Management of acute atrial fibrillation in the emergency department

Abstract

The aim of the study was to provide an overview on the current evidence on the method of cardioversion in patients presenting with recent-onset atrial fibrillation at the emergency department. ISI Web of Science and MEDLINE were explored for articles published between January 2000 and December 2011 in English or Spanish for the keywords 'acute', 'recent-onset' or 'paroxysmal' AND 'atrial fibrillation' AND 'treatment' AND 'emergency'. Original published articles were included if they enrolled patients with atrial fibrillation episodes of short duration (<48 h) and if they specifically addressed time to conversion, length of stay in the emergency department, safety, and/or relapses. Data extracted included the number of patients included, agent(s) studied, type and level of evidence of the article, rate of sinus rhythm conversion, time to conversion, discharge rate, length of stay, adverse events, embolic complications, and relapses. Fourteen papers were included in the review, eight of them prospective and randomized. Cardioversion in the emergency department had an overall high rate of conversion and few side-effects and/or embolic complications. Direct current cardioversion was the most effective therapeutic strategy in terms of sinus rhythm restoration, rate of discharge, length of stay, and safety. Class I drugs were also effective in a selected population. Amiodarone had a longer conversion time, with a similar rate of acute adverse events. Cardioversion in the emergency department is feasible and safe. Direct current cardioversion is the most effective therapeutic strategy.

Cardioversion of Atrial Fibrillation (RHYTHM-AF) International Registry in Poland

“…Rate of complications was rather low, with single patients suffering serious complications including myocardial infarction, pulmonary embolism, or heart failure. A recent meta-analysis of AF cardioversion in emergency department shows comparable results [14].…”

Stroke Prophylaxis in Atrial Fibrillation: Searching for Management Improvement Opportunities in the Emergency Department: The HERMES-AF Study

“…As in other studies, this may reflect a certain lack of knowledge of the evidence-based indications for prophylaxis stated in the guidelines. 11,19,24 Because the guidelines' recommendations have been demonstrated to be widely applicable in daily practice 9,12,19,26,27 and previous studies in local settings have demonstrated the usefulness of specific training to improve management's adequacy, 4,16,28 educational efforts to increase physicians' adherence to the guidelines appear warranted and constitute a third area of management improvement found in our study.…”

“…25 In this way, the relevant increase in the prescription of anticoagulants to high-risk patients found in Spanish EDs during this century, from 28% in the GEFAUR-1 study to 69% in HERMES-AF, 9 is promising and supports the concept that adequate thromboprophylaxis is desirable and also feasible in ED patients with atrial fibrillation. 3,8,9,12,19,26 A main reason argued by the treating physicians for not prescribing anticoagulation was that they did not consider this treatment as indicated, despite that all patients included in the analysis were at high risk and without contraindications for anticoagulation. As in other studies, this may reflect a certain lack of knowledge of the evidence-based indications for prophylaxis stated in the guidelines.…”

Emergency Department Management of Atrial Fibrillation and Flutter and Patient Quality of Life at One Month Postvisit

“…4,[6][7][8] Recent evidence suggests that aggressive protocols of ED cardioversion (pharmacologic or electrical) in patients with recent-onset paroxysmal atrial fibrillation or flutter are both safe and feasible. [9][10][11] Uptake of these protocols in clinical practice, as opposed to the traditional approach of exclusive rate control and stroke prevention, has been variable. 6 And although ED cardioversion for select patients with atrial fibrillation or flutter may be safe and effective, its ramifications on patient-oriented outcomes have not been well studied.…”