Managing Emergency Department Patients with Recent-onset Atrial Fibrillation

Thromboembolic events following cardioversion of acute atrial fibrillation and flutter: a systematic review and meta-analysis

BACKGROUND

Recent studies have presented concerning data on the safety of cardioversion for acute atrial fibrillation and flutter. We conducted this meta-analysis to evaluate the effect of oral anticoagulation use on thromboembolic events post-cardioversion of low-risk acute atrial fibrillation and flutter patients of < 48 h in duration.

METHODS

We searched MEDLINE, Embase, and Cochrane from inception through February 6, 2020 for studies reporting thromboembolic events post-cardioversion of acute atrial fibrillation and flutter. Main outcome was thromboembolic events within 30 days post-cardioversion. Primary analysis compared thromboembolic events based on oral anticoagulation use versus no oral anticoagulation use. Secondary analysis was based on baseline thromboembolic risk. We performed meta-analyses where 2 or more studies were available, by applying the DerSimonian-Laird random-effects model. Risk of bias was assessed with the Quality in Prognostic Studies tool.

RESULTS

Of 717 titles screened, 20 studies met inclusion criteria. Primary analysis of seven studies with low risk of bias demonstrated insufficient evidence regarding the risk of thromboembolic events associated with oral anticoagulation use (RR = 0.82 where RR < 1 suggests decreased risk with oral anticoagulation use; 95% CI 0.27 to 2.47; I² = 0%). Secondary analysis of 13 studies revealed increased risk of thromboembolic events with high baseline thromboembolic risk (RR = 2.25 where RR > 1 indicates increased risk with higher CHADS₂ or CHA₂DS₂-VASc scores; 95% CI 1.25 to 4.04; I² = 0%).

CONCLUSION

Primary analysis revealed insufficient evidence regarding the effect of oral anticoagulation use on thromboembolic events post-cardioversion of low-risk acute atrial fibrillation and flutter, though the event rate is low in contemporary practice. Our findings can better inform patient-centered decision-making when considering 4-week oral anticoagulation use for acute atrial fibrillation and flutter patients.

Rate control with intravenous diltiazem, verapamil, and metoprolol in acute atrial fibrillation with rapid ventricular rate

Introduction:

Diltiazem is a preferred agent for rate control in atrial fibrillation due to its quick onset, minimal side effects, and low cost. Due to its intermittent national shortage since February 2018, the utilization of intravenous metoprolol and verapamil has increased. This study investigated the effect of intravenous diltiazem, metoprolol, and verapamil on rate control in patients with atrial fibrillation with rapid ventricular rate.

Methods:

This study was a retrospective, single-center, cohort study conducted in patients with acute atrial fibrillation receiving intravenous diltiazem, metoprolol, or verapamil for rapid ventricular rate between 1 January 2012 and 31 August 2018. The primary outcome was the incidence of patients who achieved a rate less than 100 bpm within 1 h of treatment. Secondary outcomes included time to achieve rate control, heart rate at 30 min and 1 h after administration, bradycardia and hypotension incidence, the requirement of other rate control agent(s), inpatient admission, length of stay, and mortality.

Results:

A total of 73 patients were included in the study. At 1 h after receiving the initial rate control drug, there was no statistically significant difference between diltiazem, metoprolol, and verapamil in achieving rate control. Median time to ventricular rate control was 166 min in the diltiazem group, 297 min in the metoprolol group, and 100.5 min in the verapamil group.

Conclusion:

There was no difference in achieving rate control when using intravenous diltiazem, metoprolol, or verapamil. Any of the three rate control agents may be used for rate control. However, further studies are needed to determine which agent is superior for rate control.

