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Treating Rapid Atrial Fibrillation in 2018 Rich Bounds, MD, FACEP, FAAEM Program Director The NEW Emergency Medicine Residency University of Vermont Medical Center January 30, 2018 Importance • 25% lifetime risk • Variability in practice • No clear guidelines Owning the AFib patient Rhythm control or Rate control Rhythm control Electrical or Chemical Stroke Bleed AHA Recommendations no anticoagulation (Class II) no anticoagulation or ASA (Class II) or VKA/NOAC VKA/NOAC (Class I) January CT, Wann LS, Alpert JS, et al 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the ACC/AHA Task Force on Practice Guidelines and the Heart Rhythm Society Circulation 2014;64:e1-e76 Bleeding Risk? HAS-BLED Pisters R, Lane DA, Nieuwlaat R, et al A novel user-friendly score (HAS-BLED) to assess 1year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey Chest 2010;138: 1093-1100 Which Anticoagulant? Short story Apixiban seems preferred IN SUMMARY STEPWISE APPROACH • WHY? • Unstable? Electrical Cardioversion • Stable look at your patient STEPWISE APPROACH • Rhythm control – Electrical often safer than chemical – AP pad placement with pressure – Don’t forget to sync! • Rate control – Consider WPW – CCB slightly more effective than BB – Goal is 100 bpm STEPWISE APPROACH • • • • • Risk stratify for anticoagulation CHADS-VASC HAS-BLED Shared decision-making Follow-up Pause before you click qTroponin Zimetbaum PJ, Josephson ME, McDonald MJ, et al Incidence and predictors of myocardial infarction among patients with atrial fibrillation J Am Coll Cardiol 2000;36:1223-1227 Brown AM, Sease KL, Robey JL, et al The risk for acute coronary syndrome associated with atrial fibrillation among ED patients with chest pain syndromes Am J Emerg Med 2007;25: 523-528 Pause before you click qTSH Take-TO-YOUR-NEXT-SHIFT Points • Patient selection in Rhythm/Rate control • Rhythm (may be recurrent) – Electrical CV is safer/faster than chemical CV • Rate control goal is 100 – Patient selection in CCB vs BB • Run magnesium in all your patients • Stop checking troponin • Use CHADS-VASC and HAS-BLED regardless of ED d/c rhythm (>1 should be anticoagulated) Questions? Rich Bounds, MD, FACEP, FAAEM richard.bounds@uvmhealth.org ... Importance • 25% lifetime risk • Variability in practice • No clear guidelines Owning the AFib patient Rhythm control or Rate control Rhythm control Electrical or Chemical Stroke Bleed... Pheochromocytoma Why? • ATRIAL DISTENSION • CONDUCTION PROBLEM • INCREASED AUTOMATICITY or IRRITATION Cause of Afib guides treatment decisions Stable or Unstable? • • • • Not dichotomous Altered MS Hypotension