The AFFORD clinical decision aid to identify emergency department patients with atrial fibrillation at low risk for 30-day adverse events. Performance of an expedited rhythm control method for recent onset atrial fibrillation in a community hospital. Impact of a practice guideline for patients with atrial fibrillation on medical resource utilization and costs. A randomized clinical trial of early invasive intervention for atrial fibrillation (EARLY-AF) - methods and rationale. Managing emergency department patients with recent-onset atrial fibrillation. Treatment of Stable Atrial Fibrillation in the Emergency Department: A Population-Based Comparison of Electrical Direct-Current versus Pharmacological Cardioversion or Conservative Management 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. A prospective, randomized trial of an emergency department observation unit for acute onset atrial fibrillation. Ibutilide to expedite ED therapy for recent-onset atrial fibrillation flutter. Impact of an emergency department-initiated clinical protocol for the evaluation and treatment of atrial fibrillation. A prospective, randomized, controlled trial of an emergency department-based atrial fibrillation treatment strategy with low-molecular-weight heparin. Antiarrhythmics After Ablation of Atrial Fibrillation (5A Study) Thirty-day outcomes of emergency department patients undergoing electrical cardioversion for atrial fibrillation or flutter. An integrated chronic care program for patients with atrial fibrillation: study protocol and methodology for an ongoing prospective randomised controlled trial. 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. Atrial fibrillation: the rate versus rhythm management controversy. Impact of Emergency Department Management of Atrial Fibrillation on Hospital Charges
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 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 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 BACKGROUND The ideal management of patients with newly diagnosed symptomatic atrial fibrillation ( AF ) remains unknown . Current practice guidelines recommend a trial of antiarrhythmic drugs ( AAD ) prior to considering an invasive ablation procedure . However , earlier ablation offers an opportunity to halt the progressive patho-anatomical changes associated with AF , as well as impart other important clinical benefits . OBJECTIVE The aim of this study is to determine the optimal initial management strategy for patients with newly diagnosed , symptomatic atrial fibrillation . METHODS / DESIGN The EARLY-AF study ( Clinical Trials.govNCT02825979 ) is a prospect i ve , open label , multicenter , r and omized trial with a blinded assessment of outcomes . A total of 298 patients will be r and omized in a 1:1 fashion to first-line AAD therapy , or first-line cryoballoon-based pulmonary vein isolation .  Patients with symptomatic treatment naïve AF will be included . Arrhythmia outcomes will be assessed by implantable cardiac monitor ( ICM ) . The primary outcome is time to first recurrence of AF , atrial flutter , or atrial tachycardia ( AF/AFL/AT ) between days 91 and 365 following AAD initiation or AF ablation . Secondary outcomes include arrhythmia burden , quality of life , and healthcare utilization . DISCUSSION The EARLY-AF study is a r and omized trial design ed to evaluate the optimal first management approach for patients with AF . We hypothesize that catheter ablation will be superior to drug therapy in prevention of AF recurrence 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 : 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 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 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 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 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 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 Background — Atrial arrhythmias are common early after atrial fibrillation ( AF ) ablation . We hypothesized that empirical antiarrhythmic drug ( AAD ) therapy for 6 weeks after AF ablation would reduce the occurrence of atrial arrhythmias . Methods and Results — We r and omized consecutive patients with paroxysmal AF undergoing ablation to empirical antiarrhythmic therapy ( AAD group ) or no antiarrhythmic therapy ( no-AAD group ) for the first 6 weeks after ablation . In the no-AAD group , only atrioventricular nodal blocking agents were prescribed . All patients wore a transtelephonic monitor for 4 weeks after discharge and were reevaluated at 6 weeks . The primary end point of the study was a composite of ( 1 ) atrial arrhythmias lasting more than 24 hours ; ( 2 ) atrial arrhythmias associated with severe symptoms requiring hospital admission , cardioversion , or initiation/change of antiarrhythmic drug therapy ; and ( 3 ) intolerance to antiarrhythmic agent requiring drug cessation .  Of 110 enrolled patients ( age 55±9 years , 71 % male ) , 53 were r and omized to AAD and 57 to no-AAD . There was no difference in baseline characteristics between groups . During the 6 weeks after ablation , fewer patients reached the primary end point in the AAD compared with the no-AAD group ( 19 % versus 42 % ; P=0.005 ) . There remained fewer events in the AAD group ( 13 % versus 28 % ; P=0.05 ) when only end points of AF > 24 hours , arrhythmia-related hospitalization , or electrical cardioversion were compared . Conclusions — AAD treatment during the first 6 weeks after AF ablation is well tolerated and reduces the incidence of clinical ly significant atrial arrhythmias and need for cardioversion/hospitalization for arrhythmia management 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 BACKGROUND Adherence to guidelines for the management of atrial fibrillation ( AF ) is often poor , although this is associated with improved morbidity and mortality in such patients . Increasing numbers of programs are design ed to enhance appropriate