After A-Fib rate control or cardioversion do you....

[drummer girl]

Hi guys-
After getting a stable A-Fib patient back into a rate below 110, and starting anticoagulation
of some type based on CHADS2Vasc- the question is:
If you are sending the stable patient home, do you start some kind of medication
to keep them in rate control or rhythm control? Or do you sent out with no
rate or rhythm control meds and just have their PCP start the meds? I assume their
is some criteria to tell you what & when you need to start these medications or maybe the ED doctor
doesn't start these meds as it's the PCP's job???

thank you for your help-

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[Daiphon]

Hi guys-
After getting a stable A-Fib patient back into a rate below 110, and starting anticoagulation
of some type based on CHADS2Vasc- the question is:
If you are sending the stable patient home, do you start some kind of medication
to keep them in rate control or rhythm control? Or do you sent out with no
rate or rhythm control meds and just have their PCP start the meds? I assume their
is some criteria to tell you what & when you need to start these medications or maybe the ED doctor
doesn't start these meds as it's the PCP's job???

thank you for your help-

Guidelines may exist, and my approach may come from them; but I don'rlt recall evwr reading then...

Known afib = AC per CHADS2, continue prescribed meds, *maybe* bump doses after conversation with PMD or Cards.

New AFib:
Converted to sinus (chemically or spontaneously) = AC, no rhythm or rate control, but close f/u.

Converted to sinus electrically = admit, as pt was unstable enough for me to use Edison's Medicine.

Rate controlled = I don't send these home; 23h obs at the very least to figure out daily med dosage requirement.

Cheers!
-d

 

[turkeyjerky]

Guidelines may exist, and my approach may come from them; but I don'rlt recall evwr reading then...

Known afib = AC per CHADS2, continue prescribed meds, *maybe* bump doses after conversation with PMD or Cards.

New AFib:
Converted to sinus (chemically or spontaneously) = AC, no rhythm or rate control, but close f/u.

Converted to sinus electrically = admit, as pt was unstable enough for me to use Edison's Medicine.

Rate controlled = I don't send these home; 23h obs at the very least to figure out daily med dosage requirement.

Cheers!
-d

Interesting. So if someone with known afib comes in symptomatic from RVR, are you giving a bolus of dilt to get the rate down, then discharging them? I would love to have a aprotocol for giving an Iv bolus, infusion for an hr or two with an oral dose and then dc. I haven't seen one though. At my shop, these typically get a tele obs admit for transitioning to oral meds.

I'm pretty comfortable with rapid discharge after electrical conversion, but would want at least a few hours of tele observation after chemical conversion to monitor for arrtythmias.

 

[Janders]

I HAVE discharged AFIB RVR (without other complicating factors home) after IV rate control, and modification of their home regimen (i.e. increase dose of toprol XL) after conversation with their cardiologist.
I find this more often with younger/healthier/informed patients, who frankly refuse to stay in the hospital overnight after their rate comes down with an IV bolus.

That said I TYPICALLY place these in floor observation on tele for cards consult, +/- echo, verification that we are keeping their rate down appropriately.

I agree, a well documented pathway would likely all MORE of these patients to go straight home.

 

[Boatswain2PA]

You are comfortable sending someone home after sparking them back to SR? Are you quick to go to sparking? (Ie: electrically converting symptomatic but stable).

I have never sent home someone I just applied electricity to.

 

[WilcoWorld]

Assuming everything else seems OK I will discharge someone after cardioversion of a fib, either electric or chemical. I do not typically start them on anything, but I do ensure close follow up and tell them to return if they have recurrence of symptoms.

So other will anticoagulate patients after a single episode of a fib, even though they're back in sinus rhythm? I must be missing something, as this doesn't seem right to me.

It is worth noting that I'm quick to use electricity when the time of onset is clearly <48 hours (actually more like <12 hours).

It is doubly worth noting that all of the above assumes the patients can actually give me a good history and negative ROS. The patients who report vague symptoms and/or have multiple (+) on ROS get rate control, heparin and admission.

