title: Managing emergency department patients with recent-onset atrial fibrillation. Ibutilide to expedite ED therapy for recent-onset atrial fibrillation flutter. Thirty-day outcomes of emergency department patients undergoing electrical cardioversion for atrial fibrillation or flutter. Cardioversion of paroxysmal atrial fibrillation in the emergency department. An emergency department observation unit protocol for acute-onset atrial fibrillation is feasible. The AFFORD clinical decision aid to identify emergency department patients with atrial fibrillation at low risk for 30-day adverse events. A prospective, randomized trial of an emergency department observation unit for acute onset atrial fibrillation. Impact of a practice guideline for patients with atrial fibrillation on medical resource utilization and costs. Treatment of Stable Atrial Fibrillation in the Emergency Department: A Population-Based Comparison of Electrical Direct-Current versus Pharmacological Cardioversion or Conservative Management Intravenous propafenone for converting recent onset atrial fibrillation in emergency departments: a randomized placebo-controlled multicenter trial. FAPS Investigators Study Group. Effectiveness of verapamil-quinidine versus digoxin-quinidine in the emergency department treatment of paroxysmal atrial fibrillation. Effect of a Multidisciplinary Approach for the Management of Patients With Atrial Fibrillation in the Emergency Department on Hospital Admission Rate and Length of Stay. Cardioversion of acute atrial fibrillation in the short observation unit: comparison of a protocol focused on electrical cardioversion with simple antiarrhythmic treatment A prospective, randomized, controlled trial of an emergency department-based atrial fibrillation treatment strategy with low-molecular-weight heparin. Impact of an emergency department-initiated clinical protocol for the evaluation and treatment of atrial fibrillation. Emergency department use of intravenous procainamide for patients with acute atrial fibrillation or flutter. Termination of recent-onset atrial fibrillation/flutter in the emergency department: a sequential approach with intravenous ibutilide and external electrical cardioversion. Biphasic cardioversion of acute atrial fibrillation in the emergency department Performance of an expedited rhythm control method for recent onset atrial fibrillation in a community hospital. Validation of the Risk Estimator Decision Aid for Atrial Fibrillation (RED-AF) for predicting 30-day adverse events in emergency department patients with atrial fibrillation.
abstract: BACKGROUND The management of emergency department ( ED ) patients with presumed recent-onset atrial fibrillation or flutter≤48h in duration varies widely . OBJECTIVE AND METHOD We conducted a prospect i ve 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 2007 . 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 24h ) ; 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 OBJECTIVE Ibutilide is a type III antiarrhythmic agent approved for the pharmacologic conversion of atrial fibrillation ( AF ) and atrial flutter ( AFl ) . Previous studies conducted outside the ED setting have demonstrated conversion rates of 60 % to 80 % . This response has been highest in patients with recent-onset AF-AFl . These observations and the 4-hour half-life of ibutilide suggest that it may be an excellent drug with which to treat AF-AFl in the ED . The purpose of the study was to examine the efficacy and safety of ibutilide in terminating AF-AFl in patients who present to the ED with symptoms of less than 3 days ' duration , neither angina nor heart failure , and no comorbid conditions that require admission . METHODS Among 36 enrolled patients , the admission electrocardiogram demonstrated AF in 26 and AFl in 10 .  Ibutilide 1 mg was administered intravenously for 10 minutes . If sinus rhythm was not present 10 minutes after the infusion concluded , a second infusion of 1 mg was given . Successful conversion was defined as restoration of sinus rhythm within 1 hour after the last dose of ibutilide . RESULTS Sixteen ( 61.5 % ) of 26 patients with AF and 9 ( 90 % ) of 10 patients with AFl converted to sinus rhythm ( overall conversion rate=69 % ) . The mean time to arrhythmia termination was 19+/-9 minutes . The mean stay in the ED was 16.2 hours . No significant complications occurred . CONCLUSION We conclude that ibutilide is an excellent therapy option for restoring sinus rhythm in the ED . Its use may obviate the need for admission , avoid the risks and inconveniences of general anesthesia to perform electrical cardioversion , and reduce the ED length of stay in selected patients with recent-onset atrial arrhythmias OBJECTIVES While the short-term ( < 7-day ) safety and efficiency of electrical cardioversion for emergency department ( ED ) patients with atrial fibrillation or flutter have been established , the 30-day outcomes with respect to stroke , thromboembolic events , or death have not been investigated . METHODS A two-center cohort of consecutive ED patients undergoing cardioversion for atrial fibrillation or flutter between January 1 , 2000 , and September 30 , 2007 , was retrospectively investigated . This cohort was probabilistically linked with both a regional ED data base and the provincial health registry to determine which patients had a subsequent ED visit or hospital admission , stroke , or thromboembolic event or died within 30 days . In addition , trained review ers performed a detailed chart abstract ion on 150 r and omly selected patients , with emphasis on demographics , vital signs , medical treatment , and predefined adverse events . Hemodynamically unstable patients or those whose condition was the result of an underlying acute medical diagnosis were excluded . Data were analyzed by descriptive methods . RESULTS During the study period , 1,233 patients made 1,820 visits for atrial fibrillation or flutter to the ED . Of the 400 eligible patients undergoing direct-current cardioversion ( DCCV ) , no patients died , had a stroke , or had a thromboembolic event in the following 30 days ( 95 % confidence interval [ CI ] = 0.0 to 0.8 % for all outcomes ) . A total of 141 patients were included in the formal chart review , with five patients ( 3.5 % , 95 % CI = 0.5 % to 6.6 % ) failing cardioversion , six patients ( 4.3 % , 95 % CI = 0.9 % to 7.6 % ) having a minor adverse event that did not change disposition , and five patients ( 3.5 % , 95 % CI = 0.5 % to 6.6 % ) admitted to hospital at the index visit . CONCLUSIONS Cardioversion of patients with atrial fibrillation or flutter in the ED appears to have a very low rate of long-term complications STUDY OBJECTIVE Patients presenting to the emergency department with acute atrial fibrillation are traditionally admitted to hospital . The objective of this study was to review the success and safety of ED cardioversion and discharge of patients with acute atrial fibrillation . METHODS This health records survey included a cohort sample of consecutive patients presenting with acute atrial fibrillation to the ED of a university-affiliated tertiary hospital . Patients who were in unstable condition on presentation , who had a complicating cardiac diagnosis , or those with other medical or surgical conditions requiring admission were excluded from the study analysis . Patient visit information was entered into a data base that included demographics and clinical presentation , investigations , ED therapy , complications , consultations , disposition , and follow up . Patient visits were then categorized into the following groups : no ED intervention , spontaneous resolution , heart rate control , attempted chemical cardioversion , or electrical cardioversion . The data were analyzed using descriptive methods . RESULTS Of the 289 eligible patients seen during an 18-month period , 62 % ( 180 ) underwent attempted chemical cardioversion with a 50 % success rate and 28 % ( 80 ) had attempted electrical cardioversion with a 89 % success rate . Ninety-three percent of electrical cardioversions were performed by emergency physicians . There was an overall 6 % ( 19 ) complication rate , 95 % of which were regarded as minor . One patient had a complication caused by a rate control medication , which necessitated hospital admission . Ninety-seven percent ( 280 ) of the patients were discharged home directly from the ED . CONCLUSION Cardioversion and immediate discharge of patients who present to the ED with acute atrial fibrillation appears to be both safe and effective . This management approach should be prospect ively evaluated in multiple setting STUDY OBJECTIVE We sought to describe the feasibility of an emergency department observation unit ( EDOU ) treatment protocol for the management of uncomplicated acute-onset atrial fibrillation ( AAF ) .  