age cutoff for a fib cardioversion?

[prolene60]

I really love the acute onset a fib person, cardiovert them and then send them home. Besides long duration, unsure onset, would old age be a contraindication to electrical cardioversion? I mean if you had a 90 yr old lady who's very with it comes in rapid a fib, sxs started that morning, would anyone electrically cardiovert her? Had a 70 yr old woman hx of prior a fib(never before electrically cardioverted), had palpitations 12 hours ago, rapid a fib in the ED other vitals are completely stable. Normal labs. her only complaint is the palpitations. Sedate then Synch Cardiovert and she goes asystolic for like a minute, then normal sinus after 1 minute CPR. Awake, speaking, joking and eating. Now I'm 2nd guessing doing this again.

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[Tiger26]

It mainly depends on other comorbidities but if otherwise healthy and high-functioning, I have no problem doing it (provided they're certain it was within 48 hrs). With that said, chances are pretty high that they'll go right back into a-fib with increasing age

 

[Groove]

No, I would not cardiovert a hemodynamically stable 70y/o pt in the ED with a spotty history for very subjective < 48h a fib. Also, make sure the EKG doesn't look like MAT which can look very much like afib RVR. MAT is a clear contraindication along with the obvious > 48 hours onset so you'd better feel pretty confident in excluding both before you light up those pads. If you're going to do it anyway, then get an informed consent.

The <48 hours is the problem for me. Pt's perceived "palpitations" does not give me nearly enough confidence that it's indeed < 48 hrs. What if the afib has been there for awhile but they only felt palpitations 2/2 the ventricular rate? If they are stable, I've found very few pt's that I can't rate control. I also ask myself...what's best for the pt? What comorbidity, undiagnosed or otherwise, needs evaluation and/or tweaking to reduce their risk for a potentially more fatal, future arrhythmia or a recurrence of the afib?

I'm all for aggressive style when the situation calls for it and if they are hemodynamically unstable then of course, but in this case.... why? I see no reason to be aggressive in this case and it's an easy...and arguably appropriate admission for a 70 yo pt.

 

[gman33]

Interesting discussion.
It would never even enter my mind to cardiovert a stable afib.

Why did they go into afib? Is there something else going on?
The 48 hour part is tricky.
I agree with the point that it could be that they just sensed it when the rate sped up.

Cardizem, admit.

If unstable, that's a whole other thought process.
I would do whatever needed, including cardioversion.

 

[prolene60]

It's just they've been publishing all of these articles about the good option and saving an expensive admission for electrically cardioverting folks rather than spending days anticoagulating, TEE, chemical cardioverting etc.... I feel like a 30 yo guy coming in with sudden onset a fib, you run the labs, cardiovert him, he's back to normal, feeling a great, you save him an admission as well as anticoagulation. Whole process takes like less than 2 hours. He follows up with the cardiologist the next day. If anyone agrees that this is a good option for a younger patient then why not for an older patient?(whom you don't suspect MI or you r/o PE etc..)

 

[Birdstrike]

Here's my thought on this:

1- Stable afib, is "stable." I never liked the idea of putting 100 or more Jules of electricity through the heart of someone who walked into the ED and without doing anything, is almost certain to walk out. Your example is the perfect reason. If you've sparked enough people, you know that you really can never be quite sure that you are converting them to the rythm you think you are. Your rythm may change, or it may not. It may change to sinus, or it may not. It may flip into Asystole, or vfib. Most of the time it will covert as you planned, but when you're putting that much electricity directly into the heart you just really never know.

2- Despite your patient claiming beyond a shadow of a doubt, "It started 44 hours ago doc, I'm sure of it!" you really just never know. Just try an experiment. The next random 20 cardiac patients you see, ask them what rythm their heart is in, "normal rythm" or "not normal"? Ask them if them felt "palpitations" or not. Then pimp them with, "Are you 100% certain those 'palpitations' were afib or just pvc's? Could they have been pac's?"

It then becomes obvious your success rate is going to be s--t, and that patients have no clue about this. The only exception would be if you just happen to have on record, an EKG from 36 hours ago showing NSR compared to your current EKG showing afib. That would be unlikely.

3- Many new onset afibs convert on their own back to sinus in the first couple of days. Would you want your heart juiced if the afib was going to be going tomorrow am after your over-taxed liver finally got to work on your Mountain Dew, Malboro Lights and six pack of Busch Ice from last night's Nascar race? (I know: invalid question. You only drink the finest Pinot Noir from France).

