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AFIB

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An evidence-driven tool to guide the selection and management of emergency department patients with atrial fibrillation and atrial flutter.

Section IconAssess Arrhythmia
When patient presents with primary problem of atrial fib/flutter
Confirm no exclusion criteria for outpatient management are present (see exclusion criteria in next section).
Initiate rate control and anticoagulation in ED.
Consider discussing with patient’s cardiologist (if applicable).
Determine if clear onset is <48 hours.
Identify if patient adequately anticoagulated ≥4 weeks.
Afib Protocol Exclusion Criteria (to be modified by your institutions standards)
Accompanying diagnosis warranting inpatient care (e.g., acute coronary ischemia, decompensated heart failure, sepsis). Examples only, not a comprehensive list.
Renal failure (creatinine clearance <15mL/min), if new anticoagulation start anticipated.
Pregnancy
Hemodynamic instability after initial rate control attempt if cardioversion not anticipated (i.e., HR 140 - 150bpm or SBP<90mm Hg, ongoing requirement for a drip medication).
Social barriers to outpatient follow-up (e.g., poor access to follow-up care, anticipated low compliance to patient instructions).
If observation unit available and anticipated, expected Length of Stay >your institution’s maximum LOS (e.g., 2 midnights).
Rate Control
In the emergency department and observation, options include Diltiazem, 0.25mg/kg IV x1 if SBP>100 mm Hg followed by 30mg PO q6h if rate adequately controlled. Also, Lopressor, 5-10mg IV x1 if SBP>100 mm Hg followed by 25mg PO q6h if rate adequately controlled (preferred agent for patients already on a β blocker).
If rate is not controlled and SBP<100 mm Hg consider Diltiazem drip (start at 10 mg/hr IV, titrate at 5mg/hr increments to max of 25mg/hr to HR<100).
Adequate rate control for discharge home defined as resting HR<100bpm and ambulatory HR<110bpm with tolerable symptoms.
Discharge rate control for patients sent home in atrial fib/flutter should be lowest dose equivalent of long acting oral medication (i.e., if the patient did well on 30mg PO Diltiazem q6h, discharge patient with 120mg of long-acting Diltiazem once daily, first dose due 6h from previous).
Consider Magnesium 4g IV if none of the following exclusions are present: SBP <90mmHg, renal failure, impaired consciousness, wide complex ventricular response, acute myocardial infarction, sick sinus syndrome, or acute decompensated heart failure.
Anticoagulation
Direct Oral Anticoagulant (DOAC) otherwise Lovenox or unfractionated Heparin per drug administration guideline recommendations if contraindications present.
References
  1. Fromm C, Suau SJ, Cohen V, et al. Diltiazem vs. metoprolol in the management of atrial fibrillation or flutter with rapid ventricular rate in the emergency department. J Emerg Med 2015;49:175–82.
  2. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014;130:2071–104.
  3. Stiell IG, Macle L. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: management of recent-onset atrial fibrillation and flutter in the emergency department. Can J Cardiol 2011;27:38–46.
  4. Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation): developed in Collaboration With the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol 2001;38:1231–66.
  5. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Cardiothorac Surg 2016;70:e1–88.
  6. Macle L, Cairns J, Leblanc K, et al. 2016 focused update of the Canadian Cardiovascular Society guidelines for the management of atrial fibrillation. Can J Cardiol 2016;32:1170–85.
  7. Low-dose Magnesium Sulfate Versus High Dose in the Early Management of Rapid Atrial Fibrillation: Randomized Controlled Double-blind Study (LOMAGHI Study) - PubMed (nih.gov) - Learn more here
Section IconFix Rhythm
Electrical Cardioversion
Perform synchronized DC electrical cardioversion with procedural sedation (i.e., Propofol sedation with preceding analgesia with 200J with biphasic defibrillator).
Recommend anterior/posterior pad placement.
If performing procedural sedation consult your institution’s sedation policy.
Failed Electrical Cardioversion Recommendations
If no evidence of sinus rhythm after initial shock: Check pad placement and skin contact. If less than 200J used on initial attempt, increase energy to maximum and repeat shock x1.
If transient sinus rhythm after initial shock (early recurrent atrial fibrillation), consider Ibutilide.
Chemical Cardioversion
Consider for patients who are poor sedation candidates secondary to patient or department resource factors.
Options include intravenous antiarrhythmic Class III (Ibutilide), oral antiarrhythmic Class IC (Flecainide), among others.
Ibutilide
Pre-treat with Magnesium 2-4g IV x1 over 30 minutes; defibrillator at bedside and pads on patient.