 

[Daiphon]

Interesting. So if someone with known afib comes in symptomatic from RVR, are you giving a bolus of dilt to get the rate down, then discharging them? I would love to have a aprotocol for giving an Iv bolus, infusion for an hr or two with an oral dose and then dc. I haven't seen one though. At my shop, these typically get a tele obs admit for transitioning to oral meds.

I'm pretty comfortable with rapid discharge after electrical conversion, but would want at least a few hours of tele observation after chemical conversion to monitor for arrtythmias.

Depends on the scenario, comorbidities, and associated complaints... but yeah, I have done this & are comfortable doing so.

I feel it's somewhat akin to a breakthrough seizure - no other problems, classic presentation, no other issues? Check AED levels, replete as needed, maybe add another agent after talking with neuro, d/c home with close followup... but *new* seizures, or persistent AMS/deficits/status/etc = admit.

 

[deleted109597]

Canadian EPs send home after electricity all the time. It's safe, effective, and quick. Risk isn't zero, so don't expect it to pick up in the US anytime soon.

 

[Janders]

Again, I've certainly sent people home after sparking them.

What do you think cardiology does when they schedule an outpatient cardioversion?!

I don't do it all the time, but a patient with paroxysmal afib, on stable anticoagulation, with 3 hours of "horrible" rapid afib they can't stand, knowing they normally live in sinus... call cards, give some sedation, hit the SHOCK button, happy patient wakes up... home!

 

[Boatswain2PA]

Cards outpatient cardioversion is a different population group, and obviously stable.

To me, 3 hours of "horrible" afib they can't stand is (or was) a stable patient, and I will try to wait for the medications to work. I guess my fear is that if I can't get them back to SR with medications, that they take home with them in their serum to keep them in SR, then how do I know they aren't going to relapse again an hour or two after they leave. That being said, I certainly don't know how often folks get electrically converted and then lapse back into A-fib at a given time frame.

If I had a pt whose cards confirmed that "this happens all the time, shock'em and end them home" then I would do so, just haven't seen that patient yet in my very rural EDs with no on-site specialists.

Thanks for the discussion/education!

 

[xaelia]

Definitely send home paroxysmal a-fib after electricity & a-fib RVR after IV rate control both. Details of each discharge varies between patient-to-patient and their follow-up.

 

[Arcan57]

Afib, even paroxysmal afib, is a chronic disease requiring chronic management. Think of it like diabetes. Occasionally it's the main problem and needs to be emergently treated but most of the time it's along for the ride. You need to investigate precipitating sources and compliance with home regimen.

 

[Birdstrike]

Warning: Not to be read by those living or practicing medicine in Texas

Quickly cardiovertable acute PSVTs in young people with no medical problems are low risk, are in a completely different category than afib RVR and can often go home if otherwise stable, uncomplicated and quickly cardioverted.

As far as afib with RVR, these are on a case by case basis of course, but I have a few thoughts. Think of all the questionable diagnosed that get admitted, yet someone comes in with documented abnormal vitals (HR 140, for example) and corrected or not, that doesn't get them admitted, at least for overnight observation?

"Choosing Wisely" or "Choosing Poorly"?

Yes, afib is "a chronic disease" but at the same time, "No it's not." It's not, when it lands acutely in the ED. Also, the effects of your treatment for it aren't "chronic." A patient comes in with a hr of 140, you give some IV meds and get the HR down, but even if you adjust their outpatient med doses in conjunction with their PCP, there's no reasonable assurance that once your iv meds have worn off in a few hours, that your PO regimen is going to hold up its end of the bargain, is there?

Also, cardioverting supposed new onset afib, most of the time isn't new onset. People are in and out of afib all the time and hardly ever know what their rythm is doing. That's why we do ekg's. Patients aren't reliable when it comes to determining their own heart rhythm. That's why event monitors exist. Patients have no flipping clue what their heart rate's doing most of the time. Cardioverting stable afib for the sake of cardioverting it is a waste of time, for ED purposes, in my opinion. What have you accomplished by doing it? Nothing, but doing the cardiologists work for him. If it's so urgent to him, he can come in and do it. I guarantee you they won't. They don't consider it (stable afib) an emergency. Not even close.

