EBQ:Ottawa Aggressive ED Cardioversion Protocol: Difference between revisions
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==Clinical Question== | ==Clinical Question== | ||
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==Major Points== | ==Major Points== | ||
Reviews of the literature have shown that stable patients with close followup who have recent-onset atrial fibrillation after cardioversion in the ED can be safely discharged after cardioversion in the ED.<ref name="von Besser">von Besser K. et al. Is discharge to home after emergency department cardioversion safe for the treatment of recent-onset atrial fibrillation? Ann Emerg Med. 2011 Dec;58(6):517-20</ref> Also Among patients with[[EBQ:48hr_Cardioversion_for_Afib| Atrial Fibrillation clinically estimated to be <48 hours]], the likelihood of cardioversion-related clinical thromboembolism is very low.<ref name="Weigner">Weigner MJ et al. "Risk for clinical thromboembolism associated with conversion to sinus rhythm in patients with atrial fibrillation lasting less than 48 hours". Ann Intern Med. 1997. 126(8):615-620.</ref> | |||
*The relapse rate for atrial fibrillation is 3% -17% and close followup and ability to return to the ED if there is return of symptoms is essential.<ref name="von Besser"></ref> | |||
==Study Design== | ==Study Design== | ||
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==Criticisms & Further Discussion== | ==Criticisms & Further Discussion== | ||
*In general, practice guidelines recommended anticoagulation for the conversion of atrialfibillatin or flutter if duration of dysrhythmia is > 48 hours. More recent literature suggests that the 12-48 hour window in this study still only represented a 1.1% risk for 30-day thromboembolism, compared to the ~2% risk after 48 hours. | |||
===Anticoagulation prior to cardioversion=== | |||
{{Anticoagulation prior to cardioversion}} | |||
===Anticoagulation after cardioversion=== | |||
*Oral anticoagulants are recommended for all AF patients aged 65 or older or who have any one of the traditional CHADS2 risk factors of stroke, hypertension, heart failure, or diabetes (remember as CHADS-65). Otherwise, patients with a history of coronary artery disease or arterial vascular disease should be prescribed ASA. CCS recommends that the first choice for oral anticoagulation should be the novel direct-acting OACs, i.e. NOACs, for non-valvular AF. The big paradigm change is that ED physicians should prescribe OACs to at-risk AF patients before they leave the ED.<ref>Verma A, et al. 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation Canadian Journal of Cardiology 30 (2014) 1114e1130</ref> | |||
==Funding== | |||
== | ==External Links== | ||
[http://emottawa.blogspot.ca/2014/10/2014-canadian-guidelines-for-af.html EM Ottawa Blog post on Rapid Ottawa Protocol] | |||
[http://emergencymedicinecases.com/episode-57-stiell-sessions-2-update-atrial-fibrillation-2014/ Dr. Ian Stiell - Audio - EmergencyMedicineCases.com] | |||
Revision as of 15:21, 26 January 2015
Under Review Journal Club Article
Stiell I. et al.. "Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter". CJEM. May 2010. =12(3):181-91.
PubMed Full text PDF
PubMed Full text PDF
Clinical Question
What is the effectiveness and safety of the Ottawa Aggressive Protocol to perform rapid cardioversion and discharge of patients with new onset atrial fibrillation?
Conclusion
In patients with new onset atrial fibrillation or flutter with symptoms onset <48 hours, rapid conversion with procainamide or electrical cardioversion is safe and will also decrease treatment time and hospital admissions.
Major Points
Reviews of the literature have shown that stable patients with close followup who have recent-onset atrial fibrillation after cardioversion in the ED can be safely discharged after cardioversion in the ED.[1] Also Among patients with Atrial Fibrillation clinically estimated to be <48 hours, the likelihood of cardioversion-related clinical thromboembolism is very low.[2]
- The relapse rate for atrial fibrillation is 3% -17% and close followup and ability to return to the ED if there is return of symptoms is essential.[1]
Study Design
Population
Patient Demographics
Inclusion Criteria
Exclusion Criteria
Interventions
Outcomes
Primary Outcome
Secondary Outcomes
Subgroup analysis
Criticisms & Further Discussion
- In general, practice guidelines recommended anticoagulation for the conversion of atrialfibillatin or flutter if duration of dysrhythmia is > 48 hours. More recent literature suggests that the 12-48 hour window in this study still only represented a 1.1% risk for 30-day thromboembolism, compared to the ~2% risk after 48 hours.
Anticoagulation prior to cardioversion
- Anticoagulation with Heparin or LMWH should be considered before cardioversion if time permits, otherwise immediately after cardioversion. (unless you are sure it has been <48 hours since onset of afib) [3][4] [5]
- Generally cardioversion while anti-coagulated is believed to be safe with a 1.3% risk of thromboembolism if on aspirin or other anticoagulant[6] However the risk may be as great as 2% risk after 48 hours and preference should be given to anticoagulation prior to cardioversion in longer cases[7]
Anticoagulation after cardioversion
- Oral anticoagulants are recommended for all AF patients aged 65 or older or who have any one of the traditional CHADS2 risk factors of stroke, hypertension, heart failure, or diabetes (remember as CHADS-65). Otherwise, patients with a history of coronary artery disease or arterial vascular disease should be prescribed ASA. CCS recommends that the first choice for oral anticoagulation should be the novel direct-acting OACs, i.e. NOACs, for non-valvular AF. The big paradigm change is that ED physicians should prescribe OACs to at-risk AF patients before they leave the ED.[8]
Funding
External Links
EM Ottawa Blog post on Rapid Ottawa Protocol Dr. Ian Stiell - Audio - EmergencyMedicineCases.com
Sources
- ↑ 1.0 1.1 von Besser K. et al. Is discharge to home after emergency department cardioversion safe for the treatment of recent-onset atrial fibrillation? Ann Emerg Med. 2011 Dec;58(6):517-20
- ↑ Weigner MJ et al. "Risk for clinical thromboembolism associated with conversion to sinus rhythm in patients with atrial fibrillation lasting less than 48 hours". Ann Intern Med. 1997. 126(8):615-620.
- ↑ You JJ, Singer DE, Howard PA, Lane DA, Eckman MH, Fang MC, Hylek EM, Schulman S, Go AS, Hughes M, Spencer FA, Manning WJ, Halperin JL, Lip GY. Antithrombotic therapy for atrial fibrillation: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e531S-75S
- ↑ FusterV et al;American Collegeof Cardiology/ American Heart Association Task Force on Practice Guidelines; European Society of Cardiology Committee for Practice Guidelines; European Heart Rhythm Association; Heart Rhythm Society. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006;114(7):e257-e354.
- ↑ Camm AJ, Kirchhof P, Lip GY, et al; European Heart Rhythm Association; European Association for Cardio-Thoracic Surgery. Guidelines for the management of atrial fibrillation: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010;31(19):2369-2429.
- ↑ 48hr Cardioversion for A.fib.
- ↑ Nuotio I. et al. Time to cardioversion for acute atrial fibrillation and thromboembolic complications. JAMA. 2014 Aug 13;312(6):647-9
- ↑ Verma A, et al. 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation Canadian Journal of Cardiology 30 (2014) 1114e1130