counselling , treatment and coordinated care delivery including the nurse-led , guidelines -based , software-supported integrated chronic care program ( ICCP ) for patients with AF reported here . OBJECTIVES This paper outlines the study protocol and methodology currently being used to evaluate the effectiveness of a newly developed nurse-led , guideline -based , software-supported ICCP for patients with AF . DESIGN AND METHODS Evaluation of the ICCP is currently being carried out in the outpatient care setting known as the AF-Clinic . A prospect i ve r and omised controlled trial is currently underway in the outpatient AF-Clinic of a University Hospital in the Netherl and s in cooperation with the collaborating university . The primary outcome measures are cardiovascular hospitalisation and /or death . Secondary outcome measures include guideline adherence , patient knowledge about their condition , quality of life , satisfaction and other outcome measurements such as cost-effectiveness . PARTICIPANTS It was calculated that 698 participants are needed to demonstrate discernible outcomes in relation to the primary endpoint ( 349 patients in each group ) with follow-up after 1 year . RESULTS The study started in January 2007 and the first results are expected in the beginning of 2010 . CONCLUSIONS It is hypothesised that the ICCP may contribute towards closing the gap between guideline recommendations and current practice in the management of atrial fibrillation . Furthermore , it is hypothesised that the program has the potential to optimise the management of AF patients and improve the efficiency and coordination of patient care . This may lead to better patient outcomes including improved quality of life and patient satisfaction in such patients 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 The fundamental management strategy for atrial fibrillation ( AF ) is still debated . There is no doubt that those patients at risk of thromboembolic events should be offered anticoagulant therapy . However , it is uncertain whether rhythm control ( restoration and maintenance of sinus rhythm ) or rate control ( adjustment to a physiological ventricular rate while allowing AF to continue ) is the preferred primary treatment option for the reduction of symptoms and major cardiovascular ( CV ) outcomes associated with AF . Several well conducted trials comparing the two strategies led to the conclusion that there was little to choose between them . However , guidelines leaned towards recommending rate control as the initial strategy , and reserved rhythm control for those who remained symptomatic . Recently this status quo is being increasingly challenged by the clear demonstration that left atrial catheter ablation is effective at suppressing AF resistant to traditional antiarrhythmic drugs , such as those that failed to demonstrate any superiority when compared with rate control . Also , recently introduced antiarrhythmic therapy may have superior efficacy with regard to reducing unexpected CV hospitalization , CV mortality and stroke . In addition , there is a growing perception that atrial remodelling should be best prevented by early rhythm control rather than delaying until rate control has proven unsatisfactory . For these reasons the results of large r and omised clinical trials , which recruit patients soon after the presentation of AF and compare ' aggressive ' modern rhythm control against the guideline approach of primary rate control , are eagerly awaited . In the meantime the pendulum of clinical opinion has begun to swing towards a rhythm control strategy Introduction Emergency department ( ED ) cardioversion ( EDCV ) and discharge of patients with recent onset atrial fibrillation or atrial flutter ( AF ) has been shown to be a safe and effective management strategy . This study examines the impact of such aggressive ED management on hospital charges . Methods : A r and om sample of 300 AF patients were identified from an ED electronic data base and screened for timing of onset of their symptoms . Patients were considered eligible for EDCV if either nursing or physician notes documented an onset of symptoms less than 48 hours prior to ED presentation and the patient was less than 85 years of age . An explicit chart review was then performed to determine patient management and disposition . Cardioversion attempts were defined as ED administration of procainamide , flecainide , propafenone , ibutilide , amiodarone or direct current cardioversion ( DCCV ) .  Total hospital charges for each patient were obtained from the hospital billing office . Differences across medians were analyzed utilizing through Wilcoxon rank sum tests and chi square . Results : A total of 51 patients were included in the study .  EDCV  was attempted on 24 ( 47 % ) patients , 22 ( 92 % ) were successfully cardioverted to normal sinus rhythm ( NSR ) . An additional 12 ( 23 % ) spontaneously converted to NSR . Twenty ( 91 % ) of those successfully cardioverted were discharged from the ED along with 4 ( 33 % ) of those spontaneously converting . Pharmacologic cardioverson was attempted in six patients and was successful in three ( 50 % ) , one after failed DCCV attempt .  Direct current cardioversion  was attempted in 21 ( 88 % ) and was successful in 19 ( 90 % ) , two after failed pharmacologic attempts . Median charges for patients cardioverted and discharged from the ED were $ 5,460 ( IQR $ 4,677–$6,190 ) . Median charges for admitted patients with no attempt at cardioversion were $ 23,202 ( IQR $ 19,663–$46,877 ) . Median charges for patients whose final ED rhythm was NSR were $ 5,641 ( IQR $ 4,638–$12,339 ) while for those remaining inAF median charges were $ 30,299 ( IQR $ 20,655 – $ 69,759 ) . Conclusion : ED cardioversion of recent onset AF patients results in significant hospital savings
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
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 .