Patients with afib RVR generally are elderly or approaching that status, have multiple co-morbidities, often including at least HTN and some form of underlying cardiac disease and therefore are a high risk population for adverse outcomes, in general. Why be cavalier about slingshotting these people out of the ED? Sure, there are exceptions, but there's nothing to be gained by being cavalier about these patients other than getting an imaginary gold star from the those trying to save money for "the system," at risk to your liability exposure.

These patients are old (usually).

They have documented abnormal vital signs.

They almost always have significant co-morbidities.

There's almost always some justifiable reason to admit these people. The proof is that are in the ED, because some element of the outpatient treatment approach failed, wasn't available, or had some huge gap in accessibility, in the first place. That's not even to mention whatever underlying trigger, event, infection, medication non-compliance or other issue that landed them in the ED in the first place, diagnosed or undiagnosed. If IM and Cards were so good about managing them outpatient, then they would have ended up in the ED. Their monkey; their circus. Consult and admit all day long.

 

[Arcan57]

Warning: Not to be read by those living or practicing medicine in Texas

Quickly cardiovertable acute PSVTs in young people with no medical problems are low risk, are in a completely different category than afib RVR and can often go home if otherwise stable, uncomplicated and quickly cardioverted.

As far as afib with RVR, these are on a case by case basis of course, but I have a few thoughts. Think of all the questionable diagnosed that get admitted, yet someone comes in with documented abnormal vitals (HR 140, for example) and corrected or not, that doesn't get them admitted, at least for overnight observation?

"Choosing Wisely" or "Choosing Poorly"?

Yes, afib is "a chronic disease" but at the same time, "No it's not." It's not, when it lands acutely in the ED. Also, the effects of your treatment for it aren't "chronic." A patient comes in with a hr of 140, you give some IV meds and get the HR down, but even if you adjust their outpatient med doses in conjunction with their PCP, there's no reasonable assurance that once your iv meds have worn off in a few hours, that your PO regimen is going to hold up its end of the bargain, is there?

Also, cardioverting supposed new onset afib, most of the time isn't new onset. People are in and out of afib all the time and hardly ever know what their rythm is doing. That's why we do ekg's. Patients aren't reliable when it comes to determining their own heart rhythm. That's why event monitors exist. Patients have no flipping clue what their heart rate's doing most of the time. Cardioverting stable afib for the sake of cardioverting it is a waste of time, for ED purposes, in my opinion. What have you accomplished by doing it? Nothing, but doing the cardiologists work for him. If it's so urgent to him, he can come in and do it. I guarantee you they won't. They don't consider it (stable afib) an emergency. Not even close.

Patients with afib RVR generally are elderly or approaching that status, have multiple co-morbidities, often including at least HTN and some form of underlying cardiac disease and therefore are a high risk population for adverse outcomes, in general. Why be cavalier about slingshotting these people out of the ED? Sure, there are exceptions, but there's nothing to be gained by being cavalier about these patients other than getting an imaginary gold star from the those trying to save money for "the system," at risk to your liability exposure.

These patients are old (usually).

They have documented abnormal vital signs.

They almost always have significant co-morbidities.

There's almost always some justifiable reason to admit these people. The proof is that are in the ED, because some element of the outpatient treatment approach failed, wasn't available, or had some huge gap in accessibility, in the first place. That's not even to mention whatever underlying trigger, event, infection, medication non-compliance or other issue that landed them in the ED in the first place, diagnosed or undiagnosed. If IM and Cards were so good about managing them outpatient, then they would have ended up in the ED. Their monkey; their circus. Consult and admit all day long.

I'm ignoring your disclaimer but I feel like the reasoning would hold up in OH or TN as well.

First, throw out the bucket of pts with a.fib +. As mentioned in my previous post, loss of rate control or new onset a.fib is often the result of some significant acute process (PNA, COPD exacerbation, electrolyte derangments, sepsis, etc.). These patients almost universally need to come in for treatment of the inciting event.