Ibutilide 1 mg IV over 10 minutes; may repeat same dose 10 minutes after first infusion if still in AF; if still in AF at 60 minutes after last infusion consider electrical cardioversion.
Monitor on telemetry 4 hours, watch QTc (risk: Torsades de Pointes). Avoid in patients with initial QTc >450 milliseconds. Marked hypokalemia or ejection fraction <30%.
No need to confirm lack of structural heart disease or occlusive coronary disease.
Flecainide
Confirm no significant structural cardiac abnormalities (i.e., TTE within last year or during observation stay showing no wall motion abnormalities/severe valvular disease) or occlusive coronary disease (i.e., low risk or recent normal stress test in observation).
Achieve adequate rate control prior to cardioversion.
Flecainide (300mg PO x1 if ≥70kg or 200mg PO x1 if <70kg).
If still in atrial fib/flutter after 2 hours, consider electrical cardioversion.
No need for extended telemetry monitoring.
References
  1. Stiell IG, Clement CM, Perry JJ, et al. Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CJEM 2010;12:181–91.
  2. White JL, Heller MB, Kahoud RJ, Slade D, Harding JD. Performance of an expedited rhythm control method for recent onset atrial fibrillation in a community hospital. Am J Emerg Med 2015;33:957–62.
  3. Stiell IG, Clement CM, Rowe BH, et al. Outcomes for emergency department patients with recent-onset atrial fibrillation and flutter treated in Canadian hospitals. Ann Emerg Med 2017;69(562–71):e2.
  4. Ptaszek LM, White B, Lubitz SA, et al. 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. Am J Cardiol 2016;118:64–71.
  5. Elmouchi DA, VanOosterhout S, Muthusamy P, et al. Impact of an emergency department-initiated clinical protocol for the evaluation and treatment of atrial fibrillation. Crit Pathw Cardiol 2014;13:43–8.
  6. Cristoni L, Tampieri A, Mucci F, et al. Cardioversion of acute atrial fibrillation in the short observation unit: comparison of a protocol focused on electrical cardioversion with simple antiarrhythmic treatment. Emerg Med J 2011;28:932–7.
  7. Kriz R, Freynhofer MK, Weiss TW, et al. Safety and efficacy of pharmacological cardioversion of recent-onset atrial fibrillation: a single-center experience. Am J Emerg Med 2016;34:1486–90.
  8. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014;130:2071–104.
  9. Vinson DR, Lugovskaya N, Warton EM, et al. Ibutilide effectiveness and safety in the cardioversion of atrial fibrillation and flutter in the community emergency department. Ann Emerg Med 2018;71(96–108):e2. The recommended dosage for IV procainamide is 15 mg/kg in 500 ml NS administered over 30–60 minutes; procainamide should be avoided if the systolic blood pressure is < 100 mmHg or the QTc is > 500 msec. Available here  at: http://www.pdr.net/drug-summary/Procainamide-Hydrochloride-procainamide-hydrochloride-3324. Accessed Apr 7, 2018. 34. Stiell IG, Macle L. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: management of recent-onset atrial fibrillation and flutter in the emergency department. Can J Cardiol 2011;27:38–46.
  10. Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002;347:1825–33.
  11. Ballard DW, Reed ME, Singh N, et al. Emergency department management of atrial fibrillation and flutter and patient quality of life at one month postvisit. Ann Emerg Med 2015;66(646–54):e2.
  12. Atzema CL. Atrial fibrillation: would you prefer a pill or 150 Joules? Ann Emerg Med 2015;66:655–7. Seaburg L, Hess EP, Coylewright M, Ting HH, McLeod J, Montori VM. Shared decision making in atrial fibrillation: where we are and where we should be going. Circulation 2014;129:704–10.
  13. Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation): developed in Collaboration With the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol 2001;38:1231–66.
  14. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Cardiothorac Surg 2016;70:e1–88.
  15. Macle L, Cairns J, Leblanc K, et al. 2016 focused update of the Canadian Cardiovascular Society guidelines for the management of atrial fibrillation. Can J Cardiol 2016;32:1170–85.
Section IconIdentify Disposition
Disposition Criteria for Hospital Admission
Deterioration in clinical status, such as worsening or new concerning symptoms (e.g., shortness of breath or inability to tolerate oral medications).
Failed cardioversion or inadequate rate or symptom control after ED resources have been exhausted.
Disposition Criteria for Home
Adequate symptom management and rate control in atrial fib/flutter OR conversion to sinus rhythm for >1 hour.
Evaluation and treatment complete with symptoms resolved or tolerable.