METHODS This descriptive case series took place at a major suburban , university-affiliated teaching hospital . Patients were prospect ively enrolled in an EDOU treatment protocol if they had uncomplicated AAF that failed initial ED attempts to convert to sinus rhythm . In the EDOU , patients underwent ECG monitoring , serial creatine kianse MB measurements , and further rate control with optional electrical cardioversion . Primary outcomes measured were EDOU rate of conversion to sinus rhythm , rate of discharge home , length of stay , positive diagnostic outcomes , complications of AAF , and 7-day return visits . RESULTS Sixty-seven patients were studied . Patients were symptomatic for a median of 4.0 hours , had mean initial ED pulse rates of 137+/-23 beats/min , and spent 4.7+/-2.2 hours in the ED before transfer to the EDOU . While in the EDOU , 55 ( 82 % ) patients converted to sinus rhythm . Five ( 7 % ) patients were admitted because of positive test results : 2 for myocardial infa rct ion , 2 for fever , and 1 for ventricular tachycardia . Twelve ( 18 % ) patients remained in atrial fibrillation , with 9 admitted and 3 discharged . Overall , 81 % of patients were discharged in 11.8+/-7.0 hours , and 19 % were admitted after 17.6+/-9.5 hours of observation . Three discharged patients returned within 7 days , 2 for uncomplicated recurrent AAF and 1 for chest pain subsequently found to be noncardiac in origin . There were no major complications attributable to the EDOU protocol . CONCLUSION Selected patients with AAF for whom initial ED management fails can subsequently be managed in an EDOU with a high short-term conversion and discharge rate There is wide variation in the management of patients with atrial fibrillation ( AF ) in the emergency department ( ED ) . We aim ed to derive and internally vali date the first prospect i ve , ED-based clinical decision aid to identify patients with AF at low risk for 30-day adverse events . We performed a prospect i ve cohort study at a university-affiliated tertiary-care ED . Patients were enrolled from June 9 , 2010 , to February 28 , 2013 , and followed for 30 days . We enrolled a convenience sample of patients in ED presenting with symptomatic AF .  C and i date predictors were based on ED data available in the first 2 hours . The decision aid was derived using model approximation ( preconditioning ) followed by strong bootstrap internal validation . We used an ordinal outcome hierarchy defined as the incidence of the most severe adverse event within 30 days of the ED evaluation . Of 497 patients enrolled , stroke and AF-related death occurred in 13 ( 3 % ) and 4 ( < 1 % ) patients , respectively . The decision aid included the following : age , triage vitals ( systolic blood pressure , temperature , respiratory rate , oxygen saturation , supplemental oxygen requirement ) , medical history ( heart failure , home sotalol use , previous percutaneous coronary intervention , electrical cardioversion , cardiac ablation , frequency of AF symptoms ) , and ED data ( 2 hours heart rate , chest radiograph results , hemoglobin , creatinine , and brain natriuretic peptide ) . The decision aid 's c-statistic in predicting any 30-day adverse event was 0.7 ( 95 % confidence interval 0.65 , 0.76 ) . In conclusion , in patients with AF in the ED , Atrial Fibrillation and Flutter Outcome Risk Determination provides the first evidence -based decision aid for identifying patients who are at low risk for 30-day adverse events and c and i date s for safe discharge STUDY OBJECTIVE An emergency department ( ED ) observation unit protocol for the management of  acute onset atrial fibrillation  is compared with routine hospital admission and management . METHODS Adult patients presenting to the ED with atrial fibrillation of less than 48 hours ' duration without hemodynamic instability or other comorbid conditions requiring hospitalization were enrolled . Participants were r and omized to either ED observation unit care or routine inpatient care .  The ED observation unit protocol included pulse rate control , cardiac monitoring , re assessment , and electrical cardioversion if atrial fibrillation persisted . Patients who reverted to sinus rhythm were discharged with a cardiology follow-up within 3 days , whereas those still in atrial fibrillation were admitted . All cases were followed up for 6 months and adverse events recorded . RESULTS Of the 153 patients , 75 were r and omized to the ED observation unit and 78 to routine inhospital care . Eighty-five percent of ED observation unit patients converted to sinus rhythm versus 73 % in the routine care group ( difference 12 % ; 95 % confidence interval [ CI ] -1 % to 25 % ] ; P=.06 ) . The median length of stay was 10.1 