency Medicine , Volume 65 , Issue 5 , 540 - 542
PIAF-2000 AFFIRM-2002 RACE-2003 STAF-2003 HOT CAFE-2004 Okcun-2004 J-RHYTHYM-2009
Rate? -vs-
Rhythm?
Chatterjee S, Sardar P, Lichstein E, Mukherjee D, Aikat S. Pharmacologic rate versus rhythm-control strategies in atrial fibrillation: an updated comprehensive review and meta-analysis. Pacing Clin Electrophysiol. 2013 Jan;36(1):122-33. doi:
10.1111/j.1540-8159.2012.03513.x. Epub 2012 Sep 14. Review. PubMed PMID:22978656.
<65 Rhythm >65 Rate
PACE
A Clinical Decision Instrument for 30-Day Death After an Emergency Department Visit for Atrial Fibrillation: The Atrial Fibrillation in the Emergency Room (AFTER) Study Atzema, Clare L. et al.Annals of Emergency Medicine , Volume 66 , Issue 6 , 658 - 668.e6
AFTER
A Clinical Decision Instrument for 30-Day Death After an Emergency Department Visit for Atrial Fibrillation: The Atrial Fibrillation in the Emergency Room (AFTER) Study Atzema, Clare L. et al.Annals of Emergency Medicine , Volume 66 , Issue 6 , 658 - 668.e6
AgeTrop
Renal COPD
CancerDementiaBleedingAcute Ill
Relative Risk
0 0.75 1.5 2.25 3
A trial FibrillationThe ER
>65 Comorbidities Rate Control
<65 Healthy Rhythm Control
Electricity
Drugs-Vs-
Electricity
Drugs-Vs-
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;14:1158–1164.
Cardioversion of paroxysmal atrial fibrillation in the emergency department. Michael JA, Stiell IG, Agarwal S, Mandavia DP
Ann Emerg Med. 1999 Apr; 33(4):379-87.
60%
90%
• pic of pads coming at patient.
Questions? 1. Treat Patient or Rhythm? 2. How LOW should we go? 3. Who to Cardiovert? 4.How to Cardiovert? 5. Who to Anticoagulate?
Location Location Location
Location, Location, Location…
Placement doesn't matter Zhang B, Li X, Shen D, Zhen Y, Tao A, Zhang G. Anterior-posterior versus anterior-lateral electrode position for external electrical cardioversion of atrial fibrillation: a meta-analysis of randomized controlled trials. Arch Cardiovasc Dis. 2014
May;107(5):280-90. doi: 10.1016/j.acvd.2014.04.002. Epub2014 May 20. PubMed PMID: 24854873.
10 trials 1281 pts
Your Place or Mine?
Pressure?
Cohen, Todd J. et al. Active Compression Cardioversion for Refractory Atrial Fibrillation American Journal of Cardiology , Volume 80 , Issue 3 , 354 - 355
Pressure?
Cohen, Todd J. et al. Active Compression Cardioversion for Refractory Atrial Fibrillation American Journal of Cardiology , Volume 80 , Issue 3 , 354 - 355
20-40 lbs
Improves Cardioversion
Questions? 1. Treat Patient or Rhythm? 2. How LOW should we go? 3. Who to Cardiovert? 4.How to Cardiovert? 5. Who to Anticoagulate?
Anticoagulate?
0 1
CHF no yes
HTN no yes
AGE <65 >65
AGE <74 >75
DM no yes
Stroke no yes
Stroke no yes
Vasc. no yes
SEX male female
CHA2DS2 VASc
SCORE % STROKE/TIA/EMBOLISM
0 0.3%
1 0.9%
2 2.9%
3 4.6%
4 6.7%
5 10.0%
6 13.6%
7 15.7%
8 15.2%
9 17.4%
CHA2DS2 VASc
Friberg L, Rosenqvist M, Lip GY. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study. Eur Heart J. 2012 Jun;33(12):1500-10. doi: 10.1093/eurheartj/ehr488.
Epub 2012 Jan 13. PubMed PMID: 22246443.
CHA2DS2 VASc
0- NO ANTICOAG/ASA 1- Nobody knows? 2- ANTICOAGULATE
Zhu W, He W, Guo L, Wang X, Hong K. The HAS-BLED Score for Predicting Major Bleeding Risk in Anticoagulated Patients With Atrial Fibrillation: A Systematic
Review and Meta-analysis. Clin Cardiol. 2015 Sep;38(9):555-61. doi: 10.1002/clc.22435. Review. PubMed PMID: 26418409.
HAASBLEED? HEMORR2HAGES?
ATRIA?
Bleeding Risk?
Zhu W, He W, Guo L, Wang X, Hong K. The HAS-BLED Score for Predicting Major Bleeding Risk in Anticoagulated Patients With Atrial Fibrillation: A Systematic
Review and Meta-analysis. Clin Cardiol. 2015 Sep;38(9):555-61. doi: 10.1002/clc.22435. Review. PubMed PMID: 26418409.
