Atrial Fibrillation Guideline Update: Part II

Atrial fibrillation is the most common clinical arrhythmia. The newest guidelines have significant changes in diagnosis, assessment, and treatment. Join host, Geoff Wall, with guest Matt Boyd, as they evaluate the pharmacotherapy changes in the new guidelines in this two-part episode.

The GameChanger
Rate and rhythm control medications largely have the same clinical outcomes. Patients with heart failure with reduced ejection fraction should try rhythm control first. Monitoring is key for atrial fibrillation pharmacotherapy.
 
Host
Geoff Wall, PharmD, BCPS, FCCP, BCGP
Professor of Pharmacy Practice, Drake University
Internal Medicine/Critical Care, UnityPoint Health

Guest
Mathew Boyd, PharmD
Clinical Pharmacist
Unity Point

Reference
Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2023 Nov 23:S0735-1097(23)06465-3. doi: 10.1016/j.jacc.2023.08.017. Epub ahead of print. PMID: 38043043.

https://www.jacc.org/doi/10.1016/j.jacc.2023.08.017

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CPE Information
 
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Discuss rate versus rhythm control in patients with atrial fibrillation
2. Develop a monitoring plan and selection of medications in rhythm control

0.05 CEU/0.5 Hr
UAN: 0107-0000-24-030-H01-P
Initial release date: 1/5/2024
Expiration date: 1/5/2025
Additional CPE details can be found here.

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Transcript

Speaker 1: 0:08

Welcome to the Game Changers podcast, where we have clinical conversations that impact your pharmacy practice. Let's listen in as our team discusses this week's clinical practice game changer Hello, and welcome to Game Changers clinical conversations.

Speaker 2: 0:21

I'm your host, jeff Wall, professor of pharmacy practice at Drake University and internal medicine clinical pharmacist at Methodist Hospital. Welcome to our podcast. Today is part two of our two part discussion on the brand new American College of Cardiology guidelines for the treatment of atrial fibrillation. If you haven't had a chance to see them, we'll have a link in our show notes. They are voluminous. Just looking at the I just I read them a couple of times, just online. I can only imagine how many trees I would have killed had I had to print these off.

Speaker 2: 0:53

So yeah, so you know. It really is, I think, a primer on how to approach these patients, much more so than most guidelines are, and they're well worth reading, well worth knowing, if you, if you work with these patients and just about everybody I know in primary care does. Today, in part two, we're going to focus on rate and rhythm control strategies and patients. They have atrial fibrillation and I'm honored to have with me Dr Matthew Boyd. Matt is a cardiology clinical pharmacist here at Methodist. He is well versed in all areas of atrial fibrillation but in particular the different antirhythmic drugs and rate control drugs and stuff he has seen with his extensive clinical knowledge. So, matt, welcome to the pod.

Speaker 3: 1:32

Great to be here.

Speaker 2: 1:34

I appreciate Matt's time and again. His expertise is going to be pretty critical in interpreting these guidelines, I think. So we're also going to just kind of have a bit more of a discussion than me kind of, you know, vomiting a whole bunch of information at you guys and then talking about it afterwards. So the second part of the guidelines on atrial fib do an incredible deep dive into the history of rate versus rhythm control. Something that I really try to when I'm talking about atrial fib with my students is is you know how in the 90s there was this kind of big, you know the great rhythm control versus rate control debate among cardiologists and they went back and forth and we weren't really sure. And then we had the affirmed studies and the race two studies that came out that really said that, you know, mortality really wasn't any different between the two. Now I think one of the one of the things that people talk about in those guidelines is is that they didn't really talk about patients who had a severe symptom burden, who had tons of symptoms, or patients with low EFs, and so that is something kind of think about when you're interpreting these studies. That, yes, and a lot of patients are, rate control strategy is completely reasonable and in fact that's actually the very first line of this section is rate control is a suitable strategy for many patients. That age will be relation. However, there are many patients where a rhythm control strategy is is is reasonable to do. So let's first talk about rate control, of course.

Speaker 2: 2:54

A study came out a few years ago that looked at at lenient versus strict rate control in patients. Will start targeting a heart rate of less than 110 versus targeting our heart rate of less than 80. That study overall didn't find a whole lot of difference between the two, but there were some some methodological issues with the study. They were, as you might imagine, had a difficult time exactly target less than 80 versus exactly targeting less than 110. They weren't going to exclude somebody who was in the less than 110 arm, who happened to get down to less than 80 by accident or whatever. So that and the fact that they excluded patients with heart failure, with low EFs, that was the other big thing. So you know, I think in many cases if you have a patient with not a lot of structural heart disease, that a heart rate of less than 110 who doesn't have symptoms is reasonable. But there are more patients where, if you're going to do a rate control strategy, you want a little more tight control map. What's your take on that?

Speaker 3: 3:49

Yeah, honestly, I feel like a lot of the times in cardiology, especially when patients come in with this new AFib nowadays, I feel like we kind of target trying to get them out of it. But if you can't get them out of it, rate control is. You know, you only have a certain number of drugs that you can use in the first place. And when you're looking at those drugs that you're using for your rate control, you have your beta blockers and then you really have your like non-dihydropyridine calcium channel blockers and besides that your only third line agent is going to be your dejoxins, which is, as we all know as pharmacists, is quite a toxic drug, hard to kind of manage, very, very bold with a lot of our patients. So really you have two classes of drugs and if you have a patient that has heart failure, then you really only have one class of drugs to manage these rate control patients. So it makes it a little more difficult to do rate control. I know a lot of the times in cardiology too, we have kind of that chicken versus the egg. What came first, your aphib or your heart failure? So if you come in with new aphib and you have a reduced ejection fraction or you have heart failure symptoms. You're trying to figure out is this heart failure from your AFib or is your AFib from your heart failure? So it kind of has a mixed pool which kind of makes it a little more tricky to manage.

Speaker 3: 4:54

But I know we're and this will be coming up with us too, but we'll kind of transition into more rhythm control instead of rate control and rate control again. It would be more just that symptom burden or those patients who have kind of failed rhythm control previously.

Speaker 2: 5:08

So Right, and I appreciate your thoughts that. You know, yeah, if you have somebody who has, you know, heifer F, obviously they need to be on a beta blocker anyway, so you can maybe treat a couple birds with one stone, but you know it is, yeah, that is worth noting, that. You know you really have in reality two, two classes of drugs. I know there's been a few studies that have suggested that, you know, dild, even long term, isn't all that effective in the long term as well. So I mean you, you know, yeah, you're basically down to beta blockers, those long-term listeners to the pod.

Speaker 2: 5:37

Know, a couple weeks ago I did an entire rant on why is the joxin becoming popular again? And it was one of the few times I kind of let my personal feeling show through and just like, why are we doing this and I know Dr Boyd is what we're kind of on the same mindset on that is like, you know, why did this drug all of a sudden become popular again? So you know, yeah, you're really kind of stuck with kind of two, two medications or really one medication at that point. So then the guidelines kind of kind of go into. You know the notion of both acute, you know, transition of patients from atrial fib into neuronal sinus rhythm. And, as I always tell my students that you know, electively, the way we do that, of course, is electricity in the United States. That's actually not true in Europe, where they do do more chemical conversion in interneuronal sinus rhythm. And the whole pill in the pocket strategy which, matt, do you see much around here.

Speaker 3: 6:31

In the Des Moines region we don't typically use pill in the pocket. I would say, just based off of the available literature too, it sounds theoretically like a great option. But more the times patients are feeling either a palpitation or they're not even truly an aphid. So then they're taking this anti-rhythmic for something that maybe not even occurring, because it's not like they're at home on continuous telly.

Speaker 3: 6:52

So I feel like it's kind of trended away from the pill in the pocket a little bit more, just because it is hard to kind of track and figure out what's going on.

Speaker 2: 6:59

Yeah, I agree, and I understand it's still so done, not infrequently in Europe. But yeah, that's something that always kind of struck me as weird. As you're walking down the street and then you get a what you think is a palpitation is like, well, I better slam 900 of per path at home. It's like, okay, I hope your QT isn't 600 milliseconds but at any event. So yeah, so it talks first about the human, dynamically stable patient who you know, or whether they're not human and stable. What they're not, as we all know.

Speaker 2: 7:29

The guidelines are clear that they get DC cardioversion If in the acute setting they have a decompensated heart failure. Then the guidelines of the 2b recommendation recommend IV amiodarone and then they do not recommend either veraphmil or tyazem. It's a level 3 recommendation indicating harm If the patient does not have decompensated heart failure. They actually say, you know, beta blockers or non-idiparating calcium channel blockers are reasonable and actually they give that a level one recommendation. Dig is below that and amiodarone is below that. And one thing they recommend throughout both segments of acute atrial fibrillation is the use of MAG. And I got to admit I'm terrible at remembering this and you're probably better at math than I am, but I mean I read this all the time I'm like oh crap, I forget magnesium can be used.

