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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

[email protected]

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



HYPER- Pericardial- Inside- Myocardial- Pulmonary-

Sepsis- 36% CHF- 32% ARF- 7% COPD- 4% CVA- 3% GIB- 3% PE- 2%



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…

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?



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





RACE IILess is More

Goal HR <110

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.

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?


20-40 lbs

Improves Cardioversion

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?

GREAT REVIEW ARTICLE: Managing Atrial Fibrillation Atzema, Clare.et al. Annals of Emergency Medicine , Volume 65 , Issue 5 , 532 - 539

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.


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 [email protected]

Manage Afib Like a Boss

Wieters@EMedCoach

[email protected]

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