In light of this, many would argue that true new onset, stable afib doesn't even need to be admitted, cardioverted or treated with anything, in the first 24-48 hours (but that's a different discussion).

4- Despite new onset, stable afib being essentially "stable" and non-emergent, Medicine will often bite on it and admit anyways (because it's easy, if they're not overwhelmed). Easy 20 second dispo.

5. A lot of afib, that's cardioverted back to sinus, just flips right back to afib at some point, which brings you back full circle to reason #1, and the OP: why sedate a stable person, without a cardiology emergency and spark their heart in a busy ED when there's several other paths of lesser resistance which will not harm the patient one iota (and may harm them less)?

6- If you disagree with #5, and think it is such an urgent (if not "emergent") situation that they get cardioverted right away (within this shaky 48 hr time window) then cardiology can come do it. (Oh, but they won't. First reason given by them:IThey agreed it had to be done "right awa, exactly until they were asked to come make it happen. Then, it could wait.)

7- Articles shmarticles. Get used to "articles" and people telling you to save money for "the system." You still need to do your job. You can't save the broken "system" all during this shift (or ever).

 

[WilcoWorld]

If I were in a fib and confident that it had been going on for under 48 hours I would personally prefer to be cardioverted rather than rate-controlled.

I have a cardiologist who is a bit of a frequent flyer for his paroxysmal a fib - he always wants electricity. Given that he checks his pulse at least twice daily, I'm pretty comfortable with his duration estimations.

When duration is in doubt, I won't shock a stable a fib. However, in cases where the onset is reasonably clear (of course, it's never 100% certain unless they've been on a monitor the whole time), I think shocking stable a fib is a perfectly good treatment option.

 

[spyderdoc]

It's just they've been publishing all of these articles about the good option and saving an expensive admission for electrically cardioverting folks rather than spending days anticoagulating, TEE, chemical cardioverting etc.... I feel like a 30 yo guy coming in with sudden onset a fib, you run the labs, cardiovert him, he's back to normal, feeling a great, you save him an admission as well as anticoagulation. Whole process takes like less than 2 hours. He follows up with the cardiologist the next day. If anyone agrees that this is a good option for a younger patient then why not for an older patient?(whom you don't suspect MI or you r/o PE etc..)

Yes, I routinely DCCV these young AF patients. I've done it on a few older ones with good reliable story, but as someone stated above, sometimes they just don't convert back to NSR. The young ones almost always do.

 

[NinerNiner999]

Has anyone ever read any literature demonstrating how reliable patients are at timing their onset of palpitations?

Can someone provide me with literature comparing the superior outcomes of discharged ED patients to those admitted, evaluated by cardiology, and started on anticoagulation?

Are there any case reports or expert witness testimony stating this is standard of care and compelling a not guilty verdict for malpractice?

I have a hard time doing this routinely as standard practice unless these three questions are answered conclusively.


As was suggested above, there are rapid fire changes in healthcare that are going to challenge our conventional wisdom and training and compel administrators and non-practitioners to suggest cost-effective ways to prevent admissions, improve throughout, and save them CMS revenue. In the end, none of these decisions will be based on what is best or safe for the patient. Until treatment plans like these are printed in our major textbooks (Tintinalli's, Rosen's) and accepted into standard practice, you'll never have a leg to stand on to support your care...

 

[Tiger26]

For what it's worth, I did more cardioversions for new or recurrent onset A-fib in residency that I did pelvic exams, so it was pretty routine in our program. The data is really good regarding the safety.

The biggest issue is in the patient population:
-We routinely had patients who'd specifically come in for palpations or an irregular rhythm where they could tell you the onset time. After that, it was a risk/benefit/alternative discussion. If they have a pacemaker or AICD, even better because you can interrogate the device and use the interrogation machine to deliver a low-voltage shock in many cases

-You have to contrast this with the folks who are in the ED for something different and are incidentally found to be in A-fib compared to a previous EKG. This is a completely different patient population and shouldn't be cardioverted. I'd say this is more the norm for the urban type of population I've seen during my fellowship.

After this, then you really need to look at their CHA2DS2-VASc score for anti-coagulation.

Overall, the main thing is that you need to work in a good multi-disciplinary system where these patients have good followup and you have policies and guidelines for the management of this. For many resource limited EDs, this just isn't the case

 

[Apollyon]

3- Many new onset afibs convert on their own back to sinus in the first couple of days.

5. A lot of afib, that's cardioverted back to sinus, just flips right back to afib at some point

Any proof of this beyond anecdote?

 

[Birdstrike]

Any proof of this beyond anecdote?

