Cardioversion of Paroxysmal Atrial Fibrillation in the Emergency Department,☆☆,

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Abstract

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 database 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 prospectively evaluated in multiple settings.[Michael JA, Stiell IG, Agarwal S, Mandavia DP: Cardioversion of paroxysmal atrial fibrillation in the emergency department. Ann Emerg Med April 1999;33:379-387.]

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INTRODUCTION

Acute atrial fibrillation is the most common form of paroxysmal supraventricular tachycardia in patients who present to the emergency department.1, 2 The prevalence is .4% in the general population with a 10-fold increase in patients older than 60 years.3, 4 Symptoms of uncontrolled atrial fibrillation vary from palpitations to poor cardiac performance, resulting in worsening of coronary artery disease, congestive heart failure, and possible sudden cardiac death. Sustained atrial fibrillation

MATERIALS AND METHODS

A health records survey was performed of a consecutive cohort sample of ED patients presenting with the primary diagnosis of acute atrial fibrillation. The study was approved by the institutional research ethics committee.

The Ottawa Civic Hospital is a full-service, tertiary care hospital affiliated with the University of Ottawa Faculty of Medicine and has an annual ED census of 60,000 visits. The ED is staffed by certified emergency physicians 24 hours per day. Postgraduate medical trainees

RESULTS

During the 18-month study period, 655 consecutive ED patient visits were identified as having atrial fibrillation as one of their discharge diagnoses (Figure) ; 359 of these visits met exclusion criteria.

Figure. Study and ED course of all patient visits identified during an 18-month period.

A summary of patient visits excluded for medical reasons is presented in Table 1.

. Medical complications excluding patients from study.

Reasons for ExclusionNo. (%)
Additional cardiac complication128 (36)

DISCUSSION

This is the largest reported study of patients with acute atrial fibrillation with conversion to normal sinus rhythm in an ED setting and discharged directly home from the ED. Previous studies have used a retrospective review of inpatient charts to identify patients who may not have needed admission.2, 3 As recommended in these studies, emergency physicians in our group used high-risk criteria (instability on arrival, significant congestive heart failure, chest pain suggestive of significant

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Address for reprints: John A Michael, MD, Department of Emergency Medicine, North Shore Medical Center, 81 Highland Avenue, Salem, MA 01970; 978-741-1200, ext 3500;fax 978-740-4137;E-mail [email protected].

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