Follow up appointment made and communicated to patient; if after hours, appointment requested and confirm next business day
Outpatient Follow-up
Arrange for follow-up clinic visit within 3-5 day window (can be Cardiology, Primary Care or other based on institutional standards; if anticoagulant started, consider anticoagulant clinic for follow-up).
Ensure patient’s insurance will permit planned clinic follow up and new medications.
Perform patient education around atrial fibrillation and new medications.
Instruct patient around signs and symptoms warranting return to ED.
References
  1. Carter L, Gardner M, Magee K, et al. An integrated management approach to atrial fibrillation. J Am Heart Assoc 2016;5. pii: e002950.
  2. Kelly AM, Pannifex J. A clinical network project improves care of patients with atrial fibrillation with rapid ventricular response in Victorian emergency departments. Heart Lung Circ 2016;25:e33–6.
  3. Stiell IG, Macle L. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: management of recent-onset atrial fibrillation and flutter in the emergency department. Can J Cardiol 2011;27:38–46.
  4. Seaburg L, Hess EP, Coylewright M, Ting HH, McLeod CJ, Montori VM. Shared decision making in atrial fibrillation: where we are and where we should be going. Circulation 2014;129:704–10.
Section IconBegin Anticoagulation
If patient is discharged in atrial fib/flutter
Start anticoagulation if CHA2DS2-VASc score ≥2 and HAS-BLED score <3. Manage bleeding risk factors if HAS-BLED score ≥3; if not modifiable consider delaying anticoagulation start or consultation with anticoagulation expert.
Consider starting for patients with a score CHA2DS2-VASc score of 0-1 to facilitate outpatient cardioversion.
If patient is discharged in sinus rhythm
Use the CHA2DS2-VASc score to determine anticoagulation need (0-1 = no anticoagulation; ≥2 = Direct Oral Anticoagulant [DOAC]); consider either Lovenox +/- Coumadin (with bridge) for contraindications.
Manage bleeding risk factors if HAS-BLED score ≥3; if not modifiable consider delaying anticoagulation start or consultation with anticoagulation expert.
Instruct patient around signs and symptoms warranting return to ED
References
  1. Coleman CI, Peacock WF, Bunz TJ, Alberts MJ. Effectiveness and safety of apixaban, dabigatran, and rivaroxaban versus warfarin in patients with nonvalvular atrial fibrillation and previous stroke or transient ischemic attack. Stroke 2017;48:2142–9.
  2. Study Of The Blood Thinner, Apixaban, For Patients Who Have An Abnormal Heart Rhythm (Atrial Fibrillation) And Expected To Have Treatment To Put Them Back Into A Normal Heart Rhythm (Cardioversion) (EMANATE). 2017. Available here . Accessed Nov 26, 2017.
  3. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Rhythm Society. Circulation 2014;130:2071–104.
  4. Stiell IG, Macle L. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: management of recent-onset atrial fibrillation and flutter in the emergency department. Can J Cardiol 2011;27:38–46.
  5. Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation): developed in Collaboration With the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol 2001;38:1231–66.
  6. Scheuermeyer FX, Innes G, Pourvali R, et al. Missed opportunities for appropriate anticoagulation among emergency department patients with uncomplicated atrial fibrillation or flutter. Ann Emerg Med 2013;62(557–65):e2.
  7. Vinereanu D, Lopes RD, Bahit MC, et al. A multifaceted intervention to improve treatment with oral anticoagulants in atrial fibrillation (IMPACT-AF): an international, cluster-randomised trial. Lancet 2017;390:1737–46.
  8. Coll-Vinent B, Martin A, Sanchez J, et al. Benefits of emergency departments’ contribution to stroke prophylaxis in atrial fibrillation: the EMERG-AF study (Emergency Department Stroke Prophylaxis and Guidelines Implementation in Atrial Fibrillation). Stroke 2017;48:1344–52.
  9. Coll-Vinent B, Martin A, Malagon F, et al. Stroke prophylaxis in atrial fibrillation: searching for management improvement opportunities in the emergency department: the HERMES-AF study. Ann Emerg Med 2015;65:1–12.
  10. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Cardiothorac Surg 2016;70:e1–88.
  11. Macle L, Cairns J, Leblanc K, et al. 2016 focused update of the Canadian Cardiovascular Society guidelines for the management of atrial fibrillation. Can J Cardiol 2016;32:1170–85.
  12. Lane DA, Lip GY. Use of the CHA2DS2-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation. Circulation 2012;126:860–5.
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PDF Icon Example Protocol
PDF Icon Example Protocol Development Timeline
PDