A Tale of Two Atria: AF management update.
One of my jobs at the Uni is to corral medical students into producing “grand rounds” presentations. Usually I try and pick a topic that they need to know, and one that makes for a good discussion. Recently 4 of my students – Jaz O’Neill, Sally Roberts, Jeffery Smith and Amy Klemm – got handed AF: management as their brief.
In retrospect this was a big ask! It is fair to say that the acute and longer term management of AF is shrouded in uncertaintly, conflicting evidence and we have a lot of studies with confidence intervals agonisingly close to 1.00! The team put up a great effort and produce this slideshow:
A tale of two atria (Click to open pdf version) Have a read – it is 37 ‘slides’. The idea was to look at 2 patients with different risk, needs and possible prognoses – to illustrate the idea that one protocol does not fit all when it comes to AF.
I certainly learned quite a bit ‘advising’ them and reading the evidence at hand. A short summary of learning points for the average GP follows:
- AF is messy, there are a series of decision points – each with relatively weak evidence to guide clinical decision-making.
- Probably my biggest take away concept: consider the patient and where they are at in the ‘natural history’ of their own AF (age is a big clue) in order to make a rational call on the longer-term management.
- The Cardiology party line on things such as a 48 hour cut-off for acute cardioversion is based in more commonsense than actual evidence.
- The Ottawa Protocol folks are either onto something especially good, or just got lucky with their 600 off patients – would be good to see longer term data from this cohort!
- The rate vs. rhythm control debate is not even close to being resolved – there is a lot of wriggle room. Largely this decision comes down to patient preference and this requires good information from you – the doctor at the coal face!
- Anticoagulation – the new players have not provided a panacea – warfarin is still the standard and the newer agents are making a place for themselves – but remain imperfect. Watch the ACS risk – might prove a tricky one – ?Vioxx all over again?
Ok, have a read and let me know – how would you manage the two patients presented in the slideshow? Or better yet, if it were yourself – what would you like to do?
Procainamide? In rural Oz? Hmmmmm….
Awesome powerpoint slides so well done to the students! great topic for debate and discussion! Gets even more complicated when dealing with remote patients in particular Indigenous clients who may not have ready access to INR monitoring
CVA is not cool
life long warfarin not so cool too
SO Cardioversion seems a no brainer, right?
Not so simple too! Do we really know how long someone has been in AF and are we prepared to cardiovert those without adequate anticoagulation? Ottawa study suggests we can but even they used the traditional 48hr cutoff.
The exam answer for your students in those two patients in their slide presentation is that with a history of 36 hrs of symptoms. Now it reads as if a Echo was done on both and I assume it was a TOE, and I assume it did not demonstrate atrial thrombus…in this uncommon scenario..I would then discuss with BOTH patients the merit of immediate cardioversion
The more common scenario is you cant get an ECHO done, let alone a TOE which is the evidence based standard for assessing atrial clot. Then gold standard Australian based practice is rate control and anticoagulation for 4 weeks minimum, echo and if all looks good, cardioversion. Even with a 36 hr history, few ED clinicians in Australia, let alone cardiologists or general physicians would accept proceeding to immediate cardioversion without an Echo demonstrating the anatomy and excluding dogs ball obvious pathology
Now I predict there will come a time when ED clinician bedside ECHO will become the standard and it will be acceptable that bedside transthoracic ECHO will be sufficient to exclude thrombus and other pathology. In that future, Casey you would do your ECHO, get the 36 hr history, talk to the patient and proceed to cardioversion pathway.
Chemical cardioversion is always worth a shot and I use amiodarone because it is available easily or flecainide if possible. AS we know many acute AF will spont revert anyway
I must admit I have been recently influenced by the Ottawa study as well as a EMRAP podcast by Dr Al Sachetti interviewing a patient with recurrent AF who prefers cardioversion management. One telling thing she said was that why would you allow your heart to continue in AF as the longer it lasts the more permanent it becomes.
Committing someone to life long anticoagulation is a big deal and remote clients it maybe more risky than having a CVA. I must say some I have switched over to aspirin and clopidogrel combination which is recommended as an alternative option albeit less protective, in European AF guidelines.
Do you and your students want to record a podcast on this, I could talk for ages on it!