Frequency and Determinants of Spontaneous Conversion to Sinus Rhythm in Patients Presenting to the Emergency Department with Recent-onset Atrial Fibrillation: A Systematic Review

The exact frequency and clinical determinants of spontaneous conversion (SCV) in patients with symptomatic recent-onset AF are unclear. The aim of this systematic review is to provide an overview of the frequency and determinants of SCV of AF in patients presenting at the emergency department. A comprehensive literature search for studies about SCV in patients presenting to the emergency department with AF resulted in 25 articles - 12 randomised controlled trials and 13 observational studies. SCV rates range between 9-83% and determinants of SCV also varied between studies. The most important determinants of SCV included short duration of AF (<24 or <48 hours), low number of episodes, normal atrial dimensions and absence of previous heart disease. The large variation in SCV rate and determinants of SCV was related to differences in duration of the observation period, inclusion and exclusion criteria and in variables used in the prediction models.

Clinical determinants of early spontaneous conversion to sinus rhythm in patients with atrial fibrillation

Background

The current standard of care for acute atrial fibrillation (AF) focuses primarily on immediate restoration of sinus rhythm by cardioversion, although AF often terminates spontaneously.

Objective

To identify determinants of early spontaneous conversion (SCV) in patients presenting at the emergency department (ED) because of AF.

Methods

An observational study was performed of patients who visited the ED with documented AF between July 2014 and December 2016. The clinical characteristics and demographics of patients with and without SCV were compared.

Results

We enrolled 943 patients (age 69 ± 12 years, 47% female). SCV occurred within 3 h of presentation in 158 patients (16.8%). Logistic regression analysis showed that duration of AF <24 h [odds ratio (OR) 7.7, 95% confidence interval (CI) 3.5–17.2, p < 0.001], left atrial volume index <42 ml/m² (OR 1.8, 95% CI 1.2–2.8, p = 0.010), symptoms of near-collapse at presentation (OR 2.4, 95% CI 1.2–5.1, p = 0.018), a lower body mass index (BMI) (OR 0.9, 95% CI 0.91–0.99, p = 0.028), a longer QTc time during AF (OR 1.01, 95% CI 1.0–1.02, p = 0.002) and first-detected AF (OR 2.5, 95% CI 1.6–3.9, p < 0.001) were independent determinants of early SCV.

Conclusion

Early spontaneous conversion of acute AF occurs in almost one-sixth of admitted patients during a short initial observation in the ED. Spontaneous conversion is most likely to occur in patients with first-onset, short-duration AF episodes, lower BMI, and normal left atrial size.

Emergency Department Management of Recent-Onset Atrial Fibrillation

Atrial fibrillation (AF) is the most common tachyarrhythmia managed in the emergency department (ED). Visits to the ED for a presentation of AF have been increasing in recent years, with an admission rate that exceeds 60% in the United States and contributes substantially to health care costs. Recent-onset AF-defined as symptom onset less than 48 hr-is a common ED presentation for which rate control or acute electrical or pharmacological cardioversion may be appropriate treatment modalities depending on patient-specific circumstances. The focus of this review is to discuss the current recommendations regarding the management of recent-onset nonvalvular AF in the ED, discuss medication administration considerations, and identify implementation strategies in the ED to optimize throughput and reduce hospital admissions.

Practice Gap in Atrial Fibrillation Oral Anticoagulation Prescribing at Emergency Department Home Discharge

INTRODUCTION

Current U.S. cardiology guidelines recommend oral anticoagulation (OAC) to reduce stroke risk in selected patients with atrial fibrillation (AF), but no formal AF OAC recommendations exist to guide emergency medicine clinicians in the acute care setting. We sought to characterize emergency department (ED) OAC prescribing practices after an ED AF diagnosis.

METHODS

This retrospective study included index visits for OAC-naive patients ≥18 years old who were discharged home from the ED at an urban, academic, tertiary hospital with a primary diagnosis of AF from 2012-2014. Five hypothesis-blinded, chart reviewers abstracted data from patient problem lists and medical history in the electronic health record to assess stroke (CHA₂DS₂-VASc) and bleeding risk (HAS-BLED). The primary outcome was the provision of an OAC prescription at discharge in OAC-naive patients with high stroke risk. Descriptive statistics and multivariable logistic regression assessed associations between OAC prescription and patient characteristics.

