management of atrial fibrillation in emergency …epsegypt.com/upload/102013/af er 2013 cardioalex -...
TRANSCRIPT
Pr Wael Chalak
Chief of cardiology division
Faculty of Medical Sciences- Lebanese university
CardioAlex-13 June- 2013
MANAGEMENT
OF
ATRIAL FIBRILLATION
IN
EMERGENCY DEPARTEMENT
Incidence rates of AFMost common cardiac arrhythmia managed by ED. Boriani G. EHJ.2006.27.893-4
Rates are per 1000 person-years
Sphinx enigma: 4th century BC
What is the arrhythmia which will never occur during childhood, will be well tolerated during adulthood &
at high risk to kill at advanced age: AF
Clinical Outcomes Affected by AF
Outcome Parameter Relative Change in AF
Death
stroke
Hospitalization
Left Ventricular function
Quality of Life
Exercise Capacity
Death rate doubled
Risk & severity is increased
Increased
From No change to Tachycardia-
cardiomyopathy
From No effect to major Reduction,
Dyspnea, Palpitation
Euro heart survey on AF in ESC member countries:
AF management Nieuwlaat R.EHJ.2005.26.2422-34
Management of new onset AF in different ED despite the international guidelines is still
- Controversial
- Heterogeneous
Buccelletti F.Intern Emerg Med 2011; 6:149–156
Del Arco C. Ann Emerg Med 2005; 46:424–430
Some AF patient can be managed on ED without the need for hospital admission.
Fuster V .Circulation. 2006.114.700-752
Wakai A & O’Neill J O. Postgraduate Med J.: 2003; 79:313–31
Management goals
1.Initial workup?
2- Medical therapy?
3- Need for electrical cardioversion ? Which method?
4- Hospital admission?
5- Could we discharge the patient safely?
Successful management of AF should reduces CV morbidity & mortality1-5
*Total percentage of time a patient has AF as determined by the number and duration of AF episodes
1. Wolf et al. Stroke 1991;22:983-988.
2. Singh SN, et al. J Am Coll Cardiol. 2006;48:721-730.
3. Prystowsky EN. J Cardiovasc Electrophysiol 2006;17(suppl 2):S7-S10.
4. Hohnloser S, et al. J Cardiovasc Electrophysiol. 2008;19:69-73.
5. Camm AJ, Reiffel JA. European Heart Journal Supplements 2008;10(SH): H55-H78
Prevention
of
thrombo-
embolism
Reduction of
AF burden*
↓ Symptoms
↑ QoL
Reduction in the
risk
of
CV events and
hospitalisations
Reduction
in
mortality
WORKUP
Initial blood test includesEzekovitz MD.Circulation.2011.124.95-99
• Complete blood count,
• INR
• Electrolytes, urea, creatinine,
• Cardiac enzymes,
• Liver function tests,
• Blood glucose,
• Arterial blood gas,
• Thyroid function tests
• Serum toxicology .
Minor elevation in
TnI // with
mortality &
MACVE in pts with
AF.
Van Den Bos E. EHJ.2011.32. 611-7
From: Impact of Atrial Fibrillation on the Diagnostic Performance of B-Type Natriuretic Peptide Concentration
in Dyspneic Patients: An Analysis From the Breathing Not Properly Multinational Study
J Am Coll Cardiol. 2005;46(5):838-844. doi:10.1016/j.jacc.2005.05.057
AF: Predisposing FactorsWyse DG. Circ.2004. 109. 3089-95
• In acute AF, the identification & management of reversible acute clinical triggering factor may be essential to stop or to prevent recurrence of AF
- Alcohol intoxication- Cocaine addiction- Acute sepsis, pneumonia,- Caffeine effect
Hemodynamic stabilityESC-2010 : Mansourati J. Cardiol Pratique 2012.997/998. 3
AF
Hemodynamic stability
Yes No
Goals: VR< 100/mn SR : ECV (100-360 j)
EHRA Score of
AF Related Symptoms
EHRA
Class
AF Symptoms Related
Score
Class I No symptoms
Class II Mild symptoms;
Normal daily activity
Class III Severe symptoms;
Daily activity affected
Class IV Disabling symptoms;
Daily activity discontinued
European Heart Journal (2010) 31,2369-2429l
AF pathophysiology: Implications for management. Iwasaki Y-K et al.Circ.2011.124.2264-74
- Hemodynamic stabilization
- Ventricular rate control* Slowing of the ventricular response rate is the main objective
* No specific efforts are made to maintain sinus rhythm
- Prevention of embolic complications
* Antithrombotics
* “Rhythm-control strategy," to restore normal sinus rhythm:
- Antiarrhythmic drugs
- Electrical cardioversion when necessary,
Estes NAM 3rd. Circulation. 2008.171. 1101-1120 / Connolly SJ.Circulation.2008.118..2029-2037.