HAASBLEED
Bleeding Risk?
HTN NO YES
ABN Liver NO YES
ABN Renal NO YES
Stroke NO YES
Bleeding NO YES
Labile INR NO YES
Elderly >65 NO YES
ETOH NO YES
Drugs NO YES
HAASBLEED
>3 HIGH RISK
BLEEDZhu W, He W, Guo L, Wang X, Hong K. The HAS-BLED Score for Predicting Major
Bleeding Risk in Anticoagulated Patients With Atrial Fibrillation: A Systematic Review and Meta-analysis. Clin Cardiol. 2015 Sep;38(9):555-61. doi:
10.1002/clc.22435. Review. PubMed PMID: 26418409.
Score RISKBleeds/100
Patient Years
1 3.4% 1.02
2 4.1% 1.88
3 5.8% 3.72
4 8.9% 8.7
5 9.1% 12.5
6 High? High?
7 High? High?
8 High? High?
9 High? High?
HAASBLEED
Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY.A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010 Nov;138(5):1093-100. doi: 10.1378/chest.10-0134. Epub 2010 Mar 18.
Pisters R, Lane DA, Nieuwlaat R, et al. A Novel User-Friendly Score (Has-Bled) To Assess 1-Year Risk Of Major Bleeding In Patients With Atrial Fibrillation: The Euro Heart Survey. Chest. 2010;138(5):1093-1100.
CHA2DS2 VASc HAASBLEEDSCORE % STROKE/
TIA/0 0.3%
1 0.9%
2 2.9%
3 4.6%
4 6.7%
5 10.0%
6 13.6%
7 15.7%
8 15.2%
9 17.4%
Score Bleeds/100 Patient
1 1.02
2 1.88
3 3.72
4 8.7
5 12.5
6 High?
7 High?
8 High?
9 High?
CHA2DS2 VASc HAASBLEEDSCORE % STROKE/
TIA/0 0.3%
1 0.9%
2 2.9%
3 4.6%
4 6.7%
5 10.0%
6 13.6%
7 15.7%
8 15.2%
9 17.4%
Score Bleeds/100 Patient
1 1.02
2 1.88
3 3.72
4 8.7
5 12.5
6 High?
7 High?
8 High?
9 High?
GREAT REVIEW ARTICLE: Managing Atrial Fibrillation Atzema, Clare.et al. Annals of Emergency Medicine , Volume 65 , Issue 5 , 532 - 539
Questions? 1. Treat Patient or Rhythm? 2. How LOW should we go? 3. Who to Cardiovert? 4.How to Cardiovert? 5. Who to Anticoagulate?
Manage Afib Like a BossTreat Patient or Rhythm? Hyper conditions? Pericardial? Myocardial? Pulmonary?
Who to Anticoagulate?
How LOW should we go? Rate <110 better than <80
Who to Cardiovert? Unstable <48 hr. onset <65 yrs. Less Comorbidities
How to Cardiovert? Electrical beats Drugs Shortest distance 20-40lbs pressure 100-200 Jules
CHA2DS2 VASc > 2
HAASBLEED <3
Scheuermeyer et al. Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May NotBenefit From Attempts to Control Rate or Rhythm. Ann Emerg Med. 2015May;65(5):511-522.e2. doi: 10.1016/j.annemergmed.2014.09.012. Epub 2014 Nov 6.PubMed MID:
25441768.
Van Gelder IC, RACE II Investigators. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010 Apr 15;362(15):1363-73. doi: 10.1056/NEJMoa1001337. Epub 2010 Mar 15. PubMed PMID:20231232.
A Clinical Decision Instrument for 30-Day Death After an Emergency Department Visit for Atrial Fibrillation: The Atrial Fibrillation in the Emergency Room (AFTER) Study Atzema, Clare L. et al.Annals
of Emergency Medicine , Volume 66 , Issue 6 , 658 - 668.e6
Zhang B, Li X, Shen D, Zhen Y, Tao A, Zhang G. Anterior-posterior versus anterior-lateral electrode position for external electrical cardioversion of atrial fibrillation: a meta-analysis of randomized controlled trials. Arch Cardiovasc
Dis. 2014 May;107(5):280-90. doi: 10.1016/j.acvd.2014.04.002. Epub2014 May 20. PubMed PMID: 24854873.
Cohen, Todd J. et al. Active Compression Cardioversion for Refractory Atrial Fibrillation American Journal of Cardiology , Volume 80 , Issue 3 , 354 - 355
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;14:1158–1164.
Cardioversion of paroxysmal atrial fibrillation in the emergency department. Michael JA, Stiell IG, Agarwal S, Mandavia DP Ann Emerg Med. 1999 Apr; 33(4):379-87.
GREAT REVIEW ARTICLE: Managing Atrial Fibrillation Atzema, Clare L. et al. Annals of Emergency Medicine , Volume 65 , Issue 5 , 532 - 539 @EMedCoach wieters@gmail.com
Manage Afib Like a Boss
Wieters@EMedCoach
Wieters@gmail.com
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