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CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist

Published online by Cambridge University Press:  03 April 2018

Ian G. Stiell*
Affiliation:
Department of Emergency Medicine, University of Ottawa, Ottawa, ON Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON
Frank X. Scheuermeyer
Affiliation:
Department of Emergency Medicine, University of British Columbia, Vancouver, BC
Alain Vadeboncoeur
Affiliation:
Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, QC Emergency Medicine Services, Montreal Heart Institute, Montreal, Canada
Paul Angaran
Affiliation:
Division of Cardiology, Terrence Donnelly Heart Centre, St Michael’s Hospital, University of Toronto, Toronto, ON
Debra Eagles
Affiliation:
Department of Emergency Medicine, University of Ottawa, Ottawa, ON Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON
Ian D. Graham
Affiliation:
Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON
Clare L. Atzema
Affiliation:
Institute for Clinical Evaluative Sciences, Toronto, ON Sunnybrook Health Sciences Centre, Toronto, ON
Patrick M. Archambault
Affiliation:
Department of Family Medicine and Emergency Medicine, Université Laval, Laval, QC
Troy Tebbenham
Affiliation:
Peterborough Regional Health Centre, Peterborough, ON
Kerstin de Wit
Affiliation:
Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON
Andrew D. McRae
Affiliation:
Department of Emergency Medicine, University of Calgary, Calgary, AB
Warren J. Cheung
Affiliation:
Department of Emergency Medicine, University of Ottawa, Ottawa, ON Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON
Marc W. Deyell
Affiliation:
Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC
Geneviève Baril
Affiliation:
Hôpital de Granby, Granby, QC
Rick Mann
Affiliation:
Trillium Health Partners, Mississauga Hospital, Mississauga, ON
Rupinder Sahsi
Affiliation:
Division of Emergency Medicine, Department of Family Medicine, McMaster University, Hamilton, ON St. Mary’s General Hospital, Kitchener, ON
Suneel Upadhye
Affiliation:
Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON
Catherine M. Clement
Affiliation:
Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON
Jennifer Brinkhurst
Affiliation:
Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON
Christian Chabot
Affiliation:
Quebec City, QC
David Gibbons
Affiliation:
Ottawa, ON
Allan Skanes
Affiliation:
Division of Cardiology, Western University, London, ON.
*
Correspondence to: Dr. Ian G. Stiell, Clinical Epidemiology Unit, F657, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON K1Y 4E9 Canada; E-mail: istiell@ohri.ca

Abstract

Type
CAEP Position Statement
Copyright
Copyright © Canadian Association of Emergency Physicians 2018 

For a French translation of this position statement, please see the Supplementary Material at DOI: 10.107/cem.2018.26

The CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist was created to assist emergency physicians in Canada and elsewhere manage patients who present to the emergency department (ED) with acute/recent-onset atrial fibrillation or flutter. The checklist focuses on symptomatic patients with acute atrial fibrillation (AAF) or flutter (AAFL), i.e. those with recent-onset episodes (either first detected, recurrent paroxysmal or recurrent persistent episodes) where the onset is generally less than 48 hours but may be as much as seven days. These are the most common acute arrhythmia cases requiring care in the ED.Reference Connors and Dorian 1 , Reference Michael, Stiell, Agarwal and Mandavia 2 Canadian emergency physicians are known for publishing widely on this topic and for managing these patients quickly and efficiently in the ED.Reference Scheuermeyer, Innes and Pourvali 3 - Reference Stiell, Clement and Rowe 5

This project was funded by a research grant from the Canadian Arrhythmia Network and the resultant guidelines have been formally recommended by the Canadian Association of Emergency Physicians (CAEP). We chose to adapt, for use by emergency physicians, existing high-quality clinical practice guidelines (CPG) previously developed by the Canadian Cardiovascular Society (CCS).Reference Stiell and Macle 6 - Reference Macle, Cairns and Leblanc 8 These CPGs were developed and revised using a rigorous process that is based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system of evaluation.Reference Gillis and Skanes 9 , Reference Guyatt, Oxman and Vist 10 With the assistance of our PhD methodologist (IG), we used the recently developed Canadian CAN-IMPLEMENT© process adapted from the ADAPTE Collaboration. 11 - Reference Harrison, van den Hoek and Graham 13 We created an Advisory Committee consisting of ten academic emergency physicians (one also expert in thrombosis medicine), four community emergency physicians, three cardiologists, one PhD methodologist, and two patients. Our focus was four key elements of ED care: assessment and risk stratification, rhythm and rate control, short-term and long-term stroke prevention, and disposition and follow-up. The Advisory Committee communicated by a two-day face-to-face meeting in March 2017, teleconferences, and email. The checklist was prepared and revised through a process of feedback and discussions on all issues by all panel members. These revisions went through ten iterations until consensus was achieved. We then circulated the draft checklist for comment to approximately 300 emergency medicine and cardiology colleagues; their email written feedback was further incorporated and the final version created and approved by the panel.