Talajic, M. et al. J Am Coll Cardiol 2010;55:1796-1802
Current rhythm vs. rate control treatment strategywas not predictive of cardiovascular mortality, total mortality, or worsening HF.
Results of multivariate regression analysis as a time-dependent variable
Wyse G. Circ.2009. 120.1444-52
Impact of pharmacological maintenance of SR vs. HR control on clinical outcome of AF Wyse G. Circ.2009. 120.1444-52
HF worsening
Wyse G. Circ.2009. 120.1444-52. Anter E. Circ.2009.120. 1436-43
Pharmacological cardioversion
AJM .104. 1998
Major clinical trials on AAD vs placebo for AF , Proportions of patients SR at Fup meta-analysis ( Nichol G. Heart.2002.87.535-43)
Agents Proportion in sinus rhythm Proportion in in treatment arm (%) sinus rhythm
in control arm(%)IA vs Placebo 54.7 33.1 IC vs Placebo 60.2 27.1III vs placebo 46 29.11C vs IV 77.8 43.2
No differences in the effect ofDigoxine vs placebo class III vs Classes IA or IC
Decision of cardioversion mode of AF // tolerance & presence of pre-existing HD .
ESC-2010 : Mansourati J. Cardiol Pratique 2012.997/998. 3
Persistant AF > 48 h or 7d PxAF < 48h & no underlying HD:Amiodarone Flecain/Propafenon
Rapid AF +WPW with anterograde conduction:
- Flecainide iv
- ECV
Recent AF
Non Hemodynamically
Stable
ECV Underlying HD
Yes
Yes No
ACC/AHA Rx algorithms for the management of PxAF. Cinitz J. Circ.2013. 127.408-16
Clinical conditions &
Contraincated antiarrhythmic
drug Rx.
Blaau Y. Heart.2002.88.432-7
LAV at diagnosis in Lone AF predicts CVE during follow up /30y
Olmested County –USA Osranek M.EHJ.2005.26.2556-61
Clinical outcome of lone AF is benign with normal LA volume & demonstrates adverse events
with increasd LAV at diagnosis or during Fup
Pts w/o events Pts with events
AF: Classification & pattern of AF
ACC/AHA ESC 2006 GuidelinesEuropean Heart Journal (2010) 31,2369-2429l
Lasting < 7d mostly <1d
Recurrent
Lasting > 7d
Requiring CV
Recurrent
Failed/Not attempted cardioversion
Management of recurrent/ paroxysmal AFAF & Cardioversion
Boveda S. Cardiol Pratique. 2012.1014. 14-5 ( ESC-10) Fuster V.Circ.2006.114.700-52
Anticoagulation & rate control as needed
EHRA I/ II EHRA III/IV
Recommendations ACC/AHA/ESC.EHJ.2010 .31.2396-29
of AF cardioversion
1- Persistent AF recently discovered
2- Recurrent AF with invalidating Sx.
Rudaut R. Cardiol Pratique. 2012-992.
Newly discovered AF
ACC/AHA ESC 2006 Guidelines Fuster V.Circ.2006.114.700-52
,
.
Pharmacological CV of
AF of up to 7-d duration
ACC/AHA ESC 2006 Guidelines Fuster V.Circ.2006.114.700-52
Pharmacological CV of
AF of > 7-d duration
ACC/AHA ESC 2006 Guidelines Fuster V.Circ.2006.114.700-52
Success rate & complications of ECVSbragia P. AMC.2002.95.561-6/ Boveda S. Cardiol Pratique. 2012.1014. 14-5
Age & EECV
182 AF of 25-89y.:Age does not significantly influence the immediate results of EECV
Sbragia P.AMC.2002.95.561-6
• Complications of ECV- Embolic event : 1-7 % // Poor INR- VF if:
* Not synchronized on R wave* HypoK* High Digoxinemia* M. Ischemia
• ECV & PM/ICD:- Possible- Reprogrammation after ECV
• Recurrence AF: 50% at 1y
Pharmacological treatment before cardioversion in patient with
persistent AF: Effectiveness of various AAD on acute & subacute outcome of transthoracic DC shock
ACC/AHA ESC 2006 Guidelines Fuster V.Circ.2006.114.700-52
SRAF: Subacute Recurrence of AF
Maintenance of SR
ACC/AHA ESC 2006 GuidelinesFuster V.Circ.2006.114.700-52
Antiarrhythmic drugs
New and old
New
Class III agentsNovel drugs
Dofetilide Azimilide
DronedaroneTedisamil Adenosine
agonist
Connexin
modulators
5-HT4
antagonist
SAC
blockers
ARDAs
Na+/Ca2+
inhibitor
Na+/H+
inhibitor
Upstream
therapies
Amiodarone
Sotalol
Class
III
Propafenone
Flecainide
Class
IC
Multi-channel
blockers Celivarone
Antiarrhythmic medical therapies
Courtesy of J Camm, MD.
