1. Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department. Th e Florence experience A.Conti, B.Del Taglia, B.Paladini, F.Luise , F.Pieralli, A.Camaiti, G. Pepe, S. Magazzini, S.Grifoni, C. Nozzoli. Emergency Department and Chest Pain Unit, Careggi University Hospital, Florence, Italy. VI CONGRESSO NAZIONALE SIMEU RIMINI – 12-16 NOVEMBRE 2008 IL MEDICO D’EMERGENZA VERSO IL FUTURO TRA FORMAZIONE, TECNOLOGIA, INNOVAZIONE, RICERCA, ETICA E … SESSIONE “ EMERGENZE CARDIOLOGICHE”

2. VI CONGRESSO NAZIONALE SIMEU RIMINI – 12-16 NOVEMBRE 2008 IL MEDICO D’EMERGENZA VERSO IL FUTURO TRA FORMAZIONE, TECNOLOGIA, INNOVAZIONE, RICERCA, ETICA E … SESSIONE “ EMERGENZE CARDIOLOGICHE” Atrial fibrillation (AF) is the most common arrhythmia managed by emergency physicians and there is increasing evidence that selected patients with acute AF can be safely managed in the emergency department without the need for hospital admission

3. VI CONGRESSO NAZIONALE SIMEU RIMINI – 12-16 NOVEMBRE 2008 IL MEDICO D’EMERGENZA VERSO IL FUTURO TRA FORMAZIONE, TECNOLOGIA, INNOVAZIONE, RICERCA, ETICA E … SESSIONE “ EMERGENZE CARDIOLOGICHE” JAMA. 2001;285(18):2370-2375

4. Safety and efficacy of different pharmacologic treatment strategies were assessed in stable patients (pts) presenting in the Emergency Department with atrial fibrillation of recent onset (AF<24 hours) Aim Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department. Th e Florence experience G. Pepe

6. Patients who did not recover sinus rhythm were submitted to a second-line 18-hours approach and they were randomized to received:  a second i.v. bolus of the same drug previously given Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department. Th e Florence experience G. Pepe

8. 228 pts with AF enrolled in the ED 217 pts submitted treatment strategy With Amiodarone, Propafenone, Flecainide in the ED 11 pts spontaneously Recovered SR 90 pts recovered SR within the first-line approach (<6h) Enrollment and Treated and Untreated Episodes of AF. 21 pts needed DC Shock 127 pts admitted to observation and second-line approach (<18h) 106 pts recovered SR within the second-line approach (<24h)

9. p<.05 p<.ns p<.05 Sinus Rhythm after first-line treatment strategy in the Emergency Department First-line approach (< 6 hours) in the ED (n=217) Amiodaron n= 83 (38%) SR 20 (24%) Propafenon n=103 (48%) SR 47(45%) Flecainid n=31 (4%) SR 24 (77%) Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department. Th e Florence experience G. Pepe

10. Flecainide Propafenone Amiodarone Time course to sinus rhythm by treatment Propafenone and Flecainide: P<.001 vs Amiodarone Proportion of patients to sinus rhythm (%) Time (minutes) A P F Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department. Th e Florence experience G. Pepe

11. Baseline characteristic of 217 adults with AF Risk Factors Amiodaron Propafenon Flecainid DC Shock Mean age 71 65 62 63 Diabetes 13 (6%) 19 (8,7%) 4 (1,8%) 3 (1,4%) Hyperlipemia 4 (1,8%) 9 (4%) 1 (0,5%) 2 (1%) Hypertension 37 (17%) 44 (20%) 7 (3%) 10 (4,6%) Active Smoker 4 (1,8%) 8 (3,7%) 1 (0,5%) 1 (0,5%) Female 57 (26%) 50 (23%) 13 (6%) 11 (5%) Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department. Th e Florence experience G. Pepe

12. p = n.s. for all comparisons Sinus Rhythm after second-line treatment strategy during observation Second-line approach (< 18 h) (n=127) Amiodaron n= 27(21%) SR 21 (78%) Propafenon n=28(22%) SR18 (64%) Flecainid n =3(2,5%) SR 1 (33,3%) DC shock 6 (22%) DC shock 10 (36%) DC shock 2 (66,6%) Failure (< 18 h) (n=18) Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department. Th e Florence experience G. Pepe

13. Time (minutes) Amiodarone Propafenone Flecainide Sinus Rhythm by treatment (within 24 hours) Kaplan Meyer Curves Persistent atrial fibrillation % 24 h Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department. Th e Florence experience G. Pepe

14. Baseline characteristic of 127 adults needing second-line treatment ) Risck Factors Amiodaron Propafenon Flecainid Mean age 65 63 62 Diabetes 2 (1,6%) 2 (1,6%) 0 (0%) Hyperlipemia 3 (2,4%) 1 (0,8%) 0 (0%) Hypertension 13 (10%) 16 (13%) 0 (0%) Active Smoker 0 (0%) 4 (3%) 0 (0%) Female 16 (13%) 11 (9%) 2 (1,6%) Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department. Th e Florence experience G. Pepe

15. Propafenon Flecainid Amiodaron Hypertension Diabetes Mellitus Active Smoke Hyperlipemia Diabetes Mellitus Female gender Baseline characteristic of the study population in ED (n=217) p= n.s. pts . Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department. Th e Florence experience G. Pepe

16. Propafenon Flecainid Amiodaron Hypertension Diabetes Mellitus Active Smoke Hyperlipemia Diabetes Mellitus Female gender Baseline characteristic of second-line population in ED (n=127) p= n.s. pts . Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department. Th e Florence experience G. Pepe

17. AF in ED ( 6 hrs ): QRS e QTc pre e post treatment Pre-treat Post-treat. Pre-treat. Post-treat. Pre-treat. Post-treat Propafenon Flecainid Amiodaron p= n.s for all comparison msec. Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department. Th e Florence experience G. Pepe

18. AF in ED ( 24 hrs ) : QRS e QTc pre e post treatment Pre-treat Post-treat. Pre-treat. Post-treat. Pre-treat. Post-treat Propafenon Flecainid Amiodaron p= n.s for all comparisons msec. Treatment strategy for Atrial Fibrillation of recent onset in the Emergency Department. Th e Florence experience G. Pepe

20. Emergency Department and Chest Pain Unit, Careggi University Hospital, Florence, Italy. [email_address]

22. Overall time of arrythmias Propafenon Flecainid Amiodaron minutes p= .05 p= n.s. p= .05

23. Propafenon Flecainid Amiodaron Quinidine P= n.s. Overall time of arrythmias to observation p<.05 p<.05

24. Amiodarone Propafenone Flecainide SR by treatment (within 6 hours) P<.001 vs Propafenone and Flecainide Persistent atrial fibrillation % Time (minutes)

25. Time (minutes) Overall SR by treatment (within 24 hours) Persistent atrial fibrillation %