Speaker 3: 8:14

I mean, so are you're using it in the card service, or Honestly, I don't feel like we use, like you know, a bolus of magnesium to kind of get them out of AFib or help with that rate control. I know we have pretty stringent you know four and two, right your potassium and magnesium, which we monitor like a hawk most of the time on our cardiology service anyway. So MAG of two is, I would hope, already managed for most of our patients.

Speaker 3: 8:37

But again, if they come into the ER acutely ill and you don't really know what's causing the AFib and everything else is not really worked giving a two gram or four gram of MAG is not going to harm anybody, so I think it's you know a good first or second or third line option, especially if you don't really know the etiology of it.

Speaker 2: 8:54

So Right and yeah, that's it's just one of things and again, I know that that hasn't probably been studied all that much in my world which is, of course, septic shock, patients on pressers, and that's why their heart rate is 150, right, you know. But I, you know, as Dr Boyd points out, it's like you can't hurt them, you know. So, you know, I just got to be a little bit better at giving that a shot. So so then we kind of transition into talking about this rate versus rhythm control strategy. And again, the guidelines are among the best guidelines I've ever read that really break down this discussion. And you know, they say over and over in the guidelines that this is, of course, is a case by case basis and that what the patient, you know, patient decision making should play a big role.

Speaker 2: 9:35

You know, and again, you just I've not seen that in the previous iterations of the AFib guidelines, and so there are some really, really good charts, and one of them is you know, when you're talking about rate versus rhythm control, there are several factors you have to keep in mind. Some of them are patient factors. So the patient would like a shot at being in in in rhythm control and normal sinus rhythm, I think, particularly if they have a lot of palpitations or other types of symptoms, or if they have, you know, relatively low blood pressure and they're like, yeah, that's great, but every time I take metogra I fall over and hit my head, you know. So, you know, I think there's a role there. They note that younger patients, which are they're less likely to have permanent atrial fibrillation, we should probably give them a shot at rhythm control before we kind of give up and say, yeah, okay, it's kind of rate control for you and that leads to, you know, obviously, the antecedent history of heart failure short versus long. And then they note that for more symptoms a shot of rhythm control should certainly be reasonable.

Speaker 2: 10:32

I was always taught and Matt, this was a million years ago when dinosaurs roamed the earth, and you know pharmacists were using typewriters type in prescriptions. You know that I was always taught. You know, bad half ref, you should always try rhythm control first line, just because of the atrial kick thing. Or is that still a thing, or is that disappeared from the world?

Speaker 3: 10:51

Yeah, I would say a lot of the times. For majority of our patients, the first thing we try when we have any sort of a-fib is to try to get them back into normal rhythm, which is a good trend. It's especially after looking at these guidelines, I think this is the first guideline of any cardiology guideline that we have here.

Speaker 3: 11:08

That really emphasizes having that sit-down conversation between patient and provider and not just being like here you have this disease, say let's start going 15 drugs for it. I eat the heart failure guidelines, but for for this a-fib guideline, I think it does really point out like what patients would be good for this and what patients would be good for your rate versus your rhythm control. And so I know a lot in practice. We try to get them into normal rhythm as soon as we can, even if they are, you know, 60, 70 plus if this is their first occurrence. It does get a little tricky once you kind of get that echo and you're like, oh, this may be your first occurrence, but your atria is huge, so it doesn't really go well in that circumstance.

Speaker 3: 11:47

But a lot of the times we do try to focus a little bit more on rhythm just because with our heart failure patients, particularly like if you have a-fib on top of your heart failure, it's never going to go well, especially if you have an arty, weak heart and now you have a-fib that's maybe every once in a while going to go greater than 120 and you're sitting at home and you can't find your phone or your short of breath and then you're really stuck in a problem. So I know for a lot of our heart failure patients and particularly patients with this new onset a-fib, we really try to target rhythm control.

Speaker 2: 12:15

Okay, outstanding, yeah, and that's you know, it's good to know that theory really hasn't kind of disappeared or something that's kind of good to hear. And it's worth noting that. You know the studies have suggested and these are mostly retrospective studies that you know all cause mortality in patients with heffereff and atrial fib is higher than controls or controls who just have a heffereff. I think we forget about that sometimes. Well, you know, we want to make sure they're, you know they don't have a stroke. You know, yeah, sure, and we want to make sure that their symptoms are better. But I mean, there is probably a mortality benefit to rhythm control and I know I forget about that sometimes, but I think that is worth noting. And these guys note a paper that I had not read, the East AFNet 4 study, and it's a large registry study that basically shows that.

Speaker 2: 13:03

You know this is a continuum. You know, just stick somebody on amiodarone, pat him on the head and say we'll see you next year. You know that you need to monitor that. You know, are they, is it actually working? Well, you know, is a spot 12 lead EKG the way to go there then? Or you know is, do you have multiple areas where you try to put them on an event monitor or anything along those lines and you need to make more dynamic changes. And I think cardiologists are right at that. I'm not so sure that the that you know, primary care docs are particularly good at saying, okay, well, you know, you're here for your yearly checkup. We'll of course do a 12 lead EKG because you're a cardiology patient and, hey, you're at normal sinus rhythm, everything's terrific, you know, good luck, we'll see you next year. I think the guidelines really do point out the fact that this is a dynamic thing and you really should be monitoring these patients probably more frequently than that. So so then they turn to the type of anti rhythmic you're going to use, as well as ablation, which you know. Again, I like to think I can keep up on, but again, I'm really going to rely on Dr Boyd's expertise here.

Speaker 2: 14:08

You know, in the 90s and early 2000s, you know we only did ablation when everything else had absolutely failed and it didn't work most of the time. So you know, it didn't really make a difference. And there was always, you know that really rare, terrible complication, and we had a guy I'd have seen a couple of cases where they had esophageal perfs because they hurt much through the, through the atria. Whoops, sorry about that, you know, and so it's one of those things where, at the time, it just it wasn't very successful, and I know and I'm looking forward to hear what Matt has to say on this I mean, the technology has gotten so much better on this, so I mean it's now a pretty viable option in a lot of patients. So we're going to talk about that. We're going to talk about rhythm control. We're going to talk about pearls, about the medications, what you would use where and and, as pharmacists in particular, what we want to watch out for. We'll talk about that right after a message from CE impact our sponsors.

Speaker 1: 15:03

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Speaker 2: 15:33

So we're back with our part two on the ACC guidelines for atrial fibrillation, and we are talking with Dr Matt Boyd, who's our cardiology clinical pharmacist, and we are now talking, shifting to talking about the individual strategies for rhythm control in patients with atrial fibrillation, and one of the things they talk about again is okay, you've made the call, you're going to stick somebody on an anti-rhythmic and they have against great algorithms in the guidelines talking about which drugs they're going to talk about. So first up, they say, okay, if the person and I know you're not supposed to use this term anymore, but again, a million years ago when I came out of school, we called it low-n-a-fib. So patients who basically do not have LV dysfunction, they haven't had a history of coronary disease or other structural heart disease, they basically only have atrial fibrillation. The guidelines recommend, with a 2A recommendation of wide variety of medications to fetal idrenadarone, flechinide, perpapinone, and then if that doesn't work, they move on to amiodarone and if that doesn't work, you move on to sodalol with a 2B classification.

Speaker 2: 16:36

Now around here and Matt, I'm interested in your cake Well, it went, it seemed to me. In the 2000s and early 2010s we leaned a little more towards the one-C anti-rhythmics. I think largely on the theory of they're probably they don't cause as many problems, right, they don't cause your skin to turn blue or your liver to explode or any other other stuff. And so the thought was all they're relatively safe and we know from the studies clean back in the 1980s that they're safe and patient with structural heart disease. I don't see that it's on here. What's your cake on the one-C anti rhythmics and lony fib?

Speaker 3: 17:09

Yeah, honestly, I think it's a little dicey with one-C anti-rhythmics like flechinide or perpapinone. They most commonly, again, are going to be used for the pill in the pocket and a lot of the time with their mechanism of action they're really just shortening the reduction or like your ability to conduct through your AV nodes, so it kind of shortens that refractory period which gives yourself its own problems and itself. So when you're using these, or if you do see this in practice, you want to make sure they're with a beta blocker, because you do need some AV node conduction decreased, like you would have with either a beta blocker or a little tyazine. But again, those aren't used very often. I don't see flechinide, I don't see perpapinone used very often and I think this ultimately comes down to the fact that in our population, most of the time now, even when patients come in with AFib, most of them have some sort of structural heart disease. They either have previous coronary artery disease, they have some sort of heart failure or already prevalent either a reduced injection fraction or even if they have diastereal heart failure.

Speaker 3: 18:07

Sometimes I see patients or providers really kind of shy away from flechinide, perpapinone. So it's not necessarily saying that they're not good or safe drugs. Because looking at the profile of all of our class three ampyrythmixt, which we'll get into a little later, they're much cleaner in terms of like drug interaction side effect profiles that you're going to see monitoring with your QTCs that you're going to need to have. But again, flechinide perpapinone, really kind of moving out of favor, I would say, and I don't know again if that's just lack of, you know, familiarity with them, with providers, or if it's just they don't tend to work as well. But I don't necessarily see them as much in practice and I think that's a lot of the times with most of the patients we have in the hospital. It's because they don't normally come in with just a fib alone. Most of them are either advanced age with some other corner artery disease or something else going on.

