Good morning. Today we are going to talk about atrial fibrillation in the ED in a hospital setting, which again is a fairly common diagnosis and disease that we manage in the hospital. And so we're going to concentrate on that patient that presents as well as maybe what happens while patients are in the hospital for other reasons and go into AFib. So just some statistics, you know AFib is a very common cardiac rhythm disturbance. It may be the most common depending on which statistic you look at. It definitely affects millions of Americans every year and the incidence is just going up. So certainly not anything that we will not have to deal with in the future if anything we'll be managing more. It accounts for just under 500,000 hospitalizations annually and if you really dig into that statistic we find that many of those probably didn't even need to be hospitalized. But that's a whole other discussion for a different day and does contribute to a number of deaths every year. It's expensive. If you'll look at the Medicare beneficiary data it adds $8,700 per year if a patient has AFib compared to a patient that doesn't in addition to all the other expenditures that they have. So it's a big deal. So when we think about AFib, patient presents, what are some of the symptoms? And you need to understand kind of the description, ask the right questions, what's the onset or date of discovery is really important and many times we don't know if their symptoms are a little vague. Sometimes you don't know exactly when it started. Understanding the frequency and duration, severity of any of their symptoms. So oftentimes it's palpitations. Some people will describe some chest tightness, shortness of breath, and then any the qualitative piece. The typical things that we see are fatigue. They just develop kind of that exercise intolerance, activity intolerance, just don't have the get up and go that they normally have. Many of them have palpitations but not all of them. What's interesting about AFib is some patients are extremely symptomatic with it. Others don't even know they have it. So patients will present to their primary care for their yearly follow-up and get an EKG and they've got AFib and they didn't know they had it. Some again, I mentioned the exercise activity intolerance. Some will notice shortness of breath. There can be a decrease in the cardiac output related to that poor atrial activity and so they can be short of breath. Some will be hypotensive. If they're, especially if their ventricular rate is high, they may have some dizziness, lightheadedness, presyncope. Some have syncope. So we'll talk a little bit more about that when we get into this of what causes that. And then some patients, because you know, they may have some volume overload symptoms or heart failure type symptoms, and this is kind of a chicken versus the egg. Certainly AFib in some patients can, like I mentioned, decrease that cardiac output and they can end up with some volume overload related to that. In other cases, they had volume overload first and that extra strain was enough to cause the AFib. And then, like I said, quite a number of patients are asymptomatic, probably more than we realize, especially when you start looking at some of the studies around patients that are wearing monitors or some of the Apple Watch, smartwatch, and kind of things that we're finding patients have bronzo-AFib and really didn't have symptoms associated with it. So certainly asymptomatic is a big deal. So what are we looking for? Well, certainly on history we're asking about precipitating factors. So exercise, any emotion, and then alcohol. So we used to use the term holiday heart. If patients had a binge scenario, sometimes you can have AFib in that post-binge period. So that's another one. And then comorbidities. So cardiovascular disease, diabetes, hypertension, obstructive sleep apnea is a big comorbidity that can drive some of the underlying AFib. Chronic obstructive pulmonary disease, or COPD, and then thyroid disease. So really getting a good history on these patients can help with some of the understanding what their risk factors are, as well as precipitating factors. And then physical exam. You're going to want to do a complete exam to look for signs of heart failure, any structural heart disease, any cerebrovascular disease, any symptoms of stroke, TIA, that sort of thing. So good full physical exam. And then certainly rhythm identification. So your EKG or rhythm strip, this is a super ventricular rhythm that is usually associated with tachycardic. Most of the time these patients have a rapid ventricular rate. That's just part of the physiology or pathophysiology behind it. Now if the patient had previously been on a beta blocker or rate controlling medicine for maybe hypertension reasons, and they go into AFib, that rate might be slower. But again, most patients end up with a faster rate. It's an uncoordinated atrial activity that creates ineffective atrial contraction. So again, some patients have more of a decrease in cardiac output than others. The atria don't do a lot of the contractility type work. But for some patients, that lack of atrial contraction is enough to give them quite a few symptoms. But the reality is the atria are sitting there quivering, they're fibrillating, there is no organized electrical activity, therefore there is no organized contractility activity. And that's where the issue comes related to stroke. And then what do you see in your EKG? Where you're going to see a regular R to R. So regular rate, rhythm, and the R to R intervals are going to be different and variable. They'll likely be absence of distinct P waves. Now some may have where you can sort of find some P waves in there, but they're not going to be identical and clean and symmetric, you know, the way we would typically see in a sinus rhythm. They're going to be very abnormal and in most cases they're absent because of that irregular atrial activity. So the