"Spontaneous conversion to sinus rhythm occurs in almost 70% of patients presenting with atrial fibrillation of <72-h duration. Presentation with symptoms of <24-h duration is the best predictor of spontaneous conversion."

http://content.onlinejacc.org/mobile/article.aspx?articleid=1124417


"Conversion to normal sinus rhythm occurred within 24h in 32 of 50 patients (64%) in the placebo group, most of whom converted within 8h. "

http://m.eurheartj.oxfordjournals.org/content/20/24/1833


"Conclusion. A “wait and see” approach to the ED electrical cardioversion of atrial fibrillation showed that almost two-thirds of patients had spontaneous resolution without requiring cardioversion or observation in the ED or hospital. All patients were successfully reverted to normal sinus rhythm and had a high degree of satisfaction."

http://www.hindawi.com/journals/emi/2011/545023/

 

[WilcoWorld]

The Canadians are having good success with their ED cardioversion protocol. Thy did both electrical and chemical cardioversion, so it's not exactly the same as what we're discussing. But, in terms of how risky it is to use history to determine the time of onset - in the study "[t]here were no cases of torsades de pointes, stroke or death."

I second Tiger's point that we shouldn't be cardioverting people who come in for dizziness that's been going on "for awhile" and turn out to be in a fib. We also shouldn't be discharging people who have chest pain with their a fib. The population I'm selecting for this are mostly healthy folks who can tell me that at exactly XYZ o'clock they felt a sudden onset of palpitations.

 

[gman33]

For what it's worth, I did more cardioversions for new or recurrent onset A-fib in residency that I did pelvic exams, so it was pretty routine in our program.

Our hospital power grid would explode if I cardioverted more people than pelvic exams performed.

I work at a PID center of excellence.
I'm waiting for the sign in the lobby.

 

[WilcoWorld]

Our hospital power grid would explode if I cardioverted more people than pelvic exams performed.

I work at a PID center of excellence.
I'm waiting for the sign in the lobby.

Then you ought to have warmed speculums.*

*This joke is absolutely true.

 

[Old_Mil]

It's just they've been publishing all of these articles about the good option and saving an expensive admission for electrically cardioverting folks rather than spending days anticoagulating, TEE, chemical cardioverting etc.... I feel like a 30 yo guy coming in with sudden onset a fib, you run the labs, cardiovert him, he's back to normal, feeling a great, you save him an admission as well as anticoagulation. Whole process takes like less than 2 hours. He follows up with the cardiologist the next day. If anyone agrees that this is a good option for a younger patient then why not for an older patient?(whom you don't suspect MI or you r/o PE etc..)

Lawyers. All these cost savings suggestions are from public health and administrative types who don't have to take the stand if you have a bad outcome. 99% of the people encouraging EPs to discharge patients have no skin in the game.

If you are unstable in afib you will get shocked. Otherwise you will get rare controlled with a drip and admitted.

Remember, medicine is first about avoiding lawsuits, second about administrator satisfaction, third about patient satisfaction, and finally about diagnosing and curing the patient.

Sent from my Z10 using Tapatalk

 

[Birdstrike]

Lawyers. All these cost savings suggestions are from public health and administrative types who don't have to take the stand if you have a bad outcome. 99% of the people encouraging EPs to discharge patients have no skin in the game.

If you are unstable in afib you will get shocked. Otherwise you will get rare controlled with a drip and admitted.

Remember, medicine is first about avoiding lawsuits, second about administrator satisfaction, third about patient satisfaction, and finally about diagnosing and curing the patient.

Sent from my Z10 using Tapatalk

Agree. And take note that he put "physician satisfaction" nowhere on that list, because it's on no one else's list. That is the least important thing to anyone right now, including for those in power taking about "reform." You've got to put it on there yourself, otherwise you'll be writing posts about physician burnout on KevinMD.com

 

[Groove]

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.

 

[NinerNiner999]

So there is good evidence to cardiovert within less than 48 hours, pros and cons, and everything hinges on the patient's history, but:

• 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.)

That's like discharging a patient who can't walk a straight line to drive himself home without an alcohol level because he says he "didn't drink any alcohol." Of all fields in medicine that rely on patient compliance and integrity, Emergency Medicine should be the last choice for such a study IMO.

Of note, the same Canadian authors recommend using Ibutilide as their cardioversion agent. A drug that is contraindicated in "people who are likely to develop an arrhythmia." [Pharmacia-Upjohn, Corvert (ibutilide fumarate) injection package insert. July 2002: Kalamazoo, MI.]