Speaker 2: 18:55

And I agree with you. I think that's the thing, I think the whole. You know how I think before the advent of echocardiography it was easy to say somebody had a low and a fit right Because they didn't have symptoms of heart failure and you had no history of an MI. So you could go oh no, they're fine. But I think now, with the advent of the echocardiography being so common, it's pretty easy to find structural heart disease that you wouldn't have seen 20 years ago. So I think that's a good point. So in these patients, in your experience, or if, when your car team is asking you, what would you put this patient on with? Let's say, doesn't have structural heart disease?

Speaker 3: 19:30

Yeah, so I would say a lot of the time. In practice, the thing that we use probably the most is Sotolol, especially for our patients that have lone AFib Right. Just because of the ease of kind of starting it, there's less drug interactions with it and a lot of the times it's much more easily managed.

Speaker 3: 19:48

So you're not going to put someone on amiodarone, who's 40, who this is their first instance of AFib, you know long term side effects, long eyes, liver, all those things. That's just not a good drug. Maybe if you're 85 and this is your first time, but nothing when you're under the age of 65, this is definitely not a med that you want to be on long term. Dofetilide comes with its own risks. Dofetilide, although it works very well, it has so many things. Normally people have to be admitted for at least three days just to monitor EKGs while they're on it and then at any point say you forget to get a refill and you're off of it for three days. You have to come back into the hospital and start all over again. So, even though it's an effective drug, I don't think like dofetilide really is favorite only because of that reason.

Speaker 3: 20:32

We do have some that come in every once in a while, but it's never a new start. It's always like oh, you were on it. From a previous encounter Dranetarone, I would say, just from the East AFNet4 trial, that was the one that was actually used the most commonly and I can't necessarily say that Dranetarone is a bad anti-rhythmic in the sense it had these high expectations coming up to market with it being like the iodine free amyotarone, hoping it was all going to be like this perfect world where we're going to have this amyotarone drug that was like beautiful, perfect to use in every patient population. But I do think just because of cost alone and then it not really being again very common or familiar with our providers, I don't see Dranetarone used very often either and I think that's again because of the structural heart disease that we see a lot of the times with our patients too and kind of what goes on with that.

Speaker 2: 21:19

Absolutely. Again, you're probably too young to remember, but I definitely remember when Dranetarone and the reps were in my office and the multi-preps were in my office going this is great, it's the iodine, that's all the side effects, and you're not going to have smurf drug and you're not going to have any of the liver stuff. And yeah, I didn't have a lot of that stuff. But it also wasn't as effective as amyotarone and has a boxed warning for not being used in heart failure patients. So it's like so you know this, really, you know.

Speaker 2: 21:47

Yeah, I think when you took the iodine away, you must have taken something else away, because it definitely has its own set of problems. So, all right. So now you run into patients who have either stage or have an LV function less than 40%, really, new York Heart Association class occasion usually one or two or a prior MI, and so that's the next group that we're talking about. They recommend, again with a two-way recommendation, amyotarone or defedalide, and so to all is a to be an actually recommend, as you might imagine, against flec and idropaphanone because of harm, again because of the classic cast study that came out in the 1980s that found that there was an increased risk of death in those patients.

Speaker 3: 22:26

So so I saw me here and you say that maybe so long of your approach here in these patients to yeah, so even though the guidelines give so long that to be recommendation for patient population, I would say in this class alone this is kind of this I can, solely based off of the sword trial that they did a few years ago and that had like increased risk of heart failure exacerbations with patients on Soto wall.

Speaker 3: 22:47

So I would say that's kind of maybe why it has a lower recommendation on these guidelines and like our delfetalide and our amyotarone. But again, with our Soto wall you're thinking of patients who you know need that first three days monitoring. But again, soto wall is a much cleaner drug than both the delfetalide and the amyotarone. So I think that's why Soto wall is kind of almost our more preferred option in this patient population, just because of the ease of administration, the ease of follow up.

Speaker 3: 23:14

More amyotarone you're still going to get that side effect profile. Delfetalide you're still going to get that. And while you may not have like very decompensator heart failure with our patients with low EFs, you always have that risk of like CKD or progression of CKD, to which I still fettle, I even a less attractive option and having to come in and monitor that all the time too. So, despite all those problems and even though Soto wall may have a trial or two, not and maybe it's favor Soto wall still, I think, is where we lean towards in these patients. As long as you know, they're not in that age bracket where amyot might be a suitable option a sidebar question, and again I appreciate your expertise on this.