Atrial selective
Vernakalant hydrochloride for rapid ( 90 mn) conversion of AF.Roy D. Circ.2008.117.1518-25
Vernakalant iv :
3mg /Kg/10 mn iv & after 15 mn: 2mg/Kg/10mn
Ranolazine
Circulation 2011,124
The American journal of cardiology.september
2012.volume 110,Issue 5
ESC-2010
cardioversion of AF Pill-in-pocket strategyAlboni et al-2004/ Mansourati J. Cardiol Pratique 2012.997/998. 3
Next episodes of AF if the first is well tolerated: Rx in ER or at home with single dose of AAD by MD
- Flecaine (200-300 mg) or Propafenone (600 mg) //
- Use of AAD within 36 mn after Sx onset
- Efficacy: 90% & Sx disappear within 113 mn
- Hospitalisation reduced
- Sides effects: 7% mainly non cardiac
- Main indications: PxAF of rare episodes
- CI: LV dysfunction
ACTIVE-W:
AF “| high AF risk of TEA in 6707
Interrupted because of 47% excess of TEA in Clopidogrel+ASA
CVA, PAE, MI, CV death
Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events
AVK in AF patient previously not anti-coagulated
Balancing risk of ischemic stroke & intracranial bleeding
INR: 2-3Turpie A. EHJ. 2007.29.155-65
Strategy of AC with CV (Electrical or medical) ACC/AHA/ESC.EHJ.2010 .31.2396-29 of AF cardioversion
AC INR
1- AF > 24h or undetermined duration AVK=/> 3w pre & 4w post CV (1B: AF & 1C:A.Flutter) ) 2-3
2- AF < 24h
RR Stroke & Bleeding Voller H.EHJ.2005. 7. Supl E.4-9
Anticoagulant Rx in AF of elderly pts
Annual risk of CVA in placebo group patients with AF in randomized trials.Hanon O. Cardiol Pratique. 2012. 992
ATRIA. Singer DE. Chang Y. Fang MC. Et al. Ann Intern Med.2009..151.297-305 (13559 AF pts )
Benefit of AVK Rx of AF appears at age =/> 75 y
LMH in NVAF// clinical status Ederhy S. AMC.2006.99.1210-4
• The most studied anticoagulant drug is unfractioned heparin UFH and, less validated,
subcutaneous enoxaparin.
• In symptomatic patients already taking antivitamin-K, emergency management of
acute AF depends on the INR .
Steinberg JS. Circulation . 2004. 109.1973-1980
Anti-coagulation in patient with AF & not previously anti-coagulated
Heparin: UFH / LMWHPengo V. Circ.2009. 119. 2920-7
M M
Risk stratification for TEA & bleeding
Letter Risk factors for
bleeding
Points awarded
H Hypertension 1
A Abnormal renal &
liver function (1pt
each)
1 or 2
S Stroke 1
B Bleeding 1
L Labile INR’s 1
E Elderly > 65 years 1
D Drugs or Alcohol
(1pt each)
1 or 2
Max 9 points
Risk Factor for TEA Score
C CHF / LV Dysfunction 1
H Hypertension 1
A2 Age > 75 years 2
D Diabetes Mellitus 1
S2 Stroke / TIA / Thromboembolism 2
V Vascular disease (MI, PAD, Aortic plaques) 1
A Age 65 – 74 y 1
Sc Sex category (female) 1
Maximum score 9
European Heart Journal (2010) 31,2369-2429l
Stroke or TEA rates based on CHADS2 & CHAD2DS2VASc
scores & bleeding rates based on HAS-BLED score in AF. Cinitz J. Circ.2013. 127.408-16
Approach to Thrombo-Prophylaxis in AF
Risk Category CHA2-DS2-VASc
score
Recommended Anti-
Thrombotic Therapy
One major risk factor
or ≥ 2 clinically
relevant non major RF
≥ 2 OAC
One clinically relevant
non major risk factor
1 Either OAC or Aspirin
But preferred OAC
No risk factor 0
Either Aspirin or no
antithrombotic
But preferred no
antithrombotic rather
than aspirin
European Heart Journal (2010) 31,2369-2429l
AF Voller H.EHJ.2005. 7. Supl E.4-9
Risk Stratification for Anti-thrombotic Rx
,
Optimal strategy of AC in cardioversion (CV) .Caims JA. Can J Cardil. 2011.27: 74-90/ Rudaut R. Cardiol Pratique. 2012-992
,
Indications of TEE before ECV Lesbre JP.AMC.2003.96.871-9 / Rudaut R. Cardiol Pratique. 2012-992.