Second, initially abnormal vital signs that normalize and that have a reasonable explanation (out of rate control meds, started OTC diet pills, etc) don't require admission. The easiest argument to make in support of this is the initial marked tachycardia in febrile kids with viruses that we d/c routinely.

Third, if the a.fib re-occurs it's not like they're dropping dead like in V.fib. In the acute term, they come back to the ED because they're having palpitations or dyspnea. They may suffer a stroke, but if you're doing the work of dc'ing the patient then you need to calculate out the risk score and start them on the appropriate medication. Of course the risk of CVA is something that would be discussed with the patient and documented as such.

Fourth, if the patient is old and frail and you're concerned that they can't tolerate even a transient period of tachycardia (poor EF, severe pulmonary disease, etc) then you admit them.

If they pass through all these filters, I think it's reasonable to send them home. Is it more work? Obviously. But sometimes doing the right thing for the patient is worth it.

Note to those early in training: this is primarily a discussion about philosophy and risk tolerance. I'm guessing that the difference in practice between the views Bird and I are advocating are applicable to less than 1:20 patients with a.fib w/RVR presenting to the ED.

 

[xaelia]

Speaking of which, just electrically converted paroxysmal afib/RvR overnight and discharged them. LOS ~2 hours.

 

[ccfccp]

I almost always admit these patients. They usually leave the ED on a drip for the floor to titrate down while PO ramps up. I've seen too many times where patient gets cardizem (or bb) bolus, has rate control, and then jumps back up after the IV push wears off. I see almost no upside from discharging these patients other than taking on a large amount of legal risk. I'm fairly aggressive about sending people home (at least in our group), but I agree with birdstrike. I almost never see an "otherwise healthy" afib RVR patient. It seems like you guys can get your stat cardiology consult/phone call with close outpatient cardizem, but the cardiologists around here would be lining up to crucify you if one of their patients had a bad outcome (it doesn't matter what they said over the phone at 3am - i.e. "Well, the Dr. EP didn't tell me that THAT was going on and that it was THAT serious... Of course I would have admitted them.")

 

[CanadianEM]

You guys are nuts. Give them electricity and send them home. They'll feel better and you don't needlessly admit a patient. Order whatever labs and X-ray you want (no trop though) and arrange outpatient follow up if you're so inclined. Start them on ASA or warfarin/NOAC depending on their CHADS2-vasc score. This approach is well supported in the lit, and I've yet to see any bad outcome from this. The idea that I would admit an otherwise well afibber (not the septic ones, or the ones in pulmonary edema or whatever else may have triggered it) simply to control their rate is crazy to me. And I wouldn't be able to in the first place.

 

[hoot504]

You guys are nuts. Give them electricity and send them home. They'll feel better and you don't needlessly admit a patient. Order whatever labs and X-ray you want (no trop though) and arrange outpatient follow up if you're so inclined. Start them on ASA or warfarin/NOAC depending on their CHADS2-vasc score. This approach is well supported in the lit, and I've yet to see any bad outcome from this. The idea that I would admit an otherwise well afibber (not the septic ones, or the ones in pulmonary edema or whatever else may have triggered it) simply to control their rate is crazy to me. And I wouldn't be able to in the first place.

Sounds nice up there in Canada.

 

[Arch Guillotti]

What do you think cardiology does when they schedule an outpatient cardioversion?!

They watch them for a few hours as an inpatient after the cardioversion.

 

[TooMuchResearch]

They watch them for a few hours as an inpatient after the cardioversion.

Not here.

 

[Janders]

Not here.

Not here either. Patients who are electively cardioverted as outpatients get brief anesthesia, get electrically cardioverted, and have brief tele monitoring while they wake up from their anesthesia. For the RIGHT patient, I do precisely the same thing in the ED.

45yoM with paroxysmal fib, on xarelto, lives in sinus, last noted paroxysm 18mo ago, now presents with 3 hours of rapid palpitations after his 3rd espresso this AM. Noted to be in rapid afib with rate 145, otherwise benign vitals and exam. No other medical problems, though he takes 20mg statin per the rec of his cardiologist. You offer him rate control and an overnight stay on tele to get him settled. He laughs and asks if you can't just cardiovert him like his cardiologist did 18mo ago?