Speaker 2: 23:52

I'd occasionally run into patients that come in on Soto wall and the topral. Does that make sense?

Speaker 3: 23:57

Yeah, so actually we need to be patient on Sotolol on the top level Okay, fair enough, All right good. Only because, sotolol, I feel like as much as you know your cue was gonna tell you like, hey, watch out, this is a duplicate beta blocker In your mind is a pharmacist. You're like that's a beta blocker.

Speaker 3: 24:13

Sotolol, I would say, is more of like your potassium channel blocker, anti-earth banks, you can use it with beta blockers. It's not necessarily contraindicated or wrong, okay, but it is. You know, if you need more rate control on top of like your rhythm control, say your tachycardic or some other reason, I wouldn't say starting a beta blocker would be wrong.

Speaker 2: 24:31

Okay, that's good to hear.

Speaker 3: 24:33

And we do use it sometimes in practice, where we use both. Okay.

Speaker 2: 24:35

Just because I like to think of.

Speaker 3: 24:37

Sotolol as an anti-earth bank about as a beta blocker anymore.

Speaker 2: 24:39

All right, fair enough. And you know I've run into that and I've actually got questions about that and I've always said, well, if they have, you know, heiferapia and they have to be on the topolol or carbatolols or Sotolol, I guess you know. So that makes total sense. Okay, that's good to know. That's something that I've struggled with over the years. That's good to hear.

Speaker 2: 24:58

So then we kind of turned to amiodarone and you noted that you know you guys tend to use it. Your group tends to use it a little more in older patients, or probably patients who have failed. Other therapies would be my guess, as you're well aware, and you know. And again, the guidelines do a great job of talking about monitoring long-term amiodarone. I you know in particular the two and they've eased up on this and I think that's largely because we're using lower doses for atrial fib. And again, when I would, I think the iteration before the last iteration of atrial fib guidelines, they were recommending chest X-rays every year and all, and you know, dilated eye exams, and all of a sudden they've really kind of backed off on that. And really the two they've really kind of honed in on this set of guidelines was thyroid function test and LFTs every six months. I get the sense that that's not being done. What do you think, Matt?

Speaker 3: 25:46

Yeah, honestly, I can say just from an inpatient perspective, I don't think a lot of monitoring for some of these meds gets done as frequently as we want it to see whether it be, you know, our rate control drugs like dejoxin. I don't think that's monitored as well as it should be, as well as amiodarone and our long-term patient use. So, even though it's used and we're thinking about all these adverse effects as pharmacists, make sure that you know. If you have a patient that's on the floor or being discharged and you're an outpatient pharmacist and kind of seeing this medication, make sure to almost educate the patient that they need to have these things as well so that way they can have, you know, that conversation with their provider and making sure that all these things are being done, because I would hate for it to slip through the cracks.

Speaker 3: 26:26

And one day they show up with you know some crazy hepatotoxicity or they have you know off the charts TSH and they just need to have a whole new change of therapy.

Speaker 3: 26:37

So I think that's where we can kind of be the middleman both be the advocate for our patients but then also advocate for them when we're in the hospital and trying to talk to the providers. Yeah, but I was gonna say along the lines too I know a lot of the times with our 8-bit patients. Once they're loaded at the hospital we try to keep them on 200 milligrams just daily. I don't know why, but sometimes common practice here in the Des Moines region is we like to keep them on BID amiodarone for a long period of time, which I don't necessarily you know as pharmacists. We all know the half-life of amiodarone is a little over two months, so there's no need to twice a day dose it. So if you see the medication as twice a day for and they're not loading this medication, make sure that you're also, you know, reaching out, having that conversation with providers to make sure that we're only doing it daily.

Speaker 2: 27:20

You don't need to give them more of a toxic drug if we don't need to, so Right and, as I understand it, you know, a lot of the, such as the pulmonary side effects, are total dose. You know total exposure required, right? Which is why we saw a hell of a lot of it when patients were taking 400 a day for ventricular rhythmics, right? So yeah, you know, I don't know, I've read. You know there's been little studies over the years.

Speaker 2: 27:42

I know you trained in the Chicago land area back again when dinosaurs roamed the earth. You know, I see actually had a pretty good pharmacist run amiodarone clinic, but again, this was back when you had to get all this stuff done. You know, I don't wonder if you know, especially the outpatient pharmacist out there, you know, especially ones working in embedded and cards clinics, if they're already doing this, they're already saying you know, no, we'll take care of the monitoring, so the physician doesn't have to sort of thing. But I think, even if you're not, even if you're an embedded ambulatory care pharmacist, you know you can say you know there's nothing wrong with, you know, checking and setting up teas on somebody, maybe one more time than you you know should have. And I have seen, you know, over the years again, being an old man, I've seen a lot of these bizarre side effects.

