• Atrial fibrillation and flutter (AFF) are two of the most common dysrhythmias encountered in the emergency department.
• While conventional guidelines are helpful, they are often drawn from the cardiology literature, and may not always be applicable in emergency patient presentations.
• Unless the patient has an acute-ST-elevation myocardial infarction, management can be similar in urban and rural settings.

• This is very rare.
• If the patient has obvious signs of shock, ST-segment elevation, or acute pulmonary edema, immediate sedation (preferably ketamine) and electrical conversion is recommended.
• All such patients should be admitted.

• If a patient has AFF and an acute illness such as sepsis or heart failure, treatment should be directed at the underlying cause.
• It is critical to identify these patients. Almost all of them will arrive by ambulance, OR have a chief complaint of dyspnea, chest pain, or weakness, OR have a CHADS-VASC score > 2.
• In such cases, aggressive rate or rhythm control will more often lead to adverse events, rather than AFF control.
• Patients with kidney disease (eGFR < 59) have a 15% additional risk of an adverse event if managed with rate or rhythm control.
• All such patients should be admitted to hospital. Continue treating the underlying illness as appropriate.

• If the AFF onset is greater than 48 hours, OR if the patient has a CHADS2 score > 1, OR if there has been a stroke within 6 months, OR if the patient has a mechanical valve or rheumatic heart disease, then rate control (see below) should be initiated with a goal of < 100 beats per minute.
• If symptoms cannot be controlled, patients should be admitted.
• If patients can be discharged, they require oral anticoagulation for at least 4 weeks and should have internal medicine or cardiology follow-up within that time for new-onset AFF, or primary care follow-up for recurrent AFF. (See below for anticoagulation guidelines.)

• If the AFF onset is less than 48 hours (12 hours for CHADS2 > 1) OR there has been therapeutic anticoagulation for at least 3 weeks, then rhythm control (conversion by drugs or electricity) is recommended.
• Electrical-then-chemical and chemical-then-electrical approaches are both safe (low rate of adverse events) and effective (close to 100% will convert) but an electrical approach has a lower length of stay.
• If neither approach works, attempt rate control. If symptoms cannot be controlled, patients should be admitted.
• If patients can be discharged the CCS guidelines recommend 4 weeks of anticoagulation for all patients. CAEP recommends that physicians hold an informed discussion with all patients regarding risks and benefits of anticoagulation.

• Use metoprolol 2.5 – 5 mg iv q15 min up to 3 doses, then discharge on metoprolol 25 mg po twice daily.
• If metoprolol is contra-indicated, use diltiazem 0.25 mg/kg IV over 10 minutes; then q15-20 min at 0.35 mg/kg up to 3 doses, and then discharge on 30 – 60 mg po 4 times per day.

Should be dictated by balancing stroke risk (CHADS-65) and bleeding risk (HAS-BLED) and with an informed patient discussion. (Consult the Thrombosis Canada App for more detailed information)

• CHADS-65
  • If a patient has any of the following: heart failure, hypertension, diabetes, prior stroke, or is greater than 65, they are considered high-risk and warrant anticoagulation. Recent CCS guidelines emphasize that all AFF patients who convert to normal sinus require anticoagulation, but this is disputed by CAEP recommendations.
• HAS-BLED score(major bleeding risk)
  • 1 point each for hypertension; abnormal  kidney (cr > 200 umol / L / dialysis / transplant) or  liver function; (cirrhosis or ALT / AST / AP >3x normal) prior stroke; prior major bleeding; unstable international normalized ratio,;(INR time in therapeutic range < 60%) drugs (NSAIDs, clopidogrel) or alcohol use (> 8 drinks per week)  Greater than 2 points indicates high risk of bleeding.

• Patients with new-onset AFF should be seen by a cardiologist, preferably within a month.
• Patients should also be seen by a family physician, ideally within a week.

1. CAEP 2018 Atrial Fibrillation Guidelines Obsolete: Here’s Why

   
   

2. CAEP Guidelines for Management of Patients with Atrial Fibrillation in the ED

   
   

3. Consult the Thrombosis Canada App for more detailed information

   
   

1. Scheuermeyer FX, Pourvali R, Rowe BH, et al. Emergency department patients with atrial fibrillation or flutter and an acute underlying medical illness may not benefit from attempts to control rate or rhythm. Ann Emerg Med. 2015; 65: 511 – 522.e2.

   
   

2. Scheuermeyer FX, Grafstein E, Stenstrom R, et al. Thirty day outcomes of emergency department patients undergoing cardioversion for atrial fibrillation or flutter. Acad Emerg Med. 2010; 17: 408 – 15.

   
   

3. Thrombosis Canada Risk Calculators. Accessed April 25 2017.