 

[Groove]

I posted in a related thread awhile back and dug it up. It's a bit long winded, but I guess its relevant. It was from a good CDEM article.

There's a really good article in CDEM from April 2014 on this very subject. I highly recommend reading it if anyone else is a subscriber. I have a PDF version that I would gladly post in here...if it didn't break forum policy. Ahem...

The key section of the article which we are all interested in "In which stable patients with AF is emergency department cardioversion safe?"

Here were a few takeaway points that I learned from the article.

• RACE and AFFIRM trials appear to at least give the rhythm control crowd a leg to stand on with the AFFIRM trial being the larger one by far.
• 30-45% of paroxysmal AF occurs in younger pt's without demonstrable underlying cardiac disease. (The only group I would personally consider cardioversion if they were hemodynamically stable. )
• It's worth figuring out WHY? the pt went into AF. Causes: Valvular heart disease, HTN, LVH, alcohol, surgery, MI, peri/myocarditis, PE, pulmonary disease, hyperthyroidism, metabolic derangements, the list goes on and on....
• AHA 2001 guidelines recommend cardioversion of AF with duration less than 48 hrs citing "low risk of thromboembolism". This recommendation has not been reaffirmed or refuted by the 2006 or 2011 AHA updates.
• Pt perception of duration of AF is NOT accurate. Studies revealed 68% accuracy is pt perception and 40% of pt's with newly diagnosed AF are asymptomatic. 58% of pt's with implanted rhythm control devices revealing AF were also asymptomatic. (So, essentially... a pt telling you "Doc, it's def been less than 48 hours means nothing.)
• There's a few studies on the specific complications...following both pharmacologic and electrical cardioversoin. Maisel and Stiel, etc.. Relatively small studies, but citing up to 11% complication rate. However, I found it interesting they they don't discuss the specific complications. Another study tried to clarify the complications and 6% suffered sedation complications, 2% suffered burns, VTach, unstable bradycardia.
• Risk of thromboembolism following cardioversion of AF without simultaneous anticoagulation is 0-7%
• 66% of "new onset" AF will spontaneously convert to normal sinus rhythm within 24 hours and this number increases to 80% by 48 hours.
• Atrial "kick" accounting for 10-15% boost in CO does not return for days to weeks following cardioversion 2/2 atrial myocardial stunning. (This is a reason for arguing in favor for 3-4 weeks anti-coagulation following cardioversion.) The "stunning" effect is noticed both in electrical, pharmacologic, and spontaneous cardioversion.
• Although new onset AF can be atypical presentation of ACS, incidence of ACS in pt's with new onset AF ranges from 1% - 11%

Myths:

• No stroke risk with cardioversion of acute AF within 48 hours of onset. (Study showed 143 pt's with TEE prior to cardioversion of AF < 48hrs with 14% atrial clot vs 27% in chronic AF.)
• No stroke risk associated with cardioversion preceded by a negative TEE . Study showed 6% risk of thromboembolic event following negative TEE. (Is TEE imperfect screen? Or... does the clot form 2/2 atrial stunning. Consensus seems to indicate that it's forming post cardioversion due to the stunning effect which makes a stronger argument for post cardioversion anti-coagulation.)

Who can be safely discharged?

• AF in stable pt with HR < 120 needs no emergent treatment according to the authors.
• AF related to temporary causes: alcohol, surgery, pericarditis, PE, myocarditis, hyperthyroidism, metbolic disorders, --> treat underlying condition and the AF will resolve.
• HF, MI, chest pain, hypotension, renal failure, PE, hyperthyroidism, etc.. --> obviously get admitted. Of note, pt's with "structural heart disease" should also be strongly considered according to authors.

Ottawa Aggressive Protocol is a separate discussion.

Summary:

The authors seem to encourage:

• Cardioversion for hemodynamically unstable pt's, which we already knew.
• Taking into consideration RACE and AFFIRM...choosing conservatively and opting for rate control seems to maximize pt safety with diltiazem as the ideal rate control agent in nearly all pt's except those with suspected ACS or thyroid disease.
• Data on the safety of ED cardioversion in "low-risk" pt's with known AF duration of less than 48 hours is accumulating but risk of thromboembolic events as well as non thrombotic complications and a 24hr spontaneous conversion rate of 66% (80% at 48hrs) must be considered when choosing rhythm control.

So, in essence, I feel in the same boat as the authors. There is certainly enough growing evidence for the use of aggressive cardioversion and d/c in the ED but I don't feel like all the data is there yet and it's certainly not standard of care and continues to be a hotly debated topic in need of more research over the next several years before I see it ever as adopted as mainstream practice.

The biggest issues for me are: 1) Complication risk and 2) Ruling out all the other important underlying contributing etiologies to the AF that might preclude or dissuade me from aggressive cardioversion. Valvular and structural heart disease along with masked ACS is on the top of my head. Hyperthyroidism? I mean, am I going to get a reflex TSH and echo an all my pt's prior to juicing the pads? (Of note, I'm still not going to see an atrial clot with the TTE as TEE is much more sensitive.) Young pt's with no medical conditions are one thing, but that makes up a very small percentage of the "new onset" AF that I seem to see at my shop.

Either way, I see any and all complications from this practice as big lawsuits, and with the dearth in relative number of convincing studies to make this mainstream practice, I would do my best to rule out all the underlying contributing etiologies mentioned in the supporting literature that might contraindicate aggressive cardioversion since if you are involved in a lawsuit, that's the literature you're going to be using to support your decisions. If you're going to be thorough in that endeavor, it really begs the question... are you saving any time in the ED? Again, for me... almost all of these even mildly complicated pt's are easy, easy admissions.

Interesting topic and very relevant. It's good to see everyone's practice patterns. I can honestly see both sides though I definitely lean more conservative in my approach. Good stuff.

Oh, grab that CDEM issue if you can. Very high yield. Every bullet point has a supporting journal article(s) but it was just too much to post. If you want a specific reference, just ask and I'll add it to the bottom of this post.

 

[ccfccp]

45yoM with paroxysmal fib, on xarelto, lives in sinus, last noted paroxysm 18mo ago, now presents with 3 hours of rapid palpitations after his 3rd espresso this AM. Noted to be in rapid afib with rate 145, otherwise benign vitals and exam. No other medical problems, though he takes 20mg statin per the rec of his cardiologist. You offer him rate control and an overnight stay on tele to get him settled. He laughs and asks if you can't just cardiovert him like his cardiologist did 18mo ago?

Maybe it's my patient population, but including residency I'm on year 7 and and can probably count on one hand with fingers left over an Afib patient with that (or similar) age, on those meds, and with that close follow up came in the my ED. I've sent a few home like that, usually after significant documentation and offer of admission. However, my average afib RVR patient is 70+, has 3 stents, intermittently compliant with meds, and states "well, I have a cardiologist in Michigan that I saw two years ago, but even though I spend 11 months a year here I just haven't found the time to find any new doctors. Oh... and by the way, I've been having this strange pulling feeling in my chest that I was having before I got my last stent."

I don't electrically cardiovert unless unstable (which I'll do reasonably often), because I almost never have access to a VERY recent outpatient Echo.

 

[Janders]

Totally agree with you above, I'd admit that (or place in hospital observation...) rapid fib in a second.

Just depends on the totality of the situation/patient.

 

[LaBusqueda]

It seems like you guys can get your stat cardiology consult/phone call with close outpatient cardizem, but the cardiologists around here would be lining up to crucify you if one of their patients had a bad outcome (it doesn't matter what they said over the phone at 3am - i.e. "Well, the Dr. EP didn't tell me that THAT was going on and that it was THAT serious... Of course I would have admitted them.")

This. Happened A LOT at my previous shop. Sad state of affairs.

Fortunately this is location dependent as I see joke of this currently.