Speaker 2: 28:27

I've seen a few cases of pulmonary fibrosis with amiodarone and it didn't go well. And I've seen Smurf drug once, but it wasn't nearly as bad as the pictures online show. I mean, the pictures online make it look like, oh my God, you know, but we had a patient who definitely had a light blue tint to their skin and we just were all gobsmacked about that. So what, you know, what are some other pearls? I mean, I think amiodarone is still gonna be the one that most of our providers see a lot. Most of our pharmacists see it.

Speaker 3: 28:54

What other?

Speaker 2: 28:54

pearls do you have for those people about that drug?

Speaker 3: 28:57

Yeah, honestly I can say, if you see the amiodarone being used in the hospital, particularly in the ICU, which I feel like we do a lot for those patients who either are on nuance at a Bayfib or have that, you know, run of a Fib, where we're really concerned about it overnight because they're acutely ill, once you get that bowl list, if their patient resolves and returns to normal, normal signage rhythm and their course of therapy for you know their other treatment say their infection or anything continues to improve. I don't think these are patients that need to be on like life-long amiodarone because of this 10 minute spout of A-Fib that they were on. And I think the guidelines do a good job of pointing that out here, where patients who are critically ill need to be continuously reassessed. You know it's not like, oh, you had A-Fib one time in the sixties because you were acutely sick with a MRSA infection and now you need to be on anti-colegulation amiodarone for the rest of your life.

Speaker 3: 29:46

So I think that's something moving forward that as pharmacists we can really point out like, hey, you maybe had A-Fib in the hospital, but what was going on? Were you sick, were you in pain with something going on? Respiratory wise, did it resolve pretty quickly after you know either rate controlling you and you converted to normal sinus or giving that bowl list to you for amiodarone. Did you resolve and go back to normal sinus without any hint of A-Fib for the rest of your hospitalization? So kind of just checking to make sure that, even though patients might continue on amiodarone during their course of therapy, or at least in the hospital, that this isn't necessarily a drug that is a forever drug just because you had A-Fib one time.

Speaker 2: 30:21

Right, I'm sure we do a terrible job of that and God only knows how many people we send home on amiodarone that we're never really intended to do that right. And, as you point out, I mean it is true and I think there's been a couple of studies that suggest that. You know, you do have a burst of atrial fibrillation for someone who's sick in the hospital.

Speaker 2: 30:38

You need to watch them and in fact it may not be a bad idea to even do an event monitor on those patients at some point as an outpatient, because they might have a cold atrial fibrillation they're not aware of. But yeah, I have no doubt Matt is correct. We've sent tons of people on my amiodarone that probably didn't need to be on amiodarone. So last thing I wanted to touch base on and this is something I admit I know it's real bad as ablation. So where do you see ablation fit in? What's the success rate? And as a pharmacist I've now inherited I'm a dumb primary care pharmacist. I've inherited somebody from the smart cardiologists who has been ablated. What do I got to watch out for at that point?

Speaker 3: 31:14

Yeah, honestly I would say, ablation is still like kind of you alluded to earlier, very last line.

Speaker 3: 31:19

It's not something that you know. You come into the AFib, have a run of AFib and they immediately jump to like, oh, we're them control within ablation? Like that's not really where we're, you know, targeting for the ablations. Because, like you said earlier, there are the risks and even though procedures have gotten safer and better, there is still a risk with every procedure that you're going to do. So I would say that we're still using like ablations for patients who maybe have that refractory AFib or they have such bad heart failure that if they go into AFib it really exacerbates their heart failure. But for those patients I would say that's normally when EP you get kind of gets on board and you get those ablations and kind of at that point they should be the ones kind of following up and managing. But I would say ablations are relatively successful for the most part.

Speaker 3: 32:03

It is very tricky with fibrelation because normally there's multiple foes size so that they're trying to target there's a bunch of different areas where they might have to ablate and at that point maybe an AB node ablation with the pacemaker would be better, because then you're not having a bajillion different procedures or like different ablations where they're trying to burn off different parts of your heart. I've always thought it was a little, a little scary especially as a resident watching ablations, you know because you're essentially just taking like a coterie tool and just burning a little piece of your heart and hoping that it's kind of just like guessing and checking, which I'm sure we've all done during our time in school, though that I will point out that burning a piece of your heart has to be an 80s ballad somewhere there.