During the consensus and feedback processes, we addressed a number of issues and concerns, some of which required extensive discussion. We spent considerable time defining what is meant by “unstable” and highlighting the issue that many unstable patients are actually suffering from underlying medical problems rather than a primary arrhythmia. Where possible we chose to simplify the checklist, for example listing only procainamide for pharmacological cardioversion. Other drugs were considered including vernakalant, ibutilide, propafenone, flecainide, and amiodarone. We also tried to give specific drug dosage recommendations, recognizing that physicians are free to consult any number of excellent pharmaceutical references. The panel believes that, overall, a strategy of ED cardioversion and discharge home from the ED is preferable from both the patient and the healthcare system perspective, for most patients. One controversial recommendation is to consider rate control or transesophageal echocardiography (TEE)-guided CV if the duration of symptoms is 24-48 hours and the patient has two or more CHADS-65 criteria. This is based on some recent data from Finland.Reference Nuotio, Hartikainen and Gronberg 14 , Reference Stiell, Healey and Cairns 15 We emphasize the importance of evaluating long-term stroke risk by use of the CHADS-65 algorithm and encourage ED physicians to prescribe anticoagulants where indicated.

Our hope is that the CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist will standardize and improve care of AAF and AAFL in large and small EDs alike. We believe that these patients can be managed rapidly and safely, with early ED discharge and return to normal activities.

Acknowledgments

Funding for this guideline was supported by the Cardiac Arrhythmia Network of Canada (CANet) as part of the Networks of Centres of Excellence (NCE). IS has received funding from Boehringer Ingelheim Canada Ltd. and from JDP Therapeutics for participation in clinical studies. PA has received research funding and/or honoraria from BMS-Pfizer Alliance, Boehringer Ingelheim, and Servier, KD has received research funding from Bayer. MD has received honoraria and research funding from Biosense Webster, Bayer, Bristol-Myers-Squibb, Abbott, and Servier. AS has received honoraria from Boehringer Ingelheim, Bayer, Pfizer, and Servier. TT has received honoraria from Cardiome Pharma Corp. We thank the hundreds of Canadian emergency physicians and cardiologists who reviewed the draft guidelines and who provided very helpful feedback.

Supplementary material

To view supplementary material for this article, please visit https://doi.org/10.1017/cem.2018.26

APPENDICES

Figure 1 Overall management algorithm for patients presenting to the ED with acute atrial fibrillation or flutter. Adapted from CCS 2014 Figure 2.7 Notes. * Consider medical cause (e.g. sepsis, bleeding, PE, heart failure, ACS, etc) if not sudden onset, HR<150, fever, known permanent AF; cardioversion may be harmful, rate control discouraged; investigate and treat underlying condition aggressively Consider rate control or transesophageal echocardiography (TEE)-guided CV if duration 24-48 hrs and two or more CHADS-65 criteria If CHADS-65 positive, start OAC; if stable CAD, discontinue ASA; if CAD with other anti-platelets or recent PCI, consult cardiology (see Figure 2) ASA=acetylsalicylic acid; CAD=coronary artery disease; CHADS-65=age 65, congestive heart failure, hypertension, age, diabetes, stroke / transient ischemic attack; CV=cardioversion; NOAC=novel direct oral anticoagulant; OAC=oral anticoagulant; TIA=transient ischemic attack.

Figure 2 Rapid Ventricular Pre-Excitation

Figure 3 “CCS algorithm” (“CHADS65”) for long-term stroke prevention in AF

References

REFERENCES

1. Connors, S, Dorian, P. Management of supraventricular tachycardia in the emergency department. Can J Cardiol 1997;13(Suppl A):19A-24A.Google Scholar
2. Michael, JA, Stiell, IG, Agarwal, S, Mandavia, DP. Cardioversion of paroxysmal atrial fibrillation in the emergency department. Ann Emerg Med 1999;33:379-387.Google Scholar
3. Scheuermeyer, FX, Innes, G, Pourvali, R, et al. Missed opportunities for appropriate anticoagulation among emergency department patients with uncomplicated atrial fibrillation or flutter. Ann Emerg Med 2013;62(6):557-565.Google Scholar
4. Atzema, CL, Yu, B, Ivers, N, et al. Incident atrial fibrillation in the emergency department in Ontario: a population-based retrospective cohort study of follow-up care. CMAJ Open 2015;3(2):E182-E191.Google Scholar
5. Stiell, IG, Clement, CM, Rowe, BH, et al. Outcomes for ED Patients with Recent-onset Atrial Fibrillation and Flutter (RAFF) Treated in Canadian Hospitals. Ann Emerg Med 2017;69(5):562-571.Google Scholar
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Figure 0

Figure 1 Overall management algorithm for patients presenting to the ED with acute atrial fibrillation or flutter. Adapted from CCS 2014 Figure 2.7Notes.* Consider medical cause (e.g. sepsis, bleeding, PE, heart failure, ACS, etc) if not sudden onset, HR<150, fever, known permanent AF; cardioversion may be harmful, rate control discouraged; investigate and treat underlying condition aggressively Consider rate control or transesophageal echocardiography (TEE)-guided CV if duration 24-48 hrs and two or more CHADS-65 criteria If CHADS-65 positive, start OAC; if stable CAD, discontinue ASA; if CAD with other anti-platelets or recent PCI, consult cardiology (see Figure 2) ASA=acetylsalicylic acid; CAD=coronary artery disease; CHADS-65=age 65, congestive heart failure, hypertension, age, diabetes, stroke / transient ischemic attack; CV=cardioversion; NOAC=novel direct oral anticoagulant; OAC=oral anticoagulant; TIA=transient ischemic attack.

Figure 1

Figure 2 Rapid Ventricular Pre-Excitation

Figure 2

Figure 3 “CCS algorithm” (“CHADS65”) for long-term stroke prevention in AF

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