RESULTS

We included 138 patient visits in our analysis, of whom 39.9% (n = 55) were low stroke risk (CHA₂DS₂-VASc = 0 in males and 1 in females), 15.9% (n = 22) were intermediate risk (CHA₂DS₂-VASc = 1 in males), and 44.2% (n = 61) were high risk (CHA₂DS₂-VASc ≥ 2). Of patients with high stroke risk and low-to-intermediate bleeding risk (n = 57), 80.7% were not prescribed an OAC at discharge. Cardiology consultation and female gender, but not stroke risk (CHA₂DS₂-VASc score), were predictors of an ED provider prescribing an OAC to an OAC-naive AF patient at ED discharge.

CONCLUSION

The majority of OAC-eligible patients were discharged home without an OAC prescription. In OAC-naive patients discharged home from the ED, cardiology consultation and female gender were associated with OAC prescription. Our findings suggest that access to expert opinion may improve provider comfort with OAC prescribing and highlight the need for improved guidelines specific to ED-management of AF.

Potassium infusion increases the likelihood of conversion of recent-onset atrial fibrillation-A single-blinded, randomized clinical trial

BACKGROUND

The optimal antiarrhythmic management of recent-onset atrial fibrillation (ROAF) or atrial flutter is controversial and there is a considerable variability in clinical treatment strategies. It is not known if potassium infusion has the potential to convert ROAF or atrial flutter to sinus rhythm (SR). Therefore, we aimed to investigate if patients with ROAF or atrial flutter and plasma-potassium levels ≤4.0 mmol/L have increased probability to convert to SR if the plasma-potassium level is increased towards the upper reference range (4.1-5.0 mmol/L).

METHODS

In a placebo-controlled, single-blinded trial, patients with ROAF or atrial flutter and plasma-potassium ≤4.0 mmol/L presenting between April 2013 and November 2017 were randomized to receive potassium chloride (KCl) infusion (n = 60) or placebo (n = 53). Patients in the KCl group received infusions at one of three different rates: 9.4 mmol/h (n = 11), 12 mmol/h (n = 19), or 15 mmol/h (n = 30).

RESULTS

There was no statistical difference in the number of conversions to SR between the KCl group and placebo [logrank test, P = .29; hazard ratio (HR) 1.20 (CI 0.72-1.98)]. However, KCl-infused patients who achieved an above-median hourly increase in plasma-potassium (>0.047 mmol/h) exhibited a significantly higher conversion rate compared with placebo [logrank P = .002; HR 2.40 (CI 1.36-4.21)] and KCl patients with below-median change in plasma-potassium [logrank P < .001; HR 4.41 (CI 2.07-9.40)]. Due to pain at the infusion site, the infusion was prematurely terminated in 10 patients (17%).

CONCLUSIONS

Although increasing plasma-potassium levels did not significantly augment conversion of ROAF or atrial flutter to SR in patients with potassium levels in the lower-normal range, our results indicate that this treatment may be effective when a rapid increase in potassium concentration is tolerated and achieved.

Rate Control Management of Atrial Fibrillation With Rapid Ventricular Response in the Emergency Department

BACKGROUND

There exists limited evidence on managing atrial fibrillation (AF) with rapid ventricular response in the emergency department. We sought to better understand the burden of disease in patients with AF for whom rhythm control was not successful or not attempted and identify opportunities for improved care.

METHODS

We conducted a health records review of consecutive visits of patients with AF at 2 academic emergency departments. We included patients ≥ 18 years with AF, heart rate ≥ 100 beats per minute (bpm), and who were not successfully cardioverted or not attempted cardioversion. Outcomes were: (1) incidence given rate control, (2) management practices, (3) adverse events, (4) compliance with guidelines, and (5) outcomes. We performed descriptive statistics.

RESULTS

We included 665 visits, with mean age ± standard deviation 77.4 ± 12.9, female 51.6%, mean ± standard deviation heart rate 121.6 ± 17.4 bpm, AF status (permanent 53.4%; paroxysmal 29.5%; persistent 17.1%), admitted 61.4%. Of all cases, 147 (22.1%) had primary AF and 518 (77.9%) had a rapid rate secondary to a medical cause (heart failure 12.8%; pneumonia 11.7%; sepsis 8.4%). In 117 with primary AF given rate control, 59.0% had a final rate ≤ 100 bpm and 7.7% suffered adverse events. Suboptimal use of rate control occurred in 47.0% (agent 2.6%; route 27.4%; dosage 9.4%; timing 7.7%). At discharge, 11.5% with CHADS-65 risk factors were still not anticoagulated.

