Managing ED Patients with Recent-onset Atrial Fibrillation
Managing ED Patients with Recent-onset Atrial Fibrillation
Background The management of emergency department (ED) patients with presumed recent-onset atrial fibrillation or flutter ≤ 48 h in duration varies widely.
Objective and Method We conducted a prospective study across three affiliated community EDs within a large integrated health care delivery system to describe the management of patients with recent-onset atrial fibrillation or flutter, to determine the safety and effectiveness of ED cardioversion, and to measure the incidence of thromboembolism 30 days after discharge.
Results We enrolled 206 patients with convenience sampling between June 2005 and November 200 Mean age was 64.0 ± 14.4 years (range 21–96 years). Patients were grouped for analysis into four categories based on whether cardioversion was 1) spontaneous in the ED (59; 28.6%); 2) attempted with electrical or pharmacological means (115; 56.3%), with success in 110 (95.7%); 3) hoped for during a short stint of home observation (16; 7.8%, 11 of which spontaneously converted to sinus rhythm within 24 h); or 4) contraindicated (16; 7.8%). Of the entire group, 183 (88.8%) patients were discharged home. Adverse events requiring ED interventions were reported in 6 (2.9%; 95% confidence interval [CI] 1.1–6.2%) patients, all of whom recovered. Two (1.0%; 95% CI 0.1–3.5%) patients were found to have an embolic event on 30-day follow-up.
Conclusions Our approach to ED patients with presumed recent-onset atrial fibrillation or flutter seems to be safe and effective, with a high rate of cardioversion and discharge to home coupled with a low ED adverse event and 30-day thromboembolic event rate.
Atrial fibrillation is the most common sustained cardiac rhythm disturbance in adults. As a potent risk factor for ischemic stroke and a cause of worsening heart failure and bothersome symptoms, atrial fibrillation is a major public health problem. The societal and economic burden associated with atrial fibrillation is compounded by its increasing prevalence among our aging population. As a consequence, emergency department (ED) visit rates for symptomatic atrial fibrillation are on the rise and can be expected to increase.
Conventionally, most ED patients with presumed recent-onset atrial fibrillation (≤ 48 h) have been admitted to the hospital to evaluate for more serious conditions (e.g., myocardial infarction, pulmonary embolism) as well as to monitor for possible acute complications. More recently, there has been a trend in several countries to attempt elective cardioversion without anticoagulation in a sub-population of stable ED patients with presumed recent-onset atrial fibrillation. This more aggressive approach has been associated with a high rate of cardioversion to sinus rhythm and a low rate of hospitalization and complications, factors that support its safety and effectiveness. However, no consensus yet exists about whether an initial aggressive approach is better than conventional ED management, and, if so, in which subset of patients it might best be applied.
We undertook this prospective study of a convenience sample of community ED patients with presumed recent-onset atrial fibrillation or flutter to describe our practice patterns and to determine the rate of adverse events in the ED and the incidence of thromboembolic events within 30 days of index presentation.
Abstract and Introduction
Abstract
Background The management of emergency department (ED) patients with presumed recent-onset atrial fibrillation or flutter ≤ 48 h in duration varies widely.
Objective and Method We conducted a prospective study across three affiliated community EDs within a large integrated health care delivery system to describe the management of patients with recent-onset atrial fibrillation or flutter, to determine the safety and effectiveness of ED cardioversion, and to measure the incidence of thromboembolism 30 days after discharge.
Results We enrolled 206 patients with convenience sampling between June 2005 and November 200 Mean age was 64.0 ± 14.4 years (range 21–96 years). Patients were grouped for analysis into four categories based on whether cardioversion was 1) spontaneous in the ED (59; 28.6%); 2) attempted with electrical or pharmacological means (115; 56.3%), with success in 110 (95.7%); 3) hoped for during a short stint of home observation (16; 7.8%, 11 of which spontaneously converted to sinus rhythm within 24 h); or 4) contraindicated (16; 7.8%). Of the entire group, 183 (88.8%) patients were discharged home. Adverse events requiring ED interventions were reported in 6 (2.9%; 95% confidence interval [CI] 1.1–6.2%) patients, all of whom recovered. Two (1.0%; 95% CI 0.1–3.5%) patients were found to have an embolic event on 30-day follow-up.
Conclusions Our approach to ED patients with presumed recent-onset atrial fibrillation or flutter seems to be safe and effective, with a high rate of cardioversion and discharge to home coupled with a low ED adverse event and 30-day thromboembolic event rate.
Introduction
Atrial fibrillation is the most common sustained cardiac rhythm disturbance in adults. As a potent risk factor for ischemic stroke and a cause of worsening heart failure and bothersome symptoms, atrial fibrillation is a major public health problem. The societal and economic burden associated with atrial fibrillation is compounded by its increasing prevalence among our aging population. As a consequence, emergency department (ED) visit rates for symptomatic atrial fibrillation are on the rise and can be expected to increase.
Conventionally, most ED patients with presumed recent-onset atrial fibrillation (≤ 48 h) have been admitted to the hospital to evaluate for more serious conditions (e.g., myocardial infarction, pulmonary embolism) as well as to monitor for possible acute complications. More recently, there has been a trend in several countries to attempt elective cardioversion without anticoagulation in a sub-population of stable ED patients with presumed recent-onset atrial fibrillation. This more aggressive approach has been associated with a high rate of cardioversion to sinus rhythm and a low rate of hospitalization and complications, factors that support its safety and effectiveness. However, no consensus yet exists about whether an initial aggressive approach is better than conventional ED management, and, if so, in which subset of patients it might best be applied.
We undertook this prospective study of a convenience sample of community ED patients with presumed recent-onset atrial fibrillation or flutter to describe our practice patterns and to determine the rate of adverse events in the ED and the incidence of thromboembolic events within 30 days of index presentation.
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