Speaker 2: 32:43

Throw that out there. Yeah, probably a Michael Bolton song. Yeah, you know, yeah, so that's good. So you know it's improved, but still not nobody's jumping to.

Speaker 3: 32:52

Yeah, nobody jumps to it. It's not a perfect solution, you know. It's not like something that you go in, get an ablation and it's perfectly fine for the rest of it. You know, a lot of times maybe, if you have like uncontrolled A flutter which is more of a regular irregular rhythm and it normally only has like normally one foci that it's coming from, that's a little easier to target than you know, like our AFib that has multiple sites where it's firing from. But again, yeah, it's kind of that guess and check method from at least my understanding as a pharmacist about a doing ablation, which I, you know have been done a whole lot of.

Speaker 2: 33:23

But you've seen way more dias. So the question that I've gotten asked and I honestly don't know the answer to this question is okay. So you know it's last line. You've done it. There was one foci, you know you got it. Patients in normal sinus rhythm were six months out. Normal sinus rhythm stop anticoagulation.

Speaker 3: 33:42

That's kind of where I think we're trending towards okay if you have those event monitors you don't have any like AFib that's coming up on it, then I think that's kind of where you have treated this long-term problem that this patient has had, where you know, if they do have like a recurrence of your AFib, you kind of just go back to the drumming board and kind of start all over. But I do think once you kind of have normal sinus rhythm with your AFib and if it's controlled and you're been in normal sinus for a long period of time after the sublation, I can honestly say that I think we're kind of trending towards like stopping anticoagulation for AFib. That's pretty cool.

Speaker 2: 34:15

I mean, again, to me that's that's incredibly cool and it to me it means that there's only a matter of time, I think, before we cure age of it, right, I mean that we're able to burn out the six you know, you know and re-intrant cells that are causing this problem and you're done. I mean so that you know that's on the rise and it sounds like to me. So that's, that's pretty cool. Last thoughts, last pearls you'd like to give the audience about, you know, rate versus rhythm control. One question well, yeah, well, I got you here because this is something that drives me bananas and I'll be interested to take get. Your take is so you had that patient with the run of atrial fibrillation, uh, acutely in the hospital but doing fine. Uh, you know, not hemodynamically unstable kind of runs in and out a little bit. There's no plan for a DC cardio version in the near future. Do you acutely anticoagulate them with heparin?

Speaker 3: 35:03

So I would say that's honestly provider specific. I would say we have a handful providers who, as soon as they have that run of AFib, they're like you know what? Their chat's vascor is elevated. That's anticoagulate. We don't know if they've ever actually had it in the past.

Speaker 3: 35:15

Which is fair, which is fair, it's a fair assessment, but then you also have those people who are really, really, really sick, multiple pressers, intubated for a couple days and then they one night have a run of AFib, that kind of converts after amio, and I think those are the ones that we kind of have to reassess like, do you actually need to put this patient on anticoagulation in this acute setting? Well, they already have 10 000 blood draws during the course of the day, um, and their hemoglobin F baseline is now going to be seven anyway, um, so I don't really think in that situation. It's, like I said, very similar to how the guidelines laid out. It is a very patient to patient kind of breakdown of how to manage AFib. And for those acutely ill patients that are hospitalized who have the AFib like either he's persistent or just like a short run of it during the hospitalization, you kind of have to have that ongoing discussion with the provider of whether we should anticoagulate or not, um, which I oftentimes trend towards.

Speaker 3: 36:11

No, if it resolves you know within the hour, you know if you consult cardiology but by the time we see you you're a normal signage for them. I don't necessarily think you need to be on long-term anticoagulation, but if you consult us at night time and we come and see them at 10 and you're still on AFib, that's where I kind of trend towards still continuing anticoagulation and kind of continuing to monitor.

Speaker 2: 36:31

Well, okay, well, thank you, dr Boyd. We really appreciate your expertise again. I've learned a lot myself today, so it's really nice. That concludes this episode of Game Changers. Thanks for listening. This has been, I think, one of the more in-depth posibilty I've ever done, so I hope that you guys really like what you heard. We'll see you next week, but until then, remember time flies. I don't know where it's going, but the most important day is today. Take care.

Speaker 1: 36:56

Jen here. Be sure to check out our education at cempackcom. You'll find it to be your one-stop shop for all the CE resources you need. Become a pharmacist by design member today to access it all for free, including CE for this podcast. Thanks for listening. We'll talk to you next week on Game Changers clinical conversations.