• AF+ CVA/ Recent embolic event
• Valvular AF
• Hemodynamic instability requiring rapid
CV on UFH or therapeutic LMWH ( I-B)
• AF at High embolic risk:
* H/o CVA
* LA>50 mm ,
* HF
* DM,
* Permanent HBP.
• Lone AF + avoid LgT AC
Indications of TEE before ECV // number of RF
Optimal strategy of AC in cardioversion (CV) TEE-Guided CV :
ACUTE: Klein AI. NEJM. 201.344.1411-20./. Rudaut R. Cardiol Pratique. 2012-992.
- No LA/LAA Thrombus: UFH/LMWH + CV
- LA/LAA Thrombus: > 3w of AC
* No more Thrombus: CV & AVK for 1m
or for life according to RF ( IIac)
* Persistence of Thrombus: CI for CV !
* LA sludge : AC & if persistent: CI for CV & for RFA
Novel anticoagulants. Eikelboom J. Circ.2010.121.1523-32
No difference in embolic event rate
between Dabigatran 110 x2 vs 150 mg x2 vs AVK for =/ >3 w
prior to CV Nagarakanti R. Circ.2011.123.131-6
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Dabi
110 x2
Dabi
150 x2
AVK
TEA %
Place of new AC (Can J Cardiol 2011. 27.74-90) & (ACCF/AHA/HRS Revision. Circ.2011.123.144-50)
1- Dabigatran 150 mg x2/ for =/> 3w before & 4w post CV
2- Anti-Xa: No recommendations
CVA, AF & ACFauchier . Cardiol Pratique. 2012.1010-1011. 3.
• Dabigatran 150 mg x2Apixaban 5 mg x2Rivaroxaban 20mg x1
- Less CVA & Systemic embolism vs AVK- Hemorrhagic CVA: - 40to -70% vs AVK
- Ischemic CVA: -25%
• Risk vs benefit- CHADS2 : 0 & high bleeding risk:
Dabigatran 110 x2 & Apixaban:Benefit > Risk
- CHA2DSVASc: 1 Dabigatran 110 / 150 & Apixaban
Benefit > Risk- Higher TE riskDabigatran 110 / 150 & Apixaban 5 &Rivaroxaban 20mg x1
Benefit > Risk vs AVK - High TE risk & high bleeding risk Dabigatran 110 / 150 & Apixaban 5 & Rivaroxaban 20mg x1
Benefit > Risk vs AVK
Clinical conditions of AC Rx of AF. Ederhy S. Cardiol Pratique. 2012. 995-996.
Remaining indications for AVK
1- All VAF & PHV
2- Well equilibrated patients on AVK
3-No H/o CVA on Rx
4- H/o GI bleding
5-Cr Cl < 25 ml/mn
6-CAD
7- Intracardiac thrombus
WHICH SUBSET OF AF PATIENTS NEEDS HOSPITAL
ADMISSION?
• Highly symptomatic patients & Poor AF tolerance Specially in Elderly
• Structural heart disease
• Embolic event or are at high risk of thromboembolism
• Non-cardiac causes of AF
• Failure of rate control in the ED
Mansourati J. Cardiol Pratique 2012.997/998. 3
WHICH SUBSET OF AF PATIENTS CAN BE SAFELY
DISCHARGED FROM THE ED?
• No structural heart disease
• Controlled ventricular rate
• Age < 60 years
• Lone AF
• Persistent AF whose rhythm is converted to normal SR
• Patients started on Amiodarone may be safe for discharge afteremergency cardioversion
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