1. THE MANAGEMENT OF ACUTE AF. DR TRENT LIPP ROYAL BRISBANE AND WOMEN’S AND LOGAN HOSPITALS GETTING AGGRESSIVE WITH AF

2. RATE vs.. RHYTHM

3. PAROXYSMAL AF?? Most common ED Arrhythmia  No Data specific to management of this Ottawa Aggressive Protocol  A process for dealing specifically with Paroxysmal/Acute AF

4. OTTAWA

5. OTTAWA AGGRESSIVE PROTOCOL Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter Ian G. Stiell, MD, MSc;* Catherine M. Clement, RN;† Jeffrey J. Perry, MD, MSc;* Christian Vaillancourt, MD, MSc;* Cheryl Symington, RN;† Garth Dickinson, MD;* David Birnie, MD;‡ Martin S. Green, MD‡ CEJM 2010; 12(3): 181-191

6. THE PROTOCOL IN SUMMARY Acute AF  Stable  Clear Onset of less than 48hrs, or a minimum of 7 days adequate Anti-Coagulation Rhythm Control Priority  Chemical Cardioversion  Procainamide 1g IV over 60 mins  Electrical Cardioversion No mandate for Anti-Coagulation Discharge within 6 hours Rate Control if Unstable or failed Cardioversion

7. PROCAINAMIDE Type 1a Anti-Arrhythmic Blocks Voltage Gated Na Channels  Intermediate duration of about 4hours Available in QLD on SAS - $18/1g vial PROCAINAMIDEFLECAINIDEAMIODAONRE RATE OF SUCCESS~60%UP TO 90%~75% DURATION TO SUCCESS ~1 HR3-6 HRS4-6 HRS COMPLICATION RATE<10%

8. THE PROTOCOL IN SUMMARY Acute AF  Stable  Clear Onset of less than 48hrs, or a minimum of 7 days adequate Anti-Coagulation Rhythm Control Priority  Chemical Cardioversion  Procainamide 1g IV over 60 mins  Electrical Cardioversion No mandate for Anti-Coagulation Discharge within 6 hours Rate Control if Unstable or failed Cardioversion

10. ED TREATMENTS and COMPLICATIONS TREATMENTNO OF PATIENTS (%) n = 660 Success with Procainamide385 (58.3) Patients who went on to DCCV243 (36.8) Success with DCCV223 (91.8) Discharged Home639 (96.8) Discharged home in Sinus Rhythm595 (90.2) COMPLICATIONSNO.OF PATIENTS (%) n = 660 Total Events50 (7.6) Hypotension44 (6.7) Other Arrhythmia6 (.9) Stroke0 (0) Admitted21 (3.2) Relapse in 7 days57 (8.6)

11. SUMMARY OF THE PROTOCOL Safe  No episodes of CVA, Torsade's Effective  Achieves goal in over 90% of cases of Acute AF, with 8.6% recurrence rate Efficient  Median length of stay is 4.9 hours Limitations  Cohort study – prospective randomised trial suggested  Procainamide

12. ANY RECENT UPDATES??? Anti-Coagulation  Yes if age > 65 and CHADS2 > 0, AFTER.  Still had no recorded thromboembolic events No further research  Accepted practice in Canadian ED’s Other drugs  Suggests Fleccainide, and oppose Amiodarone

13. TAKE AWAY MESSAGES ED Cardioversion is Safe for Acute AF  Electrical Cardioversion for Acute A. Flutter Drugs vs. Electricity  Amiodarone? Flecainide? DCCV?  Still no prospective data – and not likely to be any in the near future No requirement for pre-procedure anticoagulation  Considered for AFTER procedure prior to discharge

14. WHERE TO FOR MORE INFO… 1 Stiell IG, et al. ED Use of IV Procainamide for Patients with Acute AF. Acad. Emerg Med 2007; 14(12):1158-1164 2 Raitt MH, et al. AFFIRM Trial. Am Heart J 2006;151:390-6 3 Stiell IG, et al. Assoc. of Ottawa Aggressive Protocol for the Management of Acute AF CJEM 2010;12(30):181-91 4 Nuoito I, et al. Time to cardioversion for Acute AF and Thromboembolic Complications. JAMA 2014;312:647-9 5 Stiell IG, et al. Urgent Cardioversion for Recent-Onset AF. Can. Jour. Cardio 2015;31:239-41 6 Stiell IG, et al. Variation in Management of Recent-Onset AF among Academic Emergency Departments Ann.Emerg.Med. 2011;57(1);13-21