CONCLUSIONS

Most patients had a rapid rhythm secondary to a medical cause. There were a concerning number of adverse events related to suboptimal use of rate control. Better awareness of guidelines will ensure safer use of rate control.

Likelihood of Spontaneous Cardioversion of Atrial Fibrillation Using a Conservative Management Strategy Among Patients Presenting to the Emergency Department

Numerous emergency department (ED) atrial fibrillation (AF) protocols have been developed to reduce hospitalizations, focusing on the use of cardioversion in the ED. An alternative strategy of rate control with early specialty follow-up may be more widely applicable. The likelihood of spontaneous cardioversion with such a protocol is unknown. Between 2015 and 2018, 157 patients who presented to the ED with a primary diagnosis of AF and were hemodynamically stable and with low to moderate symptom severity were discharged with early follow-up at an AF specialty clinic. Rhythm at short-term (within 72 hours), within 30-day follow-up, and need for electrical cardioversion was tabulated. Various demographic and co-morbidity variables were assessed to determine their association with likelihood of spontaneous cardioversion. At an average of 2.3 days, 63% and within 30 days, 83% had spontaneous cardioversion. By 90 days, only 6.3% required electrical cardioversion. Diabetes (38% vs 69%, p <0.01), coronary artery disease (39% vs 66%, p = 0.02), reduced ejection fraction (40% vs 72%, p <0.01), dilated right atrium (43% vs 73%, p <0.01) and moderate-to-severely dilated left atrium (38% vs 78%, p <0.01) predicted those who were less likely to convert to sinus rhythm. Most patients who present to the ED with AF will spontaneously convert to sinus rhythm by short-term (2 to 3 days) follow-up with a rate control strategy. In conclusion, aggressive use of electrical cardioversion in the ED may be unnecessary in hemodynamically stable patients without severe symptoms.

2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation

The Canadian Cardiovascular Society (CCS) Atrial Fibrillation Guidelines Committee provides periodic reviews of new data to produce focused updates that address clinically important advances in atrial fibrillation (AF) management. This 2018 Focused Update addresses: (1) anticoagulation in the context of cardioversion of AF; (2) the management of antithrombotic therapy for patients with AF in the context of coronary artery disease; (3) investigation and management of subclinical AF; (4) the use of antidotes for the reversal of non-vitamin K antagonist oral anticoagulants; (5) acute pharmacological cardioversion of AF; (6) catheter ablation for AF, including patients with concomitant AF and heart failure; and (7) an integrated approach to the patient with AF and modifiable cardiovascular risk factors. The recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards. Individual studies and literature were reviewed for quality and bias; the literature review process and evidence tables are included as Supplementary Material and are available on the CCS Web site. Details of the updated recommendations are presented, along with their background and rationale. This document is linked to an updated summary of all CCS AF guidelines recommendations, from 2010 to the present 2018 Focused Update, which is provided in the Supplementary Material.

Esmolol Compared with Amiodarone in the Treatment of Recent-Onset Atrial Fibrillation (RAF): An Emergency Medicine External Validity Study

BACKGROUND

Recent-onset atrial fibrillation (RAF) is the most frequent supraventricular dysrhythmia in emergency medicine. Severely compromised patients require acute treatment with injectable drugs OBJECTIVE: The main purpose of this external validity study was to compare the short-term efficacy of esmolol with that of amiodarone to treat severe RAF in an emergency setting.

METHODS

This retrospective survey was conducted in mobile intensive care units by analyzing patient records between 2002 and 2013. We included RAF with (one or more) severity factors including: clinical shock, angina pectoris, ST shift, and very rapid ventricular rate. A blind matching procedure was used to constitute esmolol group (n = 100) and amiodarone group (n = 200), with similar profiles for age, gender, initial blood pressure, heart rate, severity factors, and treatment delay. The main outcome measure was the percentage of patients with a ventricular rate control defined as heart frequency ≤ 100 beats/min. More stringent (rhythm control) and more humble indicators (20% heart rate reduction) were analyzed at from 10 to 120 min after treatment initiation.

