Rapid Treatment and Discharge of Patients with Recent-Onset Atrial Fibrillation or Flutter
Rapid cardioversion and discharge home is safe for emergency department patients who present within 48 hours of onset of atrial fibrillation or flutter.
Researchers evaluated the efficacy and safety of a protocol for rapid emergency department (ED) cardioversion and discharge of patients with recent-onset (<48 hours) atrial fibrillation or atrial flutter in a retrospective observational study of 660 consecutive patients (95% with atrial fibrillation, 5% with atrial flutter) at a single ED in Canada from 2000 to 2005. The protocol involved ED pharmacologic cardioversion with intravenous (IV) procainamide (1 g during 60 minutes) and, if needed, electrical cardioversion, followed by discharge home within 1 hour after cardioversion.
Sixty percent of patients with atrial fibrillation and 28% of those with atrial flutter converted to sinus rhythm with IV procainamide. Electrical cardioversion (not attempted in 32 patients) was successful in 92% and 100% of the remaining 243 patients with fibrillation and 20 with flutter, respectively. Overall, 97% of patients were discharged home, and 93% of discharged patients were in sinus rhythm. Median ED stay was 4.9 hours. Adverse events (including transient hypotension and bradycardia) occurred in 7.6% of patients, and 8.6% of patients relapsed within 7 days; no cases of torsades de pointes or stroke were reported and no deaths occurred.
Primary ED cardioversion (by IV or oral antidysrhythmic agent [JW Gen Med Jan 11 2005 ] or synchronized electrical cardioversion) is a reasonable option for patients with uncomplicated atrial fibrillation or atrial flutter.
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine July 2, 2010
Citation(s): Stiell IG et al. Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CJEM 2010 May; 12:181.