Course:PHAR451/Atrial Fibrillation

From UBC Wiki

Updated November 2013

Instructor

Richard S. Slavik, B.Sc.(Pharm.), Pharm.D., FCSHP
Clinical Professor
Faculty of Pharmaceutical Sciences
University of British Columbia
richard.slavik@interiorhealth.ca
Phone (250) 980-5045, Cell (250) 470-2602

Preparation for the session

  1. Sanoski CA, Bauman JL. Chapter 25 – The Arrhythmias, In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM (eds). Pharmacotherapy: A pathophysiologic approach. New York (NY): 2011. p. 273-309. (See pages 282-290 and key tables/figures.) (Available through Connect)
  2. Skanes AC, Healey JS, Cairns JA, Dorian P, Gillis AM, McMurtry MS, et al. Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: Recommendations for stroke prevention and rate/rhythm control. Can J Cardiol 2012;28:125-136. (Available through Connect)
  3. Atrial Fibrillation Powerpoint Handout (Please read prior to class and bring it with you).
  4. Atrial Fibrillation Case (Please red prior to class and bring it with you).

Pre-Session Objectives

PRIOR to the session to be adequately prepared, the student should be able to:

  1. Explain the general pathophysiology of AF, and understand where AF medications work (e.g. AV node for rate control, atrial tissue for antiarrhythmic drugs);
  2. Describe the common classification system for AF and explain what is meant by first episode, paroxysmal, persistent, and permanent AF;
  3. Recognize the clinical presentation of AF using patient symptoms and signs;
  4. List important clinical outcome goals for AF patients (e.g. symptoms, morbidity, QOL);
  5. List specific therapeutic goals for AF patients (e.g. rate or rhythm control, prevent stroke);
  6. Recommend appropriate rate control medications for acute AF in the ED;
  7. Recommend appropriate antithrombotic prophylaxis for acute AF in the ED;
  8. Recommend an appropriate agent for pharmacological conversion of acute AF in the ED;
  9. Recommend appropriate chronic ventricular rate control therapy for AF patients
  10. Recommend appropriate chronic antiarrhythmic therapy for AF patients;
  11. Recognize which patients should not receive dronedarone for AF;
  12. List risk factors for stroke using the CHADS2 scoring system;
  13. Determine an AF patient’s annual risk of stroke using the CHADS2 scoring system;
  14. Recognize generally-accepted risk factors for major bleeding on oral anticoagulants.

Post-session Objectives

AFTER completion of this session and upon further learning/reflection, student should be able to:

  1. Explain the general pathophysiology of AF, and understand where AF medications work (e.g. AV node for rate control, atrial tissue for antiarrhythmic drugs);
  2. Describe the common classification system for AF and explain what is meant by first episode, paroxysmal, persistent, and permanent AF;
  3. Recognize the clinical presentation of AF using patient symptoms and signs;
  4. List important clinical outcome goals for AF patients (e.g. symptoms, morbidity, QOL);
  5. List specific therapeutic goals for AF patients (e.g. rate or rhythm control, prevent stroke);
  6. Recommend appropriate rate control medications for acute AF in the ED;
  7. Recommend appropriate antithrombotic prophylaxis for acute AF in the ED;
  8. Discuss risk/benefit of rate control versus pharmacological conversion of acute AF in ED;
  9. Recommend an appropriate agent for pharmacological conversion of acute AF in ED;
  10. Discuss the controversy of chronic rate versus rhythm control for AF patients, and understand the proven differences of each strategy on clinical outcomes in AF patients;
  11. Discuss controversies of target heart rate for AF patients
  12. Recommend appropriate chronic ventricular rate control therapy for AF patients
  13. Recommend appropriate chronic antiarrhythmic therapy for AF patients;
  14. Recognize which patients should not receive dronedarone for AF;
  15. List the common adverse effects and formulate a safety monitoring plan for amiodarone;
  16. List risk factors for stroke using the CHADS2 scoring system;
  17. Determine an AF patient’s annual risk of stroke using the CHADS2 scoring system;
  18. Apply the generally-accepted relative risk reductions for ASA (22%), ASA/clopidogrel (44%), warfarin INR 2-3 (66%), dabigatran 100 mg bid (66%), rivaroxaban 20 mg daily (66%), apixaban (74%), dabigatran 150 mg bid (79%), to calculate the annual risk of stroke for an AF patient;
  19. Recognize generally-accepted risk factors for major bleeding on oral anticoagulants
  20. List risk factors for bleeding in the HASBLED scoring system and its limitations;

Further Reading

Canadian Clinical Practice Guidelines

Consider the following sections
(P.38-46) Management of Recent-Onset Atrial Fibrillation and Flutter in the ED
(P.47-59) Rate and Rhythm Management
(P.74-90) Prevention of Stroke and Systemic Thromboembolism in AF and Atrial Flutter

American Clinical Practice Guidelines

  • Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation). J Am Coll Cardiol 2006;48:e149–e246.
See “Section 8. Management“
See “Section 8. Management“

European Clinical Practice Guidelines

Acute Ventricular Rate Control

  • Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010 Nov 2;122(18 Suppl 3):S729-67.

Acute Conversion

  • Slavik RS, Tisdale JE, Borzak S. Pharmacologic conversion of atrial fibrillation: a systematic review of available evidence. Prog Cardiovasc Dis 2001;44:121-52.
  • Slavik RS. Intravenous amiodarone for acute pharmacological conversion of atrial fibrillation in the emergency department. CJEM. 2002 Nov;4(6):414-20.
  • Slavik RS, Zed PJ. Intravenous amiodarone for conversion of atrial fibrillation: misled by meta-analysis? Pharmacotherapy. 2004 Jun;24(6):792-8.
  • Borgundvaag B, Ovens H. Cardioversion of uncomplicated paroxysmal atrial fibrillation: a survey of practice by Canadian emergency physicians. Can J Emerg Med 2004;6:155-60.
  • DeckerWW,Smars PA, Vaidyanathan L, et al. A prospective, randomized trial of an emergency department observation unit for acute onset atrial fibrillation. Ann Emerg Med 2008;52:322-8.
  • Stiell IG, Clement CM, Brison RJ, et al. Variation in management of recent-onset atrial fibrillation and flutter (RAFF) among academic hospital emergency departments. Ann Emerg Med 2010;57:13-21.
  • Stiell IG, Clement CM, Perry JJ, et al. An aggressive protocol for rapid management and discharge of emergency department patients with recent- onset episodes of atrial fibrillation and flutter. Can J Emerg Med 2010;12:181-91.

Acute Antithrombotic Therapy

  • Klein AL, Grimm RA, Murray D, et al. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med 2001;344:1411–1420.

Chronic Rate versus Rhythm Control

  • Hohnloser SH, Kuck KH, Lilienthal J. Rhythm or rate control in atrial fibrillation—Pharmacological Intervention in Atrial Fibrillation (PIAF): A randomised trial. Lancet 2000;356:1789–1794.
  • Van Gelder IC, Hagens VE, Bosker HA, et al. The Rate Control Versus Electrical Cardioversion for Persistent Atrial Fibrillation Study Group. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002;347:1834–1840.
  • The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002;347:1825–1833.
  • Carlsson J, Miketic S, Windeler J, et al. Randomized trial of rate control versus rhythm-control in persistent atrial fibrillation: The Strategies of Treatment of Atrial Fibrillation (STAF) study. J Am Coll Cardiol 2003;41:1690–1696.
  • Opolski G, Torbicki A, Kosior DA, et al. Rate control vs rhythm control in patients with nonvalvular persistent atrial fibrillation: The results of the Polish How to Treat Chronic Atrial Fibrillation (HOT CAFE) Study. Chest 2004;126:476–486.
  • de Denus S, Sanoski CA, Carlsson J, Opolski G, Spinler SA. Rate vs rhythm control in patients with atrial fibrillation: A meta-analysis. Arch Intern Med 2005;165:258–262.
  • Roy D, Talajic M, Nattel S, et al. Rhythm control versus rate control for atrial fibrillation and heart failure (AF-CHF). N Engl J Med 2008;358:2667–2677.

Chronic Ventricular Rate Control

  • Segal JB, McNamara RL, Miller MR, et al. The evidence regarding the drugs used for ventricular rate control. J Fam Pract 2000;49:47-59.
  • Boriani G, Biffi M, Diemberger I, Martignani C, Branzi A. Rate control in trial fibrillation: choice of treatment and assessment of efficacy. Drugs 2003;63:1489-509.
  • Nikolaidou T, Channer KS. Chronic atrial fibrillation: a systematic review of medical heart rate control management. Postgrad Med J 2009;85:303-12.
  • Groenveld HF, Crijns HJ, Van den Berg MP, et al. The effect of rate control on quality of life in patients with permanent atrial fibrillation: data from the Race II (Rate Control Efficacy in Permanent Atrial Fibrillation II) study. J Am Coll Cardiol 2011;58:1795-803.