other thing with atrial fibrillation is understanding the classification. So this has kind of evolved over the years and we really have several different terms that I want to go over with you. So one, the first one is paroxysmal atrial fibrillation. This is AF that terminates spontaneously or with intervention, but within seven days of onset. Episodes may recur with variable frequency, but they're in and out and typically doesn't last more than seven days. Once it lasts longer than seven days, now we call it persistent. And if it lasts longer than 12 months, we call it long-standing persistent. And that's gotten more and more important as we look at management options related to some of the more advanced therapies. Understanding if it's paroxysmal, persistent, or long-standing is important for those decisions. And then finally permanent. Permanent AFib is used when the patient and the clinician make a joint decision to stop further attempts to restore and or maintain sinus rhythm. The acceptance of AFib represents a therapeutic attitude on the part of the patient and the clinician rather than an inherent pathophysiologic attribute of AF. And acceptance of the AF, though, may change the symptoms or efficacy of the therapeutic interventions and patient and clinician preferences evolve. So it really is a decision to say, I'm just going to live in my AF and no further treatment to try to maintain or restore sinus rhythm. And then non-valvular AFib, you'll see that a lot as far as the medication management for stroke prevention. This is AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair. Once you have valvular AFib, risk of stroke and that sort of thing changes and therefore the management changes. So just kind of an important term. All right, so patient presents acute presentation in ED and or maybe you have a patient up on the floor that was in for surgery or another reason has got into AFib. So you need to get an EKG to confirm. And again, I wouldn't go based on a monitor strip. You're going to want to get a 12-lead. Sometimes those monitor strips related to artifacts and other issues can cause. I've gotten called numerous times for atrial flutter only to find out the patient was brushing their teeth. So don't rely on your rhythm strip. Get your 12-lead EKG. Now in some cases, again if you get a patient that's not on telemetry in the hospital and they came in through the ED, you may need to order a Holter monitor or an event recorder if you weren't able to catch it on the EKG to confirm what those symptoms were for follow-up. It's really meant to identify that paroxysmal AFib if they've already gone back into their normal rhythm. Because again, your risk of stroke and that sort of thing is higher. So we need to know if they're having runs of AFib. That's really meant for longer-term follow-up. Or for those that are in AFib and you're worried about rate control. So we can control folks' rate. It rests pretty easy. But as soon as we let them go back to their normal activities, are we really managing that well and using your monitor to follow up on them? That's important. You need an echocardiogram to evaluate the left atrial and left ventricular sizes and status, as well as any valvular function. So any issues of valvular disease. But those are going to be really important for your long-term management decisions. So that is part of the initial workup once you've diagnosed someone with new AFib. And then lab-wise, you want to look at your thyroid studies, a TSH and a free T4. Because thyroid disease can certainly be an underlying driving factor. And if they have significant thyroid disease, until you correct that, you're going to have challenges trying to maintain sinus rhythm for them. Chemistry panel is important. You want to know what their BUN CREAT is. That's going to be important for if you're going to be anticoagulating them and using a non-warfarin type medication. Because those are cleared in the kidneys. So you're going to need to know that. And you want to know what their electrolytes are and their volume status and all those things. So the chemistry panel is important. CBC is the same way. Are they anemic at all? Because sometimes that can drive some of the ventricular rate or some of the issues there. And then a troponin, but only if you're suspecting ischemia. If they've got any symptoms, that they have risk factors, you're concerned about those things, then a troponin. But that's not something that you necessarily have to order on every patient with AFib. AFib can be ischemia driven, but in most cases it's not. All right, so what are your treatment goals? So we've made our diagnosis, your job, you have three jobs. You've got to think about stroke prevention. So we're going to walk through who's at risk for stroke and how do we manage that. You need to think about rate control, if they're still in it right now, and how do we manage them in the moment. And then which patients or how do we manage or start to think about rhythm control. So it can get a little complex for these patients. So who needs, first of all, let's start with who needs hospitalization. These patients that, let's say they present a D or EB, who can we send home and who absolutely needs to be admitted. So those that need to be admitted are those that have heart failure, hypotension, or difficulty with rate control. So maybe they came in with a rate of up to 180, blood pressure's 95, and so it's kind of tenuous to figure out how to get the rate down without lowering the blood pressure too much. And so you're kind of having to, you know, kind of manage that. Probably those patients need to be admitted. They have any issues with volume overload, hypoxia, those patients need to be admitted. If you're thinking about initiating an anti-arrhythmic therapy, which again, it's probably not something you're going to do right off the dock, so to well, so to speak, for new onset. But if you're managing somebody that you're looking to try