Treatment strategy for Atrial Fibrillation of recent onset in the

Emergency Department.

The Florence experience

A.Conti, B.Del Taglia, B.Paladini, F.Luise , F.Pieralli, A.Camaiti, G. Pepe, S. Magazzini, S.Grifoni, C. Nozzoli.

Emergency Department and Chest Pain Unit, Careggi University Hospital, Florence, Italy.

VI CONGRESSO NAZIONALE SIMEURIMINI – 12-16 NOVEMBRE 2008

IL MEDICO D’EMERGENZA VERSO IL FUTURO TRA FORMAZIONE, TECNOLOGIA, INNOVAZIONE, RICERCA, ETICA E …

SESSIONE “EMERGENZE CARDIOLOGICHE”

VI CONGRESSO NAZIONALE SIMEURIMINI – 12-16 NOVEMBRE 2008

IL MEDICO D’EMERGENZA VERSO IL FUTURO TRA FORMAZIONE, TECNOLOGIA, INNOVAZIONE, RICERCA, ETICA E …

SESSIONE “EMERGENZE CARDIOLOGICHE”

Atrial fibrillation (AF) is the most common arrhythmia managed by emergency physicians and there is increasing evidence that selected patients with acute AF can be safely managed in the emergency department without the need for hospital admission

JAMA. 2001;285(18):2370-2375

VI CONGRESSO NAZIONALE SIMEURIMINI – 12-16 NOVEMBRE 2008

IL MEDICO D’EMERGENZA VERSO IL FUTURO TRA FORMAZIONE, TECNOLOGIA, INNOVAZIONE, RICERCA, ETICA E …

SESSIONE “EMERGENZE CARDIOLOGICHE”

Safety and efficacy of different pharmacologic treatment strategies were assessed in stable patients (pts) presenting in the Emergency Department with atrial fibrillation of recent onset (AF<24 hours)

Aim

Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department.

The Florence experience

G. Pepe

Within a first-line 6-hours approach, depending on clinical condition, patients received:

Amiodaron 5 mg/kg i.v. bolus Propafenon 2 mg/kg i.v. bolus Flecainid 2 mg/kg i.v. bolus

Patients and Methods

Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department.

The Florence experience

G. Pepe

Patients who did not recover sinus rhythm

were submitted to a second-line 18-hours

approach and they were randomized to received:

a second i.v. bolus of the same drug

previously

given

Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department.

The Florence experience

G. Pepe

Sinus rhythm or need of DC shock.

End-points

Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department.

The Florence experience

G. Pepe

228 pts with AF enrolled in the ED

217 pts submitted treatment strategyWith Amiodarone, Propafenone,

Flecainide in the ED

11 pts spontaneously Recovered SR

90 pts recovered SR within the first-line approach

(<6h)

21 pts neededDC Shock

127 pts admitted to observation and second-line approach

(<18h)

106 pts recovered SR within the second-line

approach(<24h)

Enrollment and Treated and Untreated Episodes of AF.

p<.05 p<.ns

p<.05

Sinus Rhythm after first-line treatment strategy in the Emergency Department

First-line approach (< 6 hours) in the ED (n=217)

Amiodaronn= 83 (38%)

SR 20 (24%)

Propafenonn=103 (48%)

SR 47(45%)

Flecainidn=31 (4%)

SR 24 (77%)

Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department.

The Florence experience

G. Pepe

FlecainidePropafenoneAmiodarone

Time course to sinus rhythm by treatment

Propafenone and Flecainide: P<.001 vs Amiodarone

Prop

orti

on o

f pa

tien

ts to

sin

us r

hyth

m (

%)

Time (minutes)

A

PF

Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department.

The Florence experience

G. Pepe

Risk Factors Amiodaron Propafenon Flecainid DC Shock

Mean age 71 65 62 63

Diabetes 13 (6%) 19 (8,7%) 4 (1,8%) 3 (1,4%)

Hyperlipemia 4 (1,8%) 9 (4%) 1 (0,5%) 2 (1%)

Hypertension 37 (17%) 44 (20%) 7 (3%) 10 (4,6%)

Active Smoker 4 (1,8%) 8 (3,7%) 1 (0,5%) 1 (0,5%)

Female 57 (26%) 50 (23%) 13 (6%) 11 (5%)

Baseline characteristic of 217 adults with AF

Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department.

The Florence experience

G. Pepe

p = n.s. for all comparisons

Sinus Rhythm after second-line treatment strategy during observation

Second-line approach (< 18 h) (n=127)

Amiodaronn= 27(21%)

SR 21 (78%)

Propafenonn=28(22%)

SR18 (64%)

Flecainidn=3(2,5%)

SR 1 (33,3%)

DC shock6 (22%)

DC shock10 (36%)

DC shock2 (66,6%)

Failure (< 18 h) (n=18)

Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department.

The Florence experience

G. Pepe

Time (minutes)

AmiodaronePropafenoneFlecainide

Sinus Rhythm by treatment (within 24 hours)Kaplan Meyer Curves

P

ersi

sten

t atr

ial f

ibri

llatio

n %

24 h

Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department.

The Florence experience

G. Pepe

Risck Factors Amiodaron Propafenon Flecainid

Mean age 65 63 62

Diabetes 2 (1,6%) 2 (1,6%) 0 (0%)

Hyperlipemia 3 (2,4%) 1 (0,8%) 0 (0%)

Hypertension 13 (10%) 16 (13%) 0 (0%)

Active Smoker 0 (0%) 4 (3%) 0 (0%)

Female 16 (13%) 11 (9%) 2 (1,6%)

Baseline characteristic of 127 adults needing second-line treatment)

Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department.

The Florence experience

G. Pepe

Propafenon Flecainid Amiodaron

HypertensionDiabetes MellitusActive SmokeHyperlipemia

Diabetes Mellitus

Female gender

Baseline characteristic of the study population in ED (n=217)

p= n.s.

Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department.

The Florence experience

G. Pepe

pts.

0

10

20

30

40

50

60

70

80

0

5

10

15

20

25

Propafenon Flecainid Amiodaron

HypertensionDiabetes MellitusActive SmokeHyperlipemia

Diabetes Mellitus

Female gender

Baseline characteristic of second-line population in ED (n=127)

p= n.s.

Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department.

The Florence experience

G. Pepe

pts.

0,00

0,10

0,20

0,30

0,40

0,50

QRS

QTc

AF in ED (6 hrs): QRS e QTc pre e post treatment

Pre-treat Post-treat. Pre-treat. Post-treat. Pre-treat. Post-treat

Propafenon Flecainid Amiodaron

p= n.s for all comparison

mse

c.Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department.

The Florence experience

G. Pepe

0,00

0,10

0,20

0,30

0,40

0,50

QRS

QTc

AF in ED (24 hrs) : QRS e QTc pre e post treatment

Pre-treat Post-treat. Pre-treat. Post-treat. Pre-treat. Post-treat

Propafenon Flecainid Amiodaron

p= n.s for all comparisons

mse

c.Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department.

The Florence experience

G. Pepe

Conclusions

The management of AF in ED succeed in restoring safely and effectively SR in 91% of patients within a 24-hour treatment strategy Only 9% of patients needed DC Shock

Amiodaron needed a longer time for restoring SR as compared with Propafenone, Flecainide

Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department.

The Florence experience

G. Pepe

Emergency Department and Chest Pain Unit, Careggi University Hospital, Florence, Italy.

gpepe72@hotmail.com

0

50

100

150

200

250

300

350

Overall time of arrythmias

Propafenon Flecainid Amiodaron

minutes

p= .05

p= n.s.

p= .05

0

50

100

150

200

250

300

350

400

Propafenon Flecainid Amiodaron Quinidine

P= n.s.

Overall time of arrythmias to observation

p<.05 p<.05

AmiodaronePropafenoneFlecainide

SR by treatment (within 6 hours)

P<.001 vs Propafenone and Flecainide

P

ersi

sten

t atr

ial f

ibri

llat

ion

%

Time (minutes)

Time (minutes)

Overall SR by treatment (within 24 hours)

Per

sist

ent a

tria

l fib

rill

atio

n %