versus 25.2 hours ( difference 15.1 hours ; 95 % CI 11.2 to 19.6 ; P<.001 ) for ED observation unit and inhospital care respectively . Nine ED observation unit patients required inpatient admission . Eleven percent of the ED observation unit group had recurrence of atrial fibrillation during follow-up versus 10 % of the routine inpatient care group ( difference 1 % ; 95 % CI -9 % to 11 % ; P=.93 ) . There was no significant difference between the groups in the frequency of hospitalization or the number of tests , and the number of adverse events during follow-up was similar in the 2 groups . CONCLUSION An ED observation unit protocol that includes electrical cardioversion is a feasible alternative to routine hospital admission for acute onset of atrial fibrillation and results in a shorter initial length of stay Health care re source utilization is high for patients presenting with acute atrial fibrillation ( AF ) . The potential for treatment algorithms to safely reduce re source consumption in this setting has not been prospect ively evaluated . We design ed and implemented a practice guideline for the management of patients presenting to the emergency department ( ED ) with the primary diagnosis of AF , with emphasis on appropriate cardioversion , use of oral rate-controlling medications , and expedited referral to an outpatient AF clinic . We prospect ively collected clinical and re source utilization data on all such patients for 14 months before and after institution of the guideline . Institution of the guideline was associated with a decreased rate of hospital admission ( from 74 % to 38 % ) , with no differences in ED return visits or hospital readmission within 30 days . No strokes or deaths were observed . This large decrease in re source utilization during the intervention phase of the study translated to an average decrease in 30-day total direct health care costs of approximately $ 1,400 US dollars per patient . Our clinical and cost outcomes were minimally affected after statistical adjustment for baseline differences between study groups . We conclude that the implementation of our practice guideline was feasible , safe , and effective . Widespread adoption of such practice s may have large financial implication s for the health care system Objective : To compare the success rates and short-term complications of three treatment approaches , pharmacological and direct-current cardioversion ( DCC ) , or ‘ wait- and -watch ’ among stable atrial fibrillation ( AF ) patients in the emergency department ( ED ) . Methods : All AF-related ED admissions during a 1-year period were retrospectively review ed , and those meeting criteria of eligibility for immediate cardioversion , based on clinical stability , AF duration and adequacy of anticoagulation , were included . The propensity score approach generalized for the three groups was used to adjust for the observational non-r and omized study nature . Results : Among 374 eligible patients , the rate of successful cardioversion was higher in DCC than in pharmacological or wait- and -watch groups ( 78.2 , 59.2 and 37.9 % respectively , p < 0.001 ) , with corresponding percentages of patients discharged from ED ( 52.9 , 47.9 and 32.1 % , p < 0.01 ) and respective odds ratios of 6.00 , 2.47 and 1 , adjusting for seniority of the treating physician , age , gender and patient comorbidities . DCC was 2.43 times more effective than pharmacological treatment in achieving sinus rhythm ( 95 % confidence interval = 1.36–4.33 , p = 0.003 ) . Rehospitalization within 14 days due to probable AF-treatment-related complications of home-discharged patients was 3.4 % . Conclusions : DCC was found to be the most effective treatment , with few short-term complications following conversion of stable AF patients to sinus rhythm in the ED Atrial fibrillation ( AF ) is one of the most frequent dysrhythmias in patients coming to emergency departments ( EDs ) , and pharmacological treatment is frequently performed . The aim of this r and omized placebo-controlled multicenter trial was to compare propafenone ( a class 1C antidysrhythmic agent ) , administered i.v . in the ED , with placebo in the treatment of recent-onset AF ( < 72 h ) . We r and omly allocated 156 patients ( 88 males ; 68 females ) from 18 to 80 years old , with recent-onset AF , to receive i.v . propafenone ( 2 mg/kg for 10 min ) or the matching placebo . The patients were followed for 2 h. Exclusion criteria were the presence of one of the following : lack of informed consent , clinical evidence of heart failure , clinical hyperthyroidism , recent acute myocardial infa rct ion , atrioventricular block , cardiac valve dysfunction , a history of bronchial asthma , and current treatment with antidysrhythmic agents including digitalis . The two groups did not differ significantly in terms of sex , age , body weight , or estimated time elapsed since the beginning of atrial fibrillation . Conversion to sinus rhythm occurred in 13 of the 75 patients who received the placebo ( 17.3 % ) and in 57 of the 81 patients who were given propafenone ( 70.3 % ) . In conclusion , intravenous propafenone administration in the ED can be considered a safe and effective approach for converting AF to sinus rhythm STUDY OBJECTIVE To determine the relative effectiveness of a verapamil-quinidine sequential combination versus digoxin-quinidine in the emergency department treatment of paroxysmal atrial fibrillation ( PAF ) . METHOD This prospect i ve , double-blind , r and omized , controlled trial involved patients , aged 18 to 75 years , with new-onset ( < 48 hours ) atrial fibrillation who presented to a community-based urban hospital with an annual ED census of 65,000 . Exclusion criteria included ventricular response rate lower than 100 or higher than 200 beats/minute , allergy to study drugs , hypotension with evidence of end-organ hypoperfusion , and conduction abnormalities . Consenting patients were r and omly assigned to receive rapid digitalization ( 1.0 mg over 2 hours ) or i.v . verapamil ( sequential 5-mg boluses up to 20 mg ) . After ventricular rate was controlled ( < 100 beats/minute ) , oral quinidine ( 200 mg ) was initiated and repeated every 2 hours until conversion to normal sinus rhythm ( NSR ) occurred , until 1 g of quinidine was administered , or until adverse effects supervened . Heart rate , blood pressure , cardiac rhythm , time to conversion , and adverse effects were documented . RESULTS Forty-four patients received the study drugs . Three were withdrawn , leaving 19 in the verapamil-quinidine ( VER-Q ) group and 22 in the digoxin-quinidine ( DIG-Q ) group . Sixteen patients ( 84 % ) in the VER-Q group and 10 ( 45 % ) in the DIG-Q group converted to NSR within 6 hours ( P < .02 ) . Mean time to conversion ( + /-SD ) was 185 + /- 146 minutes for VER-Q and 368 + /- 386 minutes for DIG-Q patients ( P = NS ) . Twelve VER-Q patients ( 63 % ) and 6 DIG-Q patients ( 27 % ) were discharged from the ED ( P < .05 ) . Minor adverse effects were more common in the VER-Q group . No mortality or significant morbidity occurred . CONCLUSION The sequential combination of verapamil and quinidine , in the doses studied , is an effective treatment for PAF and is superior to digoxin-quinidine . Digoxin should no longer be considered the treatment of choice for uncomplicated PAF Management of  atrial fibrillation ( AF )  in the emergency department ( ED ) is variable because of the absence of universally adopted treatment guidelines . To address potentially preventable hospital admissions and prolonged length of stay , an AF treatment pathway was co-developed by physicians from the cardiac electrophysiology service and the department of emergency medicine at our institution . The impact of this AF pathway on patient outcomes was evaluated with a prospect i ve , observational study conducted in a single tertiary care center from July 1 , 2013 , to June 30 , 2014 . The primary study outcome was the rate of hospital admission . The secondary outcomes were duration of ED visit and inpatient length of stay . The 94 patients treated according to the AF pathway during the study period were less likely to be admitted than the 265 patients who received routine care ( 16 % vs 80 % , p < 0.001 ) . For admitted patients , the mean length of stay was shorter for patients treated according to the AF pathway ( 32 vs 85 hours , p = 0.002 ) . The time spent in the ED was longer for patients in the AF pathway ( 16 vs 85 hours , p < 0.001 ) . Utilization of a multidisciplinary pathway for management of AF  in the ED led to a significant reduction in the rate of hospital admission .  Patients who were admitted after receiving care according to the AF pathway had a shorter length of stay . In conclusion , utilization of a multidisciplinary AF pathway result ed in a 5-fold reduction in admission rate and > 2-fold reduction length of stay for admitted patients Background Direct current cardioversion ( DCC ) has been shown to be effective for the management of  atrial fibrillation ( AF )  in the emergency department ( ED ) . Pharmacological cardioversion was compared with a strategy including DCC on patients with uncomplicated , recent-onset ( < 48 h ) AF managed in a short observation unit ( SOU ) . Methods A prospect i ve observational study was undertaken over a period of 13 months in two institutions . A DCC-centred protocol was applied to 171 AF cases in a hospital ( DCC-cohort ) and pharmacological cardioversion to 151 AF cases in another hospital ( P-cohort ) . Patients remaining in AF after 24 h were admitted . The outcomes were rate of discharge in sinus rhythm , length of stay in the ED-SOU , rate of hospitalisation and complications of treatment . Data collected were analysed according to Student t test and χ2 statistics . Results Discharge in sinus rhythm was achieved in 159/171 cases in the DCC-cohort and 77/151 cases in the P-cohort ( 93 % vs 51 % ; number needed to treat ( NNT ) 2.4 ; 95 % CI 2.0 to 3.1 , p<0.001 ) , whereas mean length of stay was 7 + 7 h in the DCC-cohort and 9 + 6 h in the P-cohort ( p=0.43 ) . Eleven cases from the DCC-cohort and 67 from the P-cohort were admitted ( admission rate 6 % vs 44 % ; NNT 2.6 ; 95 % CI 2.2 to 3.5 , p<0.001 ) . Three short-term complications occurred in the DCC-cohort and five in the P-cohort ( 2 % vs 3 % , p=0.59 ) . Two strokes were registered in the DCC-cohort during 6-month follow-up ( p undefined ) . Conclusions Electrical cardioversion of recent-onset AF in the SOU is safe , effective and reduces hospitalisations . Further studies are needed to identify the most cost-effective strategy for the management of AF patients in emergency setting STUDY OBJECTIVE We assess an alternative accelerated clinical pathway approach to the management of patients with newly diagnosed or new-onset atrial fibrillation ( AF ) . METHODS A prospect i ve , r and omized pilot study of 2  AF disease-management strategies was conducted at a single university hospital . A traditional approach of hospital admission versus an accelerated emergency department-based strategy with low-molecular-weight heparin and early cardioversion to sinus rhythm was assessed in a cohort of patients with uncomplicated AF . The primary end points were length of stay and total actual direct costs . RESULTS Eighteen patients were r and omized over a 15-month period . The accelerated treatment strategy in the ED result ed in a substantial decrease in length of stay ( 2.1+/-2.3 versus < 1 day ) and a favorable trend toward mean cost reduction ( $ 1,706+/-$1,512 versus $ 879+/-$394 ; P = .15 ) . The clinical outcomes ( rate of sinus rhythm at discharge and follow-up and complications caused by AF ) related to AF were similar in the 2 groups . CONCLUSION A disease-management strategy for new , uncomplicated AF that uses an ED-outpatient treatment pathway results in a shorter length of stay at potentially lower cost . The results of this pilot study warrant further investigation OBJECTIVE Published data supporting the best practice for patients with atrial fibrillation ( AF ) presenting to the emergency department ( ED ) are limited . Our objective was to evaluate the impact of an AF clinical protocol initiated in the ED with early follow-up in a specialty AF outpatient clinic . METHODS This was a single-center prospect i ve study of all consented patients with AF who were discharged from the ED through the AF clinical pathway and were then  seen in the AF clinic . The primary endpoint was the rate of 90-day hospitalization/ED visits . Secondary endpoints included adherence to established AF anticoagulation guidelines , rate of thromboembolic events , quality of life , and patient satisfaction . RESULTS One hundred consecutive patients were enrolled in the study . Within 90 days , 15 had ED visits and 4 were hospitalized , whereas none developed thromboembolic complications . There were significant increases in the Atrial Fibrillation Effect on QualiTy of life survey quality of life ( 67.3 ± 24.8 vs. 89.2 ± 15.7 ; P < 0.001 ) and patient satisfaction ( 66.4 ± 25.3 vs. 77.9 ± 22.8 ; P < 0.001 ) scores from baseline to 90 days . Of the 29 patients with CHADS2 score ≥2 , 20 ( 69 % ) were discharged from the AF clinic with oral anticoagulation . CONCLUSIONS We describe a novel approach to the care of patients with AF presenting to the ED . Usage of the ED-initiated AF clinical pathway with early follow-up in a protocol -driven AF clinic was associated with low readmission rates , no thromboembolic complications at 90 days , improved quality of life , and high patient satisfaction OBJECTIVES Acute atrial fibrillation and flutter are very common arrhythmias seen in emergency department ( ED ) patients , but there is no consensus for their optimal management . The objective of this study was to examine the efficacy and safety of intravenous ( IV ) procainamide for acute atrial fibrillation or flutter . METHODS This health records review included a consecutive cohort of ED patients with acute-onset atrial fibrillation or atrial flutter who received IV procainamide at one university hospital ED during a five-year period . The st and ard clinical protocol involved IV infusion of 1 g of procainamide over 60 minutes , followed by electrical cardioversion if necessary . A trained observer extracted data from the original clinical records . Outcome measurements included conversion to sinus rhythm , adverse events , and relapse up to seven days . RESULTS The 341 study patients had a mean age of 63.9 years ( SD + /- 15.5 years ) , and 56.6 % were male . The conversion rates were 52.2 % ( 95 % confidence interval = 47 % to 58 % ) for 316 atrial fibrillation cases and 28.0 % ( 95 % confidence interval = 13 % to 46 % ) for 25 atrial flutter cases . Mean dose given was 860.7 mg ( SD + /- 231.2 mg ) , and median time to conversion was 55 minutes . Adverse events occurred in 34 cases ( 10.0 % ) : hypotension , 8.5 % ; bradycardia , 0.6 % ; atrioventricular block , 0.6 % ; and ventricular tachycardia , 0.3 % . There were no cases of torsades de pointes , cerebrovascular accident , or death . Most patients ( 94.4 % ) were discharged home , but 2.9 % of patients returned with a recurrence of atrial fibrillation within seven days . CONCLUSIONS This study of acute atrial fibrillation or flutter patients treated in the ED with IV procainamide suggests that this treatment is safe and effective in this setting . Procainamide should be prospect ively compared with other ED strategies Safety and effectiveness are the goals in treating patients with arrhythmias . In an open prospect i ve study , we observed the efficacy and safety of up to 2 mg intravenous ibutilide , a new class III antiarrhythmic agent in haemodynamically stable patients presenting in the emergency department ( ED ) with symptoms of recent-onset ( < 48 h ) atrial fibrillation/flutter . Arrhythmia termination within 90 min , haemodynamic parameters and proarrhythmic effects were assessed . Non-responders to the ibutilide infusion underwent external electrical cardioversion .  We included 51 patients . In 31 patients therapeutic intervention with intravenous ibutilide was successful within 90 min ( 61 % ) . In another seven patients conversion to sinus rhythm occurred after 90 min without any other intervention ( 14 % ) . Blood pressure remained stable and no relevant proarrhythmic effects were observed . The 13 patients who did not respond to ibutilide treatment underwent successful external electrical cardioversion . The overall conversion rate was 100 % . Forty-seven patients ( 92 % ) were discharged within a median of 9 h and managed as out patients . In conclusion , in haemodynamically stable patients with recent-onset atrial fibrillation/flutter intravenous ibutilide and external electrical cardioversion for conversion to sinus rhythm turned out to be effective and safe . The short duration of admission makes this strategy attractive for use in the ED Introduction : There is a trend towards accelerated management of acute atrial fibrillation ( AF ) in the emergency department ( ED ) . We report our experience with biphasic cardioversion of acute AF . Methods : This was a prospect i ve , descriptive study at a tertiary hospital ED over a 6 month period . Acute AF was defined as symptoms that had been present for < 48 hours . Patients who received biphasic cardioversion for acute AF in the ED were enrolled . Data collected included : patient demographics , past medical history , details of biphasic cardioversion , outcome , complications , disposition , and length of stay . Results : There were 34 attempts at cardioversion in 33 patients . The mean ( SD ) age was 56 ( 16 ) years and 21 patients ( 64 % ) were men .  Biphasic cardioversion was successful in 31 attempts ( 91 % ) . In 24 attempts ( 71 % ) , 100 J was selected as the initial energy level . This was successful in 21 attempts ( 88 % ) . There were three minor complications related to sedation . The mean ( SD ) length of stay was 5.6 ( 2.8 ) hours in the ED and 15 ( 25 ) hours in the hospital . The three patients who failed to revert were older ( mean age 64 years ) , had underlying cardiovascular disease , and spent longer in hospital ( 50 v 12 hours , p = 0.01 ) . Telephone follow up was conducted with 32 patients ( 97 % ) at 3 months . Recurrence of AF occurred in 7 patients ( 22 % ) . Most patients ( 31 , 97 % ) were satisfied with the biphasic cardioversion . Conclusions : Biphasic cardioversion of acute AF is effective . The majority of patients can be managed as out patients , and there is very high patient satisfaction with this approach . An initial shock energy level of 100 J is usually effective BACKGROUND A st and ard approach to recent onset atrial fibrillation ( AF ) in the emergency department ( ED ) in the United States has not been established . PURPOSE The purpose of this prospect i ve clinical trial was to determine how an ED protocol emphasizing rhythm control for recent onset AF compared similar patients receiving  st and ard therapy  in the same facility . METHODS We enrolled consecutive patients presenting to our community hospital with recent onset AF into a protocol , which called for rhythm control with procainamide and if unsuccessful electrical cardioversion and discharge home . We compared this prospect i ve cohort with matched historical controls . Primary outcome was admission rate . We also compared ED conversion rates and lengths of stay ( LOS ) . We reported 30-day data on the study group including ED recidivism , recurrent AF , outpatient follow-up , and any important adverse events . RESULTS Fifty-four patients were enrolled in the study group with 4 being admitted compared with 30 of 50 in the historical control group . Ninety-four percent of the study group converted compared with 28 % in the historical control . Both hospital and ED LOS were significantly shorter for the study group . Six patients had recurrent AF , and 4 of those returned to the ED . CONCLUSION An ED protocol that uses rhythm control decreased hospital admission and LOS , and there were no adverse events at 30 days STUDY OBJECTIVE In the United States , nearly 70 % of emergency department ( ED ) visits for atrial fibrillation result in hospitalization . The incidence of serious 30-day adverse events after an ED evaluation for atrial fibrillation remains low . This study 's goal was to prospect ively vali date our previously reported Risk Estimator Decision Aid for Atrial Fibrillation ( RED-AF ) model for estimating a patient 's risk of experiencing a 30-day adverse event . METHODS This was a prospect i ve cohort study , which enrolled a convenience sample of ED patients presenting with atrial fibrillation .  RED-AF , previously derived from a retrospective cohort of 832 patients , assigns points according to age , sex , coexisting disease ( eg , heart failure , hypertension , chronic obstructive pulmonary disease ) , smoking , home medications ( eg , β-blocker , diuretic ) , physical examination findings ( eg , dyspnea , palpitations , peripheral edema ) , and adequacy of ED ventricular rate control . Primary outcome was occurrence of greater than or equal to 1 atrial fibrillation-related adverse outcome ( ED visits , rehospitalization , cardiovascular complications , death ) within 30 days . We identified a clinical ly relevant threshold and measured RED-AF 's performance in this prospect i ve cohort , assessing its calibration , discrimination , and diagnostic accuracy . RESULTS The study enrolled 497 patients between June 2010 and February 2013 . Of these , 120 ( 24 % ) had greater than or equal to 1 adverse event within 30 days . A RED-AF score of 87 was identified as an optimal threshold , result ing in sensitivity and specificity of 96 % ( 95 % confidence interval [ CI ] 91 % to 98 % ) and 19 % ( 95 % CI 15 % to 23 % ) , respectively . Positive and negative predictive values were 27 % ( 95 % CI 23 % to 32 % ) and 93 % ( 95 % CI 85 % to 97 % ) , respectively . The c statistic for RED-AF was 0.65 ( 95 % CI 0.59 to 0.71 ) . CONCLUSION In this separate validation cohort , RED-AF performed moderately well and similar to the original derivation cohort for identifying the risk of short-term atrial fibrillation-related adverse events in ED patients receiving a diagnosis of atrial fibrillation
target: The articles were grouped into four main categories : decision aids and outcome predictors , electrical cardioversion-based protocol s , antiarrhythmic-based protocol s , and general management protocol s. 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
background: 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 .