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Converting Atrial Fibrillation to NSR Pills or Electrical Thrills Peter Holzberger MD www.mediclicks.net Background Atrial fibrillation is the most common sustained arrhythmia Affects 2 million Americans 6% over the age of 65 experience it Responsible for 15% strokes

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Converting atrial fibrillation to nsr l.jpg

Converting Atrial Fibrillation to NSR

Pills or Electrical Thrills

Peter Holzberger MD



Background l.jpg
Background

  • Atrial fibrillation is the most common sustained arrhythmia

  • Affects 2 million Americans

  • 6% over the age of 65 experience it

  • Responsible for 15% strokes

    • Benjamin E: Epidemiology of Atrial Fibrillation. In Falk RH, Podrid PJ, eds:Atrial Fibrillation: Mechanisms and Management. 2nd Ed, Lippincott-Raven Press, New York 1997, pp.1-22.


Symptoms l.jpg
Symptoms

  • Inappropriate heart rate response

  • Irregular rate

  • Loss of atrial systolic function

  • Thromboembolism


Choices for immediate treatment l.jpg
Choices for Immediate Treatment

  • Anticoagulation and Rate Control

  • Or

  • Conversion to NSR


Nsr pills or electrical thrills l.jpg

Pills

Placebo

Single Dose Antiarrhythmic Treatment

Ibutilide

Electrical Thrills

Traditional External Cardioversion

Double External Cardioversion

Biphasic Cardioversion

NSR-Pills Or Electrical Thrills


Choices l.jpg
Choices

  • 40 yr old healthy female with 6 hrs of palpitations. First time ever.

  • Found in atrial fib. Rate slowed with IV lopressor, and patient feels much better.

  • ED evaluation entirely normal

  • Next step is ?


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Choices

  • A) DC Cardioversion

  • B) P.O. Propafenone

  • C) Discharge on p.o. lopressor and revaluate next day

  • D) Admit for further workup and treatment


Predictors of conversion to nsr l.jpg
Predictors of Conversion to NSR

  • Duration of atrial fib

    • <24 hrs spontaneous conversion in up to 66%

  • Underlying cardiac function

  • Underlying cardiac disease

  • Age


Pills placebo l.jpg

Conversion of recent onset paroxysmal atrial fibrillation to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

100 patients PAF (<48 hrs)

IV Amiodarone (3 gms) vs. IV Placebo

Cotter et al,.Eur Heart J Dec 1999; 20(24):1833-42

Pills - Placebo


Placebo l.jpg
Placebo to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • Cotter et al,.Eur Heart J Dec 1999; 20(24):1833-42

P=0.0017

Conversion (%)


Choices14 l.jpg
Choices to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • 45 yr old on Coumadin for recent DVT presents with several day history of palpitations.

  • INR has been therapeutic for several months

  • Rate is controlled but still feels poorly

  • Evaluation entirely unremarkable

  • What next?


Choices15 l.jpg
Choices to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • A) DC Cardioversion

  • B) P.O. Propafenone

  • C) Discharge on p.o. lopressor and revaluate next day

  • D) Admit for further workup and treatment


Pills single dose rx l.jpg
Pills - Single Dose Rx to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • Boriani et al, Pacing Clin Electrophys Nov 1998; Vol.21 Part II, 2470-74


Single dose l.jpg
Single Dose to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • 417 patients with AF < 8 days

  • Randomized to

    • Placebo

    • IV Amiodarone 5mg/kg bolus followed by 1.8 gms/24hrs

    • IV Propafenone

    • PO Propafenone 600 mg

    • PO Flecainide 300 mg

      • Boriani et al, Pacing Clin Electrophys Nov 1998; Vol.21 Part II, 2470-74


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Single Dose to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • Boriani et al, Pacing Clin Electrophys Nov 1998; Vol.21 Part II, 2470-2474


Choices19 l.jpg
Choices to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • 45 yr old female with several week history of worsening SOB, no palpitations

  • Exam reveals, mild CHF, A fib rate 140, Echo EF 35%-global hypo

  • What next?


Choices20 l.jpg
Choices to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • A) DC cardioversion

  • B) p.o. Propafenone

  • C) Discharge on p.o. lopressor and revaluate next day

  • D) Admit for further workup and treatment


Anticoagulation prior to conversion to nsr l.jpg

At least 3 weeks to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study Therapeutic INR >2.0

Unless arrhythmia is less than 48 hours in duration

Even then heparin has been advocated in high embolic risk patients

Mitral stenosis, CHF, previous emboli

Chest. Sixth ACCP Consensus Conference on Antithrombotic Therapy Vol. 119(1) Suppl. Jan 2001 194S-206S

Anticoagulation Prior to Conversion to NSR


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www.mediclicks.net to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study


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TEE Prior to Conversion to NSR to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

Thrombus


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Pills (sort of) -Ibutilide to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study


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Pills (sort of) -Ibutilide to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study


Pills sort of ibutilide27 l.jpg
Pills (sort of) -Ibutilide to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study


Ibutilide l.jpg
Ibutilide to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • Stambler et al, Circulation October 1996; Vol 94, No 7, 1613-21


Ibutilide29 l.jpg
Ibutilide to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • 266 patients (3 hrs to 45 days)

    • 133 with atrial flutter

    • 133 with atrial fibrillation

  • Randomized to

    • Placebo/Placebo

    • 1mg/0.5mg

    • 1mg/1mg

    • Stambler et al, Circulation October 1996; Vol 94, No 7,1613-21


Ibutilide30 l.jpg
Ibutilide to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • Stambler et al, Circulation October 1996; Vol 94, No 7,1613-21


Ibutilide31 l.jpg
Ibutilide to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • Proarrhythmia

    • PMVT developed in 8.3%

      • Sustained PMVT 1.7%

    • MMVT developed in 4%

  • QTc prolonged an average of 63 msec.

