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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

Converting Atrial Fibrillation to NSR

Pills or Electrical Thrills

Peter Holzberger MD

background
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
Symptoms
  • Inappropriate heart rate response
  • Irregular rate
  • Loss of atrial systolic function
  • Thromboembolism
choices for immediate treatment
Choices for Immediate Treatment
  • Anticoagulation and Rate Control
  • Or
  • Conversion to NSR
nsr pills or electrical thrills
Pills

Placebo

Single Dose Antiarrhythmic Treatment

Ibutilide

Electrical Thrills

Traditional External Cardioversion

Double External Cardioversion

Biphasic Cardioversion

NSR-Pills Or Electrical Thrills
choices
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 ?
choices10
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
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
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
Placebo
  • Cotter et al,.Eur Heart J Dec 1999; 20(24):1833-42

P=0.0017

Conversion (%)

choices14
Choices
  • 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
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
pills single dose rx
Pills - Single Dose Rx
  • Boriani et al, Pacing Clin Electrophys Nov 1998; Vol.21 Part II, 2470-74
single dose
Single Dose
  • 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
single dose18
Single Dose
  • Boriani et al, Pacing Clin Electrophys Nov 1998; Vol.21 Part II, 2470-2474
choices19
Choices
  • 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
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
anticoagulation prior to conversion to nsr
At least 3 weeks 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
ibutilide
Ibutilide
  • Stambler et al, Circulation October 1996; Vol 94, No 7, 1613-21
ibutilide29
Ibutilide
  • 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
Ibutilide
  • Stambler et al, Circulation October 1996; Vol 94, No 7,1613-21
ibutilide31
Ibutilide
  • 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
Ibutilide
  • 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
Ibutilide
  • 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
Pills Or Electrical Thrills
  • Pills
    • Placebo
    • Single Dose Antiarrhythmic Treatment
    • Ibutilide
  • Electrical Thrills
    • Traditional External Cardioversion
    • Double External Cardioversion
    • Biphasic Cardioversion
electrical thrills dc
Electrical Thrills - DC
  • 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
Efficacy dependent on

Paddle size and position

Transthoracic impedance

Energy Waveform

Underlying disease

DC Cardioversion
paddle position
Paddle Position
  • Anterior/Posterior #1
paddle position38
Paddle Position
  • Anterior/Posterior #2
paddle position39
Paddle Position
  • Anterior/Anterior
electrical thrills double dc
Electrical Thrills - Double DC
  • Saliba et al, J Am Coll Cardiol 1999; Vol.34, No 7: 2031-34
double external cardioversion43
Double External 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
ibutilide and dc cardioversion
Ibutilide and DC 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
Ibutilide and DC 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
electrical thrills
Electrical Thrills

Damped Biphasic

biphasic af
Biphasic - AF
  • 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
biphasic af50
Biphasic - AF
  • Mittal et al, Circulation March 2000,Vol.101(11): 1282-87
conclusion
Conclusion
  • 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
conclusion52
Conclusion
  • Biphasic waveform is superior and desirable
  • Ibutilide will have a role
    • unable to perform anesthesia
    • very effective for atrial flutter
    • facilitate DC cardioversion