Atrial Fibrillation/Flutter (ECS 2024)

Before you start

Whats the cause? – treating the precipitant often sorts the AF (adding B-Blockers to Sepsis can make things worse)
Stable or Unstable? – Electricity vs. Drugs
Rate/Rhythm control
CHADS-VASC vs. ORBIT– Anticoagulation
NEW Symptomatic Arrhythmia Clinic [6-8weeks] – referral form attached tho the PDF

Discharge? – If all of following

- No compromise
- HR<110 for 2hr
- No precipitants requiring admission

AF/SVT Clinic – AF/SVT clinic Referral form

This clinic is only for:
- Symptomatic patients with new onset AF /SVT (where the presenting symptoms are definitely due to AF /SVT)
- And patients have fast ventricular rates.
- ECG shows AF/SVT

Unstable AF

Haemodynamically UNSTABLE patients

Any of:

- Shock sBP <90mmHg – poor perfusion
- Reduced level of consciousness – poor brain perfusion
- Cardiac Ischaemia – poor heart perfusion
- Pulmonary Oedema – poor lung perfusion

Emergency DC Cardioversion (DCC) is the mainstay of treatment. Obviously DCC is uncomfortable experience and sedation is preferable, however, if unstable sedation may not be an option.

DC Cardioversion (SYNCRONISED)

- Consent (best interest if needed)
- Sedation if possible (may require anaesthetic assistance)
- DC Cardiaversion
  1. Syncronise (white dots appear over QRS on monitor)
  2. Energy
    - 1st shock 70J
    - 2nd shock 120J
    - 3rd shock 200J
  3. Charge & Shock (oxygen away, everyone clear!)
  4. Reassess – repeat for further shocks if required

Tachycardia Guide line – Resus Council

Causes/Tests

Causes

It’s essential any Modifiable causes are treated, these include:

- Haemodynamic stress: Valvular disease/Hypertension/LVD/Thrombus
- Atrial ischemia: Ischaemic Heart Disease
- Inflammation: Sepsis/Myocarditis/pericarditis
- Noncardiovascular respiratory causes: PE/Pneumonia/Lung Cancer
- Alcohol and drug use: Alcohol/Cocaine/Amphetamine
- Endocrine disorders: Hyperthyroid/Diabetes/Phaeochromacytoma/Electrolyte prob.
- Neurologic disorders: Subarachnoid Haemorrhage/Stroke
- Genetic factors
- Advancing age

Tests (NEW AF)

12 Lead ECG
Bloods: FBC, U&E, Bone profile, Magnesium, LFT, TFT, Clotting, Glucose
Others: individualised to the patient.

STABLE – Rate/Rhythm Control

Rate Control

First line:
- β-Blocker – outperforms calcium channel blockers in studies
- Non-dihydropyridine calcium channel blockers (Diltiazem/Verapamil) – esp. in Severe COPD/Asthma
Second Line:Consider adding in
- Digoxin – however, digoxin alone is not effective in patients with increased sympathetic drive. Observational studies have associated digoxin use with excess mortality in AF patients)
- Amiodarone can be useful as a last resort when heart rate cannot be controlled with combination therapy in patients who do not qualify for non-pharmacological rate control

Rhythm control in ED

“Early cardioversion is not recommended without appropriate anticoagulation or transoesophageal echocardiography if AF duration is longer than 24 h, or there is scope to wait for spontaneous cardioversion.”

In reality risks increase beyond 12hrs from onset, and those reverted in ED will often return to AF by the time they get to AF clinic follow up.

STABLE – Stroke Prevention

Anticoagulation

AF increases the chance of Stroke by 5x (and those recently diagnosed are least likely be on any form of protection)

ESC/NICE recommends using the CHADS-VASc to assess stroke risk and ORBIT to assess bleeding risk
There are currently significant delays getting to “New AF” clinic as well as to GP’s, making assessment of Stroke risk in ED more important than ever

CHADS-VASc outcome recommendations

- Males (0), Female (1) – No anticoagulation recommended
- Males (1) – Consider anticoagulation (DOAC) in light of bleed risk
- ALL (≥2) – Anticoagulation recommended (DOAC)- Trust DOAC guide, NICE/CKS
- Use Apixaban where first line, significantly cheaper. If using alternative please document reasons.

ORBIT outcome recommendations

- Modifiable risks – Address ALL modifiable risk factors
- Most will benefit from anticoagulation – but discuss personalised risk with patients

Contraindications to Anticoagulation inc:

- Active serious bleeding (where the source should be identified and treated)
- Associated comorbidities (e.g. severe thrombocytopenia <50 platelets/lL, severe anaemia under investigation, etc.)
- Recent high-risk bleeding event such as intracranial haemorrhage (ICH).

STABLE – Comorbidities

Cardiovascular risk factors

- Life Style
  - Obesity: Risk of AF, Recurrence of AF and Stoke all increase with BMI
  - Alcohol: Alcohol excess both increases the risk of AF and of Bleeding, so patient should support to reduce aldol intake is recommended
  - Caffeine: It is unlikely caffeine consumption causes AF. Habitual caffeine use may reduce the risk of developing AF. But increases the symptoms
  - Exercise: Moderate cardiavasclar exercise is protective, however higher rates of AF are seen in elite athletes and vigorous physical activity
- Specific conditions- patient should follow up with GP/Clinic (treatment may start in ED)
  - Hypertension
  - Heart Failure
  - Coronary artery disease
  - Diabetes Mellitus
  - Sleep Apnoea

STABLE – CARE