Guidelines on the management of atrial fibrillation in the emergency department: a critical appraisal

Abstract

Several guidelines often exist on the same topic, sometimes offering divergent recommendations. For the clinician, it can be difficult to understand the reasons for this divergence and how to select the right recommendations. The aim of this study is to compare different guidelines on the management of atrial fibrillation (AF), and provide practical and affordable advice on its management in the acute setting. A PubMed search was performed in May 2014 to identify the three most recent and cited published guidelines on AF. During the 1-week school of the European School of Internal Medicine, the attending residents were divided in five working groups. The three selected guidelines were compared with five specific questions. The guidelines identified were: the European Society of Cardiology guidelines on AF, the Canadian guidelines on emergency department management of AF, and the American Heart Association guidelines on AF. Twenty-one relevant sub-questions were identified. For five of these, there was no agreement between guidelines; for three, there was partial agreement; for three data were not available (issue not covered by one of the guidelines), while for ten, there was complete agreement. Evidence on the management of AF in the acute setting is largely based on expert opinion rather than clinical trials. While there is broad agreement on the management of the haemodynamically unstable patient and the use of drugs for rate-control strategy, there is less agreement on drug therapy for rhythm control and no agreement on several other topics.

Risk prediction of clinical adverse outcomes with machine learning in a cohort of critically ill patients with atrial fibrillation

“…Despite this, and in absence of specifically-designed risk scores, stratification with CHA 2 DS 2 -VASc and HAS-BLED is still recommended by experts also in critical illness 6 . This is in line with other indications for the AF management in an emergency care setting observed in several guidelines 4 . However, since the in-hospital occurrence of thromboembolism or bleeding in a critically ill patient could radically modify the prognosis 7 , more accurate solutions are required to correctly stratify the risk of this specific category of subjects.…”

“…Nowadays, the baseline assessment of thromboembolic and bleeding in the routine management of clinically stable AF patients represents a pivotal step for all the major international guidelines 3 . Notwithstanding, the management of AF in the critically ill patient is still object of debate 4 , being both thromboembolic and hemorrhagic risk difficult to be assessed for several confounding factors, as coagulation abnormalities, platelet number and function alterations, drug therapies, drug-drug and drug-pathology interactions which can occur in those patients.…”

The impairment of the Growth Hormone/Insulin-like growth factor 1 (IGF-1) axis in heart failure: A possible target for future therapy

“…Even if lower than in HFrEF, the prevalence of hormone deficiency (HD) in HFpEF was remarkable, considering that more than half of HFpEF had at least 1 hormone deficiency. In this study a major prevalence of atrial fibrillation (AF) in HFpEF was recorded, as expected [51,52]. However, the small sample size did not allow any further investigation regarding the occurrence of AF in patients with hormonal deficiencies and HFpEF.…”

The challenge of implementing Less is More medicine: A European perspective

“…A recent study performed by the residents of the European Federation of Internal Medicine (EFIM) Summer School, comparing three major guidelines on atrial fibrillation management in an acute setting, revealed that evidence on this particular clinical topic is largely based on expert opinion rather than clinical trials. While there is broad agreement on the management of the haemodynamically unstable patient and the use of drugs for rate-control strategy, there is less agreement on drug therapy for rhythm control but no agreement on several other clinical questions [45].…”