RESULTS

Patient characteristics were comparable for both groups: age 66 ± 16 years, male 71%, treatment delay < 1 h 36%, 1-2 h 29%, > 2 h 35%, chest pain 61%, ST shift 62%, ventricular rate 154 ± 26 beats/min, and blood pressure 126/73 mm Hg. The superiority of esmolol was significant at 40 min (64% rate control with esmolol vs. 25% with amiodarone) and for all indicators from 10 to 120 min after treatment onset.

CONCLUSION

In "real life emergency medicine," esmolol is better than amiodarone in the treatment of RAF.

Management and Disposition of Atrial Fibrillation in the Emergency Department: A Systematic Review

Introduction

Management of atrial fibrillation (AF) and atrial flutter (AFL) in the emergency department (ED) varies greatly, and there are currently no United States guidelines to guide management with regard to patient disposition after ED treatment. The aim of this systematic review was to evaluate the literature for decision aids to guide disposition of patients with AF/AFLin the ED, and assess potential outcomes associated with different management strategies in the ED.

Methods and Results

A systematic review was done using PubMed (MEDLINE), Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE, combining the search terms "Atrial Fibrillation", "Atrial Flutter", "Emergency Medicine", "Emergency Service", and "Emergency Treatment". After removal of duplicates, 754 articles were identified. After initial screening of titles and abstracts, 69full text articles were carefully reviewed and 34 articles were ultimately included in the study based on inclusion and exclusion criteria. The articles were grouped into four main categories: decision aids and outcome predictors, electrical cardioversion-based protocols, antiarrhythmic-based protocols, and general management protocols.

Conclusion

This systematic review is the first study to our knowledge to evaluate the optimal management of symptomatic AF/AFLin the ED with a direct impact on ED disposition. There are several viable management strategies that can result in safe discharge from the ED in the right patient population, and decision aids can be utilized to guide selection of appropriate patients for discharge.

Safety of cardioversion in atrial fibrillation lasting less than 48 h without post-procedural anticoagulation in patients at low cardioembolic risk

Currently, there is no unified consensus on short-term anticoagulation after cardioversion of atrial fibrillation lasting less than 48 h in low-cardioembolic-risk patients. The aim of this study is to evaluate the rate of transient ischemic attacks, stroke and death in this subset of patients after cardioversion without post-procedural anticoagulation. In a prospective observational study, patients with recent-onset AF undergoing cardioversion attempts in the Emergency Department were evaluated over the past 3 years. Inclusion criteria were conversion to sinus rhythm, low thromboembolic risk defined by a CHA2DS2VASc score of 0-1 points for males (0-2 points for females aged over 65 years), and hospital discharge without anticoagulant treatment. Patients with severe valvular heart disease, underlying systemic causes of AF, and those discharged with anticoagulant therapy were excluded. The main outcomes measured were TIA, stroke and death at thirty days' follow-up after discharge. During the study period, 218 successful cardioversions, obtained both electrically and pharmacologically, were performed on 157 patients. One hundred and eleven patients were males (71%), the mean age was 55.2 years (±standard deviation 10.7), 99 patients (63%) reported a CHA2DS2VASc score of 0, and the remaining 58 (37%) had a risk profile of 1 point. Of these, latter 8 were females (5%) older than 65 years (risk score 2 points). At the thirty days outcome, none of the 150 enrolled patients who completed a follow-up visit has reported TIA or stroke, nor died, in the overall 211 successful cardioversions evaluated. In our study, the rate of thromboembolic events after cardioversion of recent-onset AF of less than 48 h duration, in patients with a 0-1 CHA2DS2VASc risk profile (females 0-2), appeared to be extremely low even in absence of post-procedural anticoagulation. These findings seem to confirm data from previous studies, and suggest that routine post-procedural short-term anticoagulation may be considered as an overtreatment in this very low-risk subset of patients.

Ibutilide Effectiveness and Safety in the Cardioversion of Atrial Fibrillation and Flutter in the Community Emergency Department

STUDY OBJECTIVE

Little is known about the use of ibutilide for cardioversion in atrial fibrillation and flutter outside of clinical trials. We seek to describe patient characteristics, ibutilide administration patterns, cardioversion rates, and adverse outcomes in the community emergency department (ED) setting. We also evaluate potential predictors of cardioversion success.

METHODS

Using a retrospective cohort of adults who received ibutilide in 21 community EDs between January 2009 and June 2015, we gathered demographic and clinical variables from electronic health records and structured manual chart review. We calculated rates of cardioversion and frequency of ventricular tachycardia within 4 hours and estimated adjusted odds ratios (aOR) in a multivariate regression model for potential predictors of cardioversion.

RESULTS

Among 361 patients, the median age was 61 years (interquartile range 53 to 71 years) and most had recent-onset atrial fibrillation and flutter (98.1%). Five percent of the cohort had a history of heart failure. The initial QTc interval was prolonged (>480 ms) in 29.4% of patients, and 3.1% were hypokalemic (<3.5 mEq/L). The mean ibutilide dose was 1.5 mg (SD 0.5 mg) and the rate of ibutilide-related cardioversion within 4 hours was 54.8% (95% confidence interval [CI] 49.6% to 60.1%), 50.5% for atrial fibrillation and 75.0% for atrial flutter. Two patients experienced ventricular tachycardia (0.6%), both during their second ibutilide infusion. Age (in decades) (aOR 1.3; 95% CI 1.1 to 1.5), atrial flutter (versus atrial fibrillation) (aOR 2.7; 95% CI 1.4 to 5.1), and no history of atrial fibrillation and flutter (aOR 2.0; 95% CI 1.2 to 3.1) were associated with cardioversion.

CONCLUSION

The effectiveness and safety of ibutilide in this community ED setting were consistent with clinical trial results despite less stringent patient selection criteria.

Incidence of Thromboembolic Complications Within 30 Days of Electrical Cardioversion Performed Within 48 Hours of Atrial Fibrillation Onset

OBJECTIVES

This study sought to compare the risk of thromboembolism after cardioversion within 48 h of atrial fibrillation (AF) onset in patients therapeutically versus not therapeutically anticoagulated.

BACKGROUND

Although guidelines do not mandate anticoagulation for cardioversion within 48 h of AF onset, risk of thromboembolism in this group has been understudied.

METHODS

Patients undergoing cardioversion within 48 h after AF onset were identified from a prospectively collected database and retrospectively reviewed to determine anticoagulation status and major thromboembolic events within 30 days of cardioversion.

RESULTS

Among 567 cardioversions in 484 patients without therapeutic anticoagulation (mean CHA₂DS₂-VASc score, 2.3 ± 1.7), 6 had neurological events (1.06%), all in patients on aspirin alone. Among 898 cardioversions in 709 patients on therapeutic anticoagulation (mean CHA₂DS₂-VASc score, 2.6 ± 1.7; p = 0.017), 2 neurological events occurred (0.22%; OR: 4.8; p = 0.03), both off anticoagulation at the time of stroke. No thromboembolic events occurred in patients with CHA₂DS₂-VASc score <2 (p = 0.06) or in patients with postoperative AF.

CONCLUSIONS

In patients with acute-onset AF, odds of thromboembolic complications were almost 5 times higher in patients without therapeutic anticoagulation at the time of cardioversion. However, no events occurred in post-operative patients and in those with CHA₂DS₂-VASc scores of <2, supporting the utility of accurate assessment of AF onset and risk stratification in determining the need for anticoagulation for cardioversion of AF <48 h in duration.

[The management of atrial fibrillation and characteristics of its current care in outpatients. AFABE observational study]

AIM

To provide insights into the characteristics and management of outpatients when their atrial fibrillation (AF) was first detected: diagnosis, treatment and follow-up in the context of the public health system.

