Anticoagulation after afib spontaneous coversion?

[emergentmd]

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healthy male 30's, new onset afib with RVR for about 1 hr who converted in er. Workup neg.

Discharge on xarelto or not? Start on low dose cardizem or metoprolol?

I have seen it done man different ways.

 

[Hook_EM]

Chads vasc score. If 1 or greater then yes for 1 then ANtiplatelet or ac with risk/benefit discussion. >1 then AC

No metop or cardizem.

 

[RoyBasch]

I would discuss with cardiology. I think you'll be surprised the variety of answers you get.

I find a surprising number of our cardiologist will start ChadsVasc patients with a 0 or 1 on full anticoagulation anyways. I am not sure if this is a medico-legal hedge on their side or what seems to motivate that decision (seems if you have a bleeding complication and patient had a ChadsVasc of 0 you could be in peril medicolegally just as well).

I think the bottom line is the ultimate answer to this question may require information you do not have at the point of care in the ER. I think some cardiologist would probably want to do some kind of outpatient event monitoring to determine the patient's total burden of a fib. If it is very low with short paroxysmal infrequent episodes they may do neither rate controller nor anticoagulant (especially if low ChadsVasc).

Though there are some cardiologist that think in more binary terms and probably will fully treat the patient even if the AF burden is low. Either you have AF or you don't.

Also you didn't mention it, but you said "converted" in the ER. Was this spontaneous conversion? If they required a bolus of a rate controller (even just one) then there is a much better chance they need to continue a rate control med PO. Also, was this a case of holiday heart? I have seen some alcohol related AF in 30 year olds that does not need any further treatment.

Thus with this patient, I would call the cardiologist and ask them what they want while coordinating close outpatient follow up so they can start the process of gathering the additional clinical data they need to make the best possible decision.

Furthermore, although this is an apparently straight forward decision with well established guidelines, there is certainly some nuance to it (such as this case where the burden appears to be very low). Given the variety of practices by the specialists and the medicolegal hazard of thromboembolic vs. bleeding complications, I have no problem at this point in my career punting these kinds of decisions to the specialists.

So you say: "But Roy, what if you are practicing in rural Manitoba in a snow storm and there phone lines are down and the cardiologist isn't available and cannot be reached?" If I were practicing in a relative vaccum and you want me to put my nickel down...

I would calculate a ChadsVasc score and follow that strictly either starting ASA or anticoagulation and I would probably start low dose PO cardizem while awaiting follow up with the cardiologist. My rationale: I do not trust patients to reliably know when they are in and out of AF, I do not think palpitations or other symptoms always completely correlate with AF. I think many patients--even younger ones--may be in AF without symptoms and thus in the absence of monitoring not know that they are. Thus if the patient had one proven episode of paroxysmal AF without an apparent trigger (surgery, infection, whatever) I would assume they are at risk for recurrent episodes and thus should be treated for AF until a cardiologist decides otherwise.

 

[Tenk]

If their chadsvasc2 score is 0, absolutely not.

Get them a holter to find out their burden and refer them to an EP.

 

[turkeyjerky]

Patient the OP described? DC, next.

Any complicating factors, sure coordinate followup with cards or PCP and consider initiation of AC. But I'm not bothering the on call cards with a spontaneously resolved exacerbation of a nonemergent condition in the middle of the night.

A patient with a CHADS2Vasc score of 1 has a 0.6% of a stroke per year. Meaning, about a 1 in 10,000 chance of stroke per week. So I'm ok telling them to call their doc on the morning.

 

[southerndoc]

If there is evidence of PAF, then a lot of low score patients are anticoagulated as there is increased risk of stroke from PAF instead of chronic AF.

Most of these I send home on Eliquis and have cardiology decide whether to keep them on or not.

 

[southerndoc]

Patient the OP described? DC, next.

Any complicating factors, sure coordinate followup with cards or PCP and consider initiation of AC. But I'm not bothering the on call cards with a spontaneously resolved exacerbation of a nonemergent condition in the middle of the night.

A patient with a CHADS2Vasc score of 1 has a 0.6% of a stroke per year. Meaning, about a 1 in 10,000 chance of stroke per week. So I'm ok telling them to call their doc on the morning.

That risk is with chronic AF and not paroxysmal AF.

 

[emergentmd]

Again, it seems like I have seen it done differently depending on the cardiologist.

This pt has no risk factors, AF for about 1 hr total, ChadscVasc score 0. Cards wanted him started on Asa and toprol.

I am sure the next time it will be something different.

 

[namethatsmell]

Again, it seems like I have seen it done differently depending on the cardiologist.

This pt has no risk factors, AF for about 1 hr total, ChadscVasc score 0. Cards wanted him started on Asa and toprol.

I am sure the next time it will be something different.

Yup, it's always different next time.

Similar to how if you ask two different orthopods about the same Fx you get three different opinions.

 

[TooMuchResearch]

We have a policy using chadsvasc, I just do what the flow sheet says

 

[RoyBasch]

If there is evidence of PAF, then a lot of low score patients are anticoagulated as there is increased risk of stroke from PAF instead of chronic AF.

Interesting, I didn't know that. That would seem to explain some of the paradoxical anticoagulation recommendationss I see despite low ChadsVasc scores. Although as others have said, some cardiologist recommend against anticoagulation as well in these types of patients.

 

[WilcoWorld]

That risk is with chronic AF and not paroxysmal AF.

Cardiologist now worry about thrombus formation in the peri-fibrillation period from "atrial stunning" in PAF patients. This is an issue that is unfortunately getting more, rather than less, complicated.

 

[nlax30]

That risk is with chronic AF and not paroxysmal AF.

Eh, there’s still conflicting data on how strike risk varies based on “type” of AF, whether paroxysmal vs persistent/permanent. In clinical practice I’d say the majority of us don’t really place a whole lot of stock into that as a major factor and rather go by the CVASC2 risk profile. Am I LESS concerned about a 30yr with NO other risk factors and one lone episode of AF, sure, but for the majority of other pts.... our typical 70yr w/ AF, DM, and HTN I’m not really treating paroxysmal for persistent AF different when it comes to AC.

All this to say that we really don’t yet even have a good grasp on what exactly AF is..... is it a disease itself that then leads to atrial fibrosis and itself is a direct risk factor for stroke or rather is it just a manifestation or marker of some other underlying disease that is the actual direct risk factor for stroke. Hence why you’ll find some that may be willing to forgo AC in someone after an ablation who has been AF free for quite some time while others who strictly go back the CVASC2 score without regard to burden.

 

[nlax30]

Short answer.... in this pt with CVASC2 presumably zero then I’m not faulting you for just sending home on ASA and having them follow up.

+/- BB/CCB depending on the clinical circumstances.

 

[southerndoc]

Short answer.... in this pt with CVASC2 presumably zero then I’m not faulting you for just sending home on ASA and having them follow up.

+/- BB/CCB depending on the clinical circumstances.

No way could you be held liable if the patient with a score of 0 or 1 is discharged with aspirin, subsequently has a stroke, and the family decides to sue you. If you follow any validated scoring algorithm, you're pretty much defensible.

 

[DrDrummer]

Is there anyone on here who looks as a HAS-BLED or similar score for bleeding risk in these patients you're considering starting on DOACs for their AF? If so, how are you using this alongside the thrombotic risk factor scoring tools to decide whether or not you anticoagulant patients?

This is something that wasn't really within the wheelhouse of EM for a long time, but now is starting to be a question turfed to us as the standard of care becomes discharging new-onset AF from the ED. Sometimes I worry that we're starting people on both an anti-coagulant and a fall risk-increasing medication simultaneously when we rate control them and DC... it would be interesting to look at the rates of ICH or other serious bleeding events post-discharge for these patients v the stroke risk and see if there's an optimal way of managing this.

 

[thegenius]

healthy male 30's, new onset afib with RVR for about 1 hr who converted in er. Workup neg.

Discharge on xarelto or not? Start on low dose cardizem or metoprolol?

I have seen it done man different ways.

Whether permanent afib or paroxysmal afib, I use the CHAD2 score or the CHADS2-Vasc score.

A young healthy guy in his 30's with afib would score a 0 on both scores, so no anticoagulation.

Whether to give metoprolol or some other nodal blocker really doesn't matter as afib itself is usualyl not an emergency. It's the strokes and heart failure that old people get into that's a bigger deal.

Remember....for most of these patients who you start on anticoaguation, the yearly risk of getting a stroke being in AFib or PAF is somewhere between 2-5% (depending on your CHADs2 vasc score). That means their daily risk of getting a stroke is very low. It's not the end of the world if they delay their anticoagulation for several days if they have good follow-up.

I regularly discharge uncomplicated new onset Afib, without anticoagulatio, in those who need, or likely need AC if I can get them to their doctor in the next day or two. Let their doctor make that decision.

Docs freak out about afib, we admit old people with new onset afib all the time and I think it's kind of silly.

 

[Groove]

Personally, if he's young and healthy and there are no high risk features, first episode, then chadsvasc which we know is not going to recommend anti-coagulation and I virtually always give cards a quick call to nail down a firm f/u. At that point, it's whatever cards wants... they are the ones having to f/u with these guys in the clinic. There's no reason not to call them on these people. Plus, you never know what they are going to recommend depending on the cardiologist for the day. He might say a) home on no anti-coagulation, I'll see him in a few days. b) xarelto, I'll see him in a few days. c) stick him in, echo, full dose heparin, I'll see him in the hospital, yada, yada....

I've found this type of pt live in this nebulous penumbra of unpredictability regarding management that is solely dependent on the cardiologist on call for the day.

If I couldn't get in touch with cards. I would recommend no anti-coagulation unless the history suggested paroxysmal afib, then I would recommend anti-coagulation and go over all the typical risks, etc.. Done. Next pt.

 

[gro2001]

If there is evidence of PAF, then a lot of low score patients are anticoagulated as there is increased risk of stroke from PAF instead of chronic AF.

Most of these I send home on Eliquis and have cardiology decide whether to keep them on or not.

Recent data suggests the opposite:

Link et al. Stroke and Mortality Risk in Patients With Various Patterns of Atrial Fibrillation. Circ Arrhythm Electrophysiol. 2017
https://www.ahajournals.org/doi/pdf/10.1161/CIRCEP.116.004267

The rates are all pretty low and pretty close (statistically significant difference, but probably not clinically significant). But the trend is in the opposite (intuitive to me) direction: paroxysmal suffered fewest, persistent suffered more, chronic suffered most.

 

[TooMuchResearch]

Personally, if he's young and healthy and there are no high risk features, first episode, then chadsvasc which we know is not going to recommend anti-coagulation and I virtually always give cards a quick call to nail down a firm f/u. At that point, it's whatever cards wants... they are the ones having to f/u with these guys in the clinic. There's no reason not to call them on these people. Plus, you never know what they are going to recommend depending on the cardiologist for the day. He might say a) home on no anti-coagulation, I'll see him in a few days. b) xarelto, I'll see him in a few days. c) stick him in, echo, full dose heparin, I'll see him in the hospital, yada, yada....

I've found this type of pt live in this nebulous penumbra of unpredictability regarding management that is solely dependent on the cardiologist on call for the day.

If I couldn't get in touch with cards. I would recommend no anti-coagulation unless the history suggested paroxysmal afib, then I would recommend anti-coagulation and go over all the typical risks, etc.. Done. Next pt.

Or just get a protocol put together. No phone call, just risk stratify and get them the number for same week cardiology follow-up (or PCP if they prefer).

 

[RoyBasch]

I've found this type of pt live in this nebulous penumbra of unpredictability regarding management that is solely dependent on the cardiologist on call for the day.

Well put.

 

[gro2001]

Also, while I don't criticize anyone for calling a cardiologist about a case like the OP's (or any case for that matter), I just want to throw it out there that I would not consult for the case as described. I say this for a couple of reasons:

1) This is well within our scope of practice. While some will want the backup in their decision making, I don't want to give any residents/students the impression that it's imperative to consult someone in this case. It's entirely reasonable to not consult, especially if you have some other way of arranging relatively rapid follow up. I could consult on every single case in the ED if I wanted to, but that ties up resources, increases length of stay, and would earn me the reputation as an undiscerning colleague. I want to have the relationship with my consultants such that when I call, they know the patient needs to be admitted, have a procedure done, or I genuinely need their help with a sick patient or tricky situation.

2) You never know what you are going to get on the other end of the line. I've certainly had the experience of consulting cardiologists who choose to do unusual/unnecessary/harmful things in situations like this. This usually happens with docs who are out of date on the evidence for some reason. It's harder to defend not following someone's recommendations once you consulted them than using your best judgement in the first place.

 

[Old_Mil]

healthy male 30's, new onset afib with RVR for about 1 hr who converted in er. Workup neg.

Discharge on xarelto or not? Start on low dose cardizem or metoprolol?

I have seen it done man different ways.

Someone who should see an electro physiologist to see if they need an ablation? I would assume that an otherwise healthy and active 30 year old probably is a higher bleed risk from anticoagulants than an otherwise sedentary person twice his age.

 

[TXEMC344]

Not to derail this thread, but similar case this week. 39 year old female, presents to the ED with a HR of >220. Only complaint was "a little chest pain". Negative PMHX. Converted after 6 mg Adenosine to a SR rate of 90 or so. Was discharged home. No cardiology consult. Just F/U with PCP.

 

[southerndoc]

Not to derail this thread, but similar case this week. 39 year old female, presents to the ED with a HR of >220. Only complaint was "a little chest pain". Negative PMHX. Converted after 6 mg Adenosine to a SR rate of 90 or so. Was discharged home. No cardiology consult. Just F/U with PCP.

I'm failing to see your point here.

 

[RustedFox]

Not to derail this thread, but similar case this week. 39 year old female, presents to the ED with a HR of >220. Only complaint was "a little chest pain". Negative PMHX. Converted after 6 mg Adenosine to a SR rate of 90 or so. Was discharged home. No cardiology consult. Just F/U with PCP.

That's what's supposed to happen.

 

[TXEMC344]

My point was just to see if others agreed with the disposition. Nothing more, nothing less.

 

[TooMuchResearch]

My point was just to see if others agreed with the disposition. Nothing more, nothing less.

Yes

 

[emergentmd]

My point was just to see if others agreed with the disposition. Nothing more, nothing less.

So you treated SVT? Never called Cards for uncomplicated SVT.

 

[WilcoWorld]

Someone who should see an electro physiologist to see if they need an ablation? I would assume that an otherwise healthy and active 30 year old probably is a higher bleed risk from anticoagulants than an otherwise sedentary person twice his age.

A higher cumulative lifetime risk perhaps, but not a higher annual risk. Young healthy vessels are less prone to bleeding.

 

[WilcoWorld]

Not to derail this thread, but similar case this week. 39 year old female, presents to the ED with a HR of >220. Only complaint was "a little chest pain". Negative PMHX. Converted after 6 mg Adenosine to a SR rate of 90 or so. Was discharged home. No cardiology consult. Just F/U with PCP.

Totally appropriate. I'd prolly check lytes, HCG & a TSH. If no PE risk factors, skip the d dimer. Cardiovert, give 'em the primary care clinic number for follow up and discharge.

NEXT

 

[enalli]

I want to have the relationship with my consultants such that when I call, they know the patient needs to be admitted, have a procedure done, or I genuinely need their help with a sick patient or tricky situation.

Does this actually work for you? Consultants never hear about the times we don't call, so some of them think they are being called for every case.

 

[gro2001]

Does this actually work for you? Consultants never hear about the times we don't call, so some of them think they are being called for every case.

That's true. It definitely doesn't work with every consultant. But you do develop a reputation in the hospital whether you realize it or not. Sometimes not so much with the residents because of the turn over, but even among them, word travels. If you have IM residents at your hospital, ask them who they think the most ridiculous EM attendings are in terms of tests/consults/admissions, and they will surely have an opinion. In fact, their opinion may well be similar to yours.

To be clear, I am not doing or not doing anything with the primary goal of pleasing consultants. I have no problem being disagreeable or pushing for something, whether a consult, admission, or whatever if I feel it's called for. I have no problem waking up an attending in the middle of the night if I think it's necessary. But I want to be discriminate about how I use that resource, so when I really do need the surgeon to drop everything and come see my patient now, they know it's serious. This seems to work for me.

 

[nlax30]

Not to derail this thread, but similar case this week. 39 year old female, presents to the ED with a HR of >220. Only complaint was "a little chest pain". Negative PMHX. Converted after 6 mg Adenosine to a SR rate of 90 or so. Was discharged home. No cardiology consult. Just F/U with PCP.

Very different than the treatment therapies/issues that need to be considered in Afib.

 

[Groove]

That's true. It definitely doesn't work with every consultant. But you do develop a reputation in the hospital whether you realize it or not. Sometimes not so much with the residents because of the turn over, but even among them, word travels. If you have IM residents at your hospital, ask them who they think the most ridiculous EM attendings are in terms of tests/consults/admissions, and they will surely have an opinion. In fact, their opinion may well be similar to yours.

To be clear, I am not doing or not doing anything with the primary goal of pleasing consultants. I have no problem being disagreeable or pushing for something, whether a consult, admission, or whatever if I feel it's called for. I have no problem waking up an attending in the middle of the night if I think it's necessary. But I want to be discriminate about how I use that resource, so when I really do need the surgeon to drop everything and come see my patient now, they know it's serious. This seems to work for me.

Do you work in academics? If so, I find the academic culture entirely out of touch with emergency medicine within a community/private practice setting. Also, why should anybody care what a group of IM residents thinks about an EM attending? I chuckled at that part... No offense to any residents in here but I can't remember the last time I cared what a resident thought of me, certainly not an IM or FM resident.

There's so much bravado, inferiority complexes and indentured servitude (scutting out residents/fellows as first line consultants for the ER) that it oftentimes creates a very malignant, pugilistic and adversarial relationship with the ED. Meanwhile the ED gets so hyper focused on trying to avoid wearing the proverbial "I'm with Stupid!" t-shirt for the week that they often times don't want to pick up the phone unless they absolutely have to.

Hospital medical staff develop an opinion over time, not based on solitary cases like this one. If you're good, the hospital staff will know it...period. Personally, none of my guys would scoff at a curbside consult for this one, if for nothing more than to close the loop and cleanly establish f/u. I mean...how many healthy afib RVRs are you seeing at your shop that spontaneously convert, have no other major comorbidities and get dc'd home? I might have 1 or 2 a year in my shop. Most of my new onset afib or afib w/RVRs are absolute train wrecks and wouldn't convert for Mother Teresa if she miraculously appeared in front of them. (Unless I cardioverted them out of spite for their hypotension)

Anyway, I may be off target but man...this thread got me so grateful I don't have to deal with academic ivory tower shenanigans anymore. Your consultants are on call to serve you, not the other way around. They are getting paid to be on call to the ER for a reason. I say take advantage of that resource. In general, consultants are SO much easier to deal with out in the community.

 

[gro2001]

Do you work in academics? If so, I find the academic culture entirely out of touch with emergency medicine within a community/private practice setting. Also, why should anybody care what a group of IM residents thinks about an EM attending? I chuckled at that part... No offense to any residents in here but I can't remember the last time I cared what a resident thought of me, certainly not an IM or FM resident.

There's so much bravado, inferiority complexes and indentured servitude (scutting out residents/fellows as first line consultants for the ER) that it oftentimes creates a very malignant, pugilistic and adversarial relationship with the ED. Meanwhile the ED gets so hyper focused on trying to avoid wearing the proverbial "I'm with Stupid!" t-shirt for the week that they often times don't want to pick up the phone unless they absolutely have to.

Hospital medical staff develop an opinion over time, not based on solitary cases like this one. If you're good, the hospital staff will know it...period. Personally, none of my guys would scoff at a curbside consult for this one, if for nothing more than to close the loop and cleanly establish f/u. I mean...how many healthy afib RVRs are you seeing at your shop that spontaneously convert, have no other major comorbidities and get dc'd home? I might have 1 or 2 a year in my shop. Most of my new onset afib or afib w/RVRs are absolute train wrecks and wouldn't convert for Mother Teresa if she miraculously appeared in front of them. (Unless I cardioverted them out of spite for their hypotension)

Anyway, I may be off target but man...this thread got me so grateful I don't have to deal with academic ivory tower shenanigans anymore. Your consultants are on call to serve you, not the other way around. They are getting paid to be on call to the ER for a reason. I say take advantage of that resource. In general, consultants are SO much easier to deal with out in the community.

I do work in academics. Though the best way to describe the hospital I work at is probably as a mixed model. We do have lots of residencies and fellowships, but for some services the interaction with the ED is primarily through attendings on the consulting service. So depending which specialty I call, I may expect to get a resident, fellow, or attending.

I disagree on the "I don't care what IM residents think about me stance" though I think I understand what you are saying. It doesn't keep me up at night, and it's not nearly the top of my priorities, but I think there's a lot to be said for setting up an environment of mutual respect where in interactions both people are coming in with good priors. So while I don't worry per se about what they think, if I can do something to make their life slightly easier without jeopardizing patient care, and that breeds good will, I see that as a win.

I agree that if you are good, the hospital staff will know. Part of being good is not calling consults for management decisions within the scope of EM practice.

I haven't seen that many patients with that exact presentation, but I have electrically cardioverted a bunch of young, healthy afib patients and discharged. Made the decision for/against anticoagulation by myself. Would also not call a consult for that. Again, not blaming anyone for calling, and all for getting specialist opinions if something is a little off from the ordinary. But for stuff that's straight forward, it's often better not to call just because the consultant is available.

I definitely used to have your exact attitude earlier in my career (although I'd still describe myself as early career). And I partially agree with you now. From an operational perspective it's an absolute truth that the rest of the hospital exists to support the emergency department. From an intangible, human factor perspective, I feel my practice is a lot more satisfying to me when I practice with more discrimination. Mostly because I think it's better medicine, but partly also because it's appreciated by my non EM colleagues.