Outcomes for Emergency Department Patients With Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals

Abstract

Although most recent-onset atrial fibrillation and flutter patients were treated aggressively in the ED, there were few 30-day serious outcomes. Physicians underprescribed oral anticoagulants. Potential risk factors for adverse events include longer duration from arrhythmia onset, previous stroke or transient ischemic attack, pulmonary congestion on chest radiograph, and not being in sinus rhythm at discharge. An ED strategy of sinus rhythm restoration and discharge in most patients is effective and safe.

A Multicenter Randomized Trial to Evaluate a Chemical‐first or Electrical‐first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation

“…Emergency department–specific CCS guidelines emphasize that uncomplicated AF patients with symptom duration of less than 48 hours may undergo rate or rhythm control and ED‐based rhythm control has been shown to be safe in thousands of patients over numerous retrospective and prospective analyses . Our study showed that, similar to prior findings, approximately half of patients undergoing chemical conversion alone converted to normal sinus rhythm.…”

“…Of our patients receiving electrical countershock first, half were discharged within 1 hour of randomization, and some patients who received procainamide first were discharged in a similar time frame. The recent cohort of Stiell et al . had a median ED LOS of 5 hours, but our data suggest that far shorter times—perhaps 1 to 2 hours—may be routinely possible.…”

“…Importantly, the rates of stroke and death postrhythm control have been very low . In a recent prospective Canadian six‐ED study enrolling 1,091 patients with acute AF nearly exclusively managed with rhythm control, Stiell et al . described no 30‐day deaths and a single stroke—an 81‐year‐old on coumadin with an ED INR of 2.3 who spontaneously converted and had an ischemic stroke on Day 23.…”

Creation and Implementation of an Outpatient Pathway for Atrial Fibrillation in the Emergency Department Setting: Results of an Expert Panel

“…The panel agreed on the general strategy of ED cardioversion and discharge home for eligible patients, as seen in the most recent AF pathway examples in the literature . One key area of controversy was the eligibility criteria for ED cardioversion related to anticoagulation status.…”

“…Emergency department management of AF appears to vary by country, with providers in the United States historically more likely to prefer the strategy of rate control rather than rhythm control, unlike peers in other western countries such as Canada, Australia, and the United Kingdom . Potential drivers of this practice include prior research suggesting no benefit in outcomes from a preference of rhythm over rate control, the perceived or actual burden on ED resources to perform cardioversion, prior versions of specialty society guidelines, and lack of payer scrutiny of short‐stay AF inpatient hospitalizations or readmissions versus other conditions such as chest pain, syncope, and congestive heart failure .…”