DESIGN

AFABE is an observational, multicentre descriptive study with retrospective data collection relating to the practice patterns, management and initial strategies of treatment of patients with diagnosed AF in the context of primary care, emergency and cardiologists of the public health system.

SETTING

Primary and Specialist care. Baix Ebre region. Tarragona. Spain.

SUBJECTS

A representative sample of 182 subjects > 60-year-old with AF who have been randomized, recruited among the registered patients with AF in 22 primary care centres in the area of the study.

MESUREMENTS

Demographic data, comorbidities (AF), CHA2DS2-VASc and HAS_BLED scores, and practice patterns results between Primary Care and referral services.

RESULTS

A total of 182 patients were included (mean age 78.5 SD:7.3 years; 50% women). Most patients (68.3% 95%CI; 60.3-76.3) had the first contact in Primary Care, of which 56.3% (95%CI; 45.2-66.0) were sent to Hospital Emergency Department where 72.7% (95%CI: 63.5-79.0) of the oral anticoagulation and 58.4% (95%CI: 49.4-66.9) of antiarrhytmic treatments were started. More than half (55.9%:95%CI; 47.2-64.7, of patients with permanent AF were followed-up by the Cardiology department.

CONCLUSIONS

Most patients with newly diagnosed AF made a first contact with Primary Care, but around half were sent to Hospital Emergency departments, where they were treated with an antiarrhythmic and/or oral anticoagulation.

An international view of how recent-onset atrial fibrillation is treated in the emergency department

OBJECTIVES

This study was conducted to determine if there is practice variation for emergency physicians' (EPs) management of recent-onset atrial fibrillation (RAF) in various world regions (Canada, United States, United Kingdom, and Australasia).

METHODS

The authors completed a mail and e-mail survey of members from four national emergency medicine (EM) associations. One prenotification letter and three survey letters were sent to members of the Canadian Association of Emergency Physicians (CAEP; Canada-1,177 members surveyed), American College of Emergency Physicians (ACEP; United States-500), College of Emergency Medicine UK (CEM; United Kingdom-1,864), and Australasian College for Emergency Medicine (ACEM; Australasia-1,188) as per the modified Dillman technique. The survey contained 23 questions related to the management of adult patients with symptomatic RAF (either a first episode or paroxysmal-recurrent) where onset is less than 48 hours and cardioversion is considered a treatment option. Data were analyzed using descriptive and chi-square statistics.

RESULTS

Response rates were as follows: overall, 40.5%; Canada, 43.0%; United States, 50.1%; United Kingdom, 38.1%; and Australasia, 38.0%. Physician demographics were as follows: 72% male and mean (±SD) age 41.7 (±8.39) years. The proportions of physicians attempting rate control as their initial strategy are United States, 94.0%; Canada, 70.7%; Australasia, 61.1%; and United Kingdom, 43.1% (p < 0.0001). Diltiazem is the predominant agent for rate control in Canada (65.36%) and the United States (95.22%), while metoprolol is used in Australasia (65.94%) and the United Kingdom (67.64%). Cardioversion is attempted at varying rates in Canada (65.9%), Australasia (49.9%), United Kingdom (49.5%), and the United States (25.9%) (p < 0.0001). Pharmacologic cardioversion is attempted first in all regions, with the preferred drug being procainamide in Canada (61.93%) and amiodarone in Australasia (63.39%), the United Kingdom (47.97%), and the United States (22.41%; p < 0.0001). If drugs fail, electrical cardioversion is then attempted in Canada (70.64%), Australasia (46.19%), the United States (29.69%), and the United Kingdom (27.78%; p < 0.0001).

CONCLUSIONS

There is much variation in emergency department (ED) management of RAF among world regions, most markedly for use of rate versus rhythm control, choice of drugs, and use of electrical cardioversion. Canadians are more likely to use an aggressive approach for management of RAF, whereas Americans are more likely to employ conservative management. U.K. and Australasian EPs fall somewhere in the middle. These differences demonstrate the need for better evidence, or better synthesis of existing knowledge, to create guidelines to guide ED management of this common dysrhythmia.