  • No hemodynamic effects

    • Stambler et al, Circulation October 1996; Vol 94, No 7,1613-21


Ibutilide32 l.jpg
Ibutilide to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • Contraindications

    • Hx of Torsades

    • QTc > 440

    • K< 4.0 mEq/L

    • Concomitant Type 1 or III drug

    • HR <60

    • Severe LV dysfunction (EF < 30%)


Ibutilide33 l.jpg
Ibutilide to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • Key Points

    • Close monitoring during infusion

      • For NSR, PMVT (3 beats), QTc >600msec, conduction or hemodynamic problems

    • Monitor post infusion for at least 4 hours or until QTc returns to baseline

      • (longer with hepatic dysfunction)

  • Trained personnel, defibrillator, Code Cart and IV magnesium should be present


Pills or electrical thrills l.jpg
Pills Or Electrical Thrills to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • Pills

    • Placebo

    • Single Dose Antiarrhythmic Treatment

    • Ibutilide

  • Electrical Thrills

    • Traditional External Cardioversion

    • Double External Cardioversion

    • Biphasic Cardioversion


Electrical thrills dc l.jpg
Electrical Thrills - DC to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • Used for conversion of atrial fib by Dr Bernard Lown in the 1960’s

    • 94% of 456 cases of atrial fib

  • Overall efficacy felt to be about 85%

  • Use of high energy (360J) associated with skin burns and possible myocardial stunning


Dc cardioversion l.jpg

Efficacy dependent on to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

Paddle size and position

Transthoracic impedance

Energy Waveform

Underlying disease

DC Cardioversion


Paddle position l.jpg
Paddle Position to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • Anterior/Posterior #1


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Paddle Position to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • Anterior/Posterior #2


Paddle position39 l.jpg
Paddle Position to normal sinus rhythm: The effect of no treatment and high-dose amiodarone. A randomized, placebo controlled study

  • Anterior/Anterior


Transthoracic impedance l.jpg

Lowered by putting pressure on the anterior paddle during cardioversion

Transthoracic Impedance


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Electrical Thrills - Double DC cardioversion

  • Saliba et al, J Am Coll Cardiol 1999; Vol.34, No 7: 2031-34


Double external cardioversion l.jpg
Double External Cardioversion cardioversion

  • Double Shock


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Double External Cardioversion cardioversion

  • 55 patients who had all failed conventional DC cardioversion

  • 84% success rate

    • 9 patients received more than one 720J

  • No complications

    • Saliba et al, J Am Coll Cardiol 1999; Vol.34, No 7: 2031-34


Pills and electrical thrills l.jpg

Oral et al, NEJM 1999, Vol. 340 No24:1849-54 cardioversion

Pills and Electrical Thrills


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Ibutilide and DC Cardioversion cardioversion

  • 100 consecutive patients

    • 50 assigned conventional DC

    • 50 pretreated with 1 mg Ibutilide

      • Oral et al, NEJM 1999, Vol. 340 No24:1849-54

P<0.001


Ibutilide and dc cardioversion47 l.jpg
Ibutilide and DC Cardioversion cardioversion

  • 20% treated with Ibutilide converted without DC

  • 14 patients who did not convert with DC alone were then pretreated with Ibutilide

    • None converted with drug alone

    • All converted with DC

      • Oral et al, NEJM 1999, Vol. 340 No24:1849-54


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Electrical Thrills cardioversion

Damped Biphasic


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Biphasic - AF cardioversion

  • 165 patients randomized to monophasic vs. biphasic shocks

    • Stepped approach

      • Biphasic: 70,120,150,170

      • Monophasic:100,200,300,360

        • Mittal et al, Circulation March 2000,Vol.101(11): 1282-87


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Biphasic - AF cardioversion

  • Mittal et al, Circulation March 2000,Vol.101(11): 1282-87


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Conclusion cardioversion

  • Prior to conversion:

    • A fib less than 48 hrs or,

    • Anticoagulation with an INR >2.0 for 3 weeks, or

    • TEE showing no clot at time of conversion

  • Pills work about 40% of the time

  • Electrical Thrills work about 90% of the time


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Conclusion cardioversion

  • Biphasic waveform is superior and desirable

  • Ibutilide will have a role

    • unable to perform anesthesia

    • very effective for atrial flutter

    • facilitate DC cardioversion


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www.mediclicks.net cardioversion


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