Chronic Antiarrhythmic Therapy

  • Roy D, Talajic M, Dorian P, et al. Amiodarone to prevent recurrence of atrial fibrillation. Canadian Trial of Atrial Fibrillation Investigators. N Engl J Med 2000;324:913–920.
  • Singh BN, Singh SN, Reda DJ, et al. Amiodarone versus sotalol for atrial fibrillation. N Engl J Med 2005;352:1861–1872.
  • Pedersen OD, Bagger H, Keller N, et al. Efficacy of dofetilide in the treatment of atrial fibrillation-flutter in patients with reduced left ventricular function, A Danish Investigation of Arrhythmia and Mortality ON Dofetilide (DIAMOND) Substudy. Circulation 2001;104: 292–296.
  • Singh S, Zoble RG, Yellen L, et al. Efficacy and safety of oral dofetilide in converting and maintaining sinus rhythm in patients with chronic atrial fibrillation or atrial flutter. The Symptomatic Atrial Fibrillation Investigative Research on Dofetilide (SAFIRE-D) Study. Circulation 2000;102:2385–2390.
  • Pedersen OD, Bagger H, Keller N, et al. Efficacy of dofetilide in the treatment of atrial fibrillation-flutter in patients with reduced left ventricular function: A Danish investigations of arrhythmia and mortality on dofetilide (DIAMOND) substudy. Circulation 2001;104:292–296.
  • Deedwania PC, Singh BN, Ellenbogen K, et al; Department of Veterans Affairs CHF-STAT Investigators. Spontaneous conversion and maintenance of sinus rhythm by amiodarone in patients with heart failure and atrial fibrillation: observations from the veterans affairs congestive heart failure survival trial of antiarrhythmic therapy (CHF-STAT). Circulation 1998;98:2574-9.
  • Singh BN, Connolly SJ, Crijns HJGM, et al. Dronedarone for maintenance of sinus rhythm in atrial fibrillation or flutter. N Engl J Med 2007;357:987–999.
  • Hohnloser SH, Crijns HJGM, van Eickels M, et al. Effect of dronedarone on cardiovascular events in atrial fibrillation. N Engl J Med 2009;360:668–678.
  • Kober L, Torp-Pedersen C, McMurray JJV, et al. Increased mortality after dronedarone therapy for severe heart failure. N Engl J Med 2008;358:2678–2687.
  • Heuzey JY, Ferrari GM, Radzik D, et al. A short-term, randomized, double- blind, parallel-group study to evaluate the efficacy and safety of dronedarone versus amiodarone in patients with persistent atrial fibrillation: the DIONYSOS study. J Cardiovasc Electrophysiol 2010;21:597-605.
  • Connolly SJ, Camm AJ, Halperin JL, Joyner C, Alings M, Amerena J, et al. Dronedarone in high-risk permanent atrial fibrillation. N Engl J Med. 2011 Dec 15;365(24):2268-76. Epub 2011 Nov 14.

Chronic Antithrombotic Therapy

  • Hart RG, Pearce LA, Aguilare MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Int Med 2007;146:857-67.
  • Hart RG, Pearce LA, Aguilar MI. Adjusted-dose warfarin versus aspirin for preventing stroke in patients with atrial fibrillation. Ann Intern Med 2007;147:590-2.
  • Connolly SJ, Pogue J, Hart R, et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): A randomised controlled trial. Lancet 2006;367:1903–1912.
  • ACTIVE Investigators. Effect of clopidogrel added to aspirin in patients with atrial fibrillation (ACTIVE A). N Engl J Med 2009;360:2066-78.
  • Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:1139-51.
  • Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. New Engl J Med 2011;365:883-91.
  • Granger CB, Alexander JH, McMurray JJV, et al. Apixaban versus warfarin in patients with atrial fibrillation. New Engl J Med 2011;365:981-93.
  • Stroke Risk in Atrial Fibrillation Working Group. Comparison of 12 risk stratification schemes to predict stroke in patients with nonvalvular atrial fibrillation. Stroke 2008;39:1901-10.
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