to maintain sinus rhythm and you're initiating one of the anti-arrhythmics, oftentimes those patients are admitted. A great example is Tickison. They're admitted because they need to be monitored for QT intervals to make sure that medication is safe for them. Treatment of associated medical problems, so if they're hypertensive, have infections, thyroid storms, COPD, PE, persistent myocardial ischemia, or any acute pericarditis. So sometimes there's things that can precipitate AFib, and so if those are underlying conditions that need to be managed, they probably need to be admitted for those things. Again, if you're looking for long-term management and you're bringing them in for an ablation, those patients may need to be admitted. And then severe bradycardia or prolonged pauses after conversion. So earlier I mentioned that syncope could be a symptom. Typically what drives the syncope isn't a ventricular rate that's too fast. It's actually when the patient converts, and even sometimes when they self-convert, they can have a significant pause, several seconds, and enough that they can cause a syncopal episode. And so there is something called tachybrady syndrome. I'm not going to go into a lot of details on that other than to say there are patients that are very difficult to manage, whether they're too fast or too slow. Medications make them too slow, but with no medicines they're too fast. Or they have these long pauses after a conversion, even a self-conversion. Those patients may need to be admitted for management, and sometimes they end up with a pacemaker or some type of a device. So let's talk about stroke prevention. First of all, we've got some great risk stratification models that help us understand who should be anticoagulated and who should not. So the first thing you want to do is calculate their stroke risk, and the typical tool that we're using now is the CHADS-VASC that takes into account multiple comorbidities, and I'll show you that here in a minute. And then you will want to utilize the updated 2019 guidelines, and I've included that as part of your readings, but it's section 4 of those guidelines that are going to go through, and I've got that here on the next slide. And then a part of those guidelines for long-term management is you need to understand your bridging therapies, who requires short-term IV therapy because of very high stroke risk versus those that you can just start on oral therapy. Their risk is still pretty low, so even a couple days of being sub-therapeutic is okay, that the risk of putting them on IV is higher than the risk of just starting the meds and getting them going. Now the non-warfarin, the half-life on those medicines are pretty short, and their ability to get them to therapeutic ranges is also pretty short, you know, matter of, you know, hours to a day or two. So back in the days when we used a lot of warfarin and it would take five to seven days to get these patients therapeutic, we've got a lot of better options now for those patients that can tolerate the NOACs, and I'll talk about that in a minute. So here's your CHADS-VASc score, and you can kind of see all the comorbidities on the left, systolic dysfunction, hypertension, age, diabetes, history of stroke, vascular disease, age, female, you know, second age, because if they're greater than 75, they get two points, 65 to 75 gets one, and then you can kind of see where their rate of stroke starts to go up annually based on their score. So then if we look at those 2019 guidelines for patients with AF and a CHADS-VASc of two or greater in men or three or greater in women, oral anticoagulants are recommended, and this is really whether or not their AF is paroxysmal, persistent, they have AF at some point, and so if their CHADS-VASc is elevated, we need to think about anticoagulating them. I gave you some of the different options. The NOACs are recommended over warfarin, and those patients that are eligible, those that have moderate to severe microstenosis or mechanical heart failure are not eligible, so those are warfarin at this point until we learn more or have better outcomes. Select your anticoagulation therapy should be based on the risk of thromboembolism irrespective of the AF pattern, so whether they're, again, paroxysmal, persistent, both of those would require anticoagulation if their CHADS-VASc indicates. And then atrial flutter, I haven't spent a lot of time talking about atrial flutter. Atrial flutter is very similar. The stroke risk is the same for all intensive purposes for recommendations, so if they have that CHADS-VASc and they have a flutter, we're going to go ahead and want to anticoagulate them. Again, the only difference with a flutter is it's more organized, but the atria are contracting quickly, you know, 150 to 225 or 300, and so that's just enough that that blood can still pool and those crevices and embolisms can occur and cause stroke or other issues. So let's talk about rate control. So a patient presents to your ED or you get a call post-op, patient went into AFib and their rates are 150, 175, what are we going to do? The typical management is beta blockers or the non-dihydropyridine calcium channel blockers. Both have rate controlling properties, flow down the flow through the AV node and therefore decrease ventricular rate. So oral versus IV, different places do things a little bit differently. There's, so I would, number one, go back to your teams and find out what the typical process or protocol or care pathway is. Some programs use IV card exam. The nice part about that is the half-life is short. It's an IV drip or a small bolus and you can quickly turn that off if blood pressure drops and that kind of thing. Others use low presser or other type of beta blocker. Part of that I think it, some, again I'm just kind of giving you things that I've heard over my many years of doing this work, because it tends to drive that heart rate that the low presser, that beta blockade in some cases can be a little bit more effective. But in this case it's oral, the half-life is longer and so if you're at all worried about managing blood pressure or any hypotension with this, you don't have this easy of a option to just turn the drip off and let the half-life work its way through quickly. This one's going to be on board for quite a bit longer. So just things to think about and work with your clinical teams and physicians that you'll be working with as far as what they have seen and what their preferences are. So then when we think about rhythm management, and in this case cardioversion, some of the things to think about. So when your AFib lasts longer than 48 hours, patients really for stroke risk control need to be anticoagulated for at least three weeks and then of course four weeks after. And that's no matter what their Chaz Vasquez, that's just related to wanting to anticoagulate them for that just in case that they may have an embolism in there. If you think that the symptoms have been less than 48 hours and you're confident that can define the timeline, and I would suggest that over the years we've become less and less confident that that can define the timeline, then you can go ahead and cardiovert. But if there's any concern at all but you feel the patient needs to be cardioverted in the short term, and that would be things like hemodynamic instability, you're having a hard time managing that blood pressure, patients are quite hypotensive and so it makes it difficult to get the rates down, or they're having heart failure symptoms, then you can do a TEE, again looking for that thrombus that at some point might become an embolism, and look for that on the front end before you cardiovert. So again, lots of decision-making here. This is definitely something that as you work with your clinical teams and to make these decisions that it's important to understand the guidelines and really minimize that risk of stroke. What's interesting is that in most patients and new onset AFib, when we follow them out, most of them will spontaneously convert within 48 to 72 hours, and again on their own, and so sometimes it's just a matter of waiting a little bit. But it's, you know, these are the kinds of things that we stand around the hallways and have discussions about are the best way to manage these patients. So get used to working with your care teams and having those discussions. One other thing I do want to mention for the lower risk patients that don't have a lot of comorbidities, there is a pharmacologic cardioversion option called pill-in-the- pocket, or kind of a term we endearingly think of it as, with either using fluconide or propanone, and this can be utilized to terminate paroxysmal AFib. When I say paroxysmal, they're in it, we're trying to get them out of it, but you have to rule out ischemic heart disease first. So if this patient just showed up and this was their first visit or their first issue with AFib and they have no, have never had a cardiac workup in the past, this is not going to be an option for them. So they're going to need some type of stress testing before you can safely give this medication to them. Most of the protocols include beta blockers. Again, this is something that you're going to want to work closely with your physician teams on and even your EP teams on to understand how you want and what the protocol looks like in your facility, in your program, and these are typically, again, cardiology supported approaches. Now I have seen really great coordination and collaboration between cardiology and emergency rooms where these things can be managed, but again, this is all very much care pathway set out on the front end with the inclusion and exclusion criteria very outlined very well. So, but I just want you to be aware of it. This may be something that you'll see as well. So additional considerations, I talked about that post-op AFib. Sometimes this is cardiac post-op and sometimes these are non-cardiac surgical patients, but your goal is to slow the ventricular rate and monitor. Again, in some patients, we will use antiarrhythmics. Again, these are inpatient, so we may start amiodarone. That's a common one and many of our programs do have protocols in place or pathways, so I would ask about those as far as loading criteria and IV infusion versus oral. There's different things to think about, but again, anticoagulation, you got to think about that Chaz Vest score and also risk versus benefit. These are post-op patients. You got all kinds of things to think about from a bleeding perspective, so definitely a shared decision, but as you evaluate these patients, and this is a fairly common thing that we see, so if you're working in the hospital, you're going to get called on these patients and how to best manage. And then for follow-up for our patients, if we're able to send them home or even admit them and then send them home, we recommend managing these patients back in the clinic in three to five days. They are going to have a ton of questions. Again, we have three things to think about, so stroke prevention, rate control, and rhythm control, and they're going to have questions on all three of those things, and so bringing them back in, many of these ends up with a couple new, two or three new medicines. They're going to want to have questions on that, so following them closely is really important, and then getting them plugged in to develop a long-term plan for if this comes back or any other comorbidities that need to be managed, like sleep apnea, hypertension, those sorts of things. So that brings us to the end, and again, if you have any questions or concerns or thoughts, please reach out to the Academy, and we'll be happy to get back with you and answer any of those questions, and again, we always appreciate the feedback. So thank you for your time today, and good luck managing AFib.

atrial fibrillation

symptoms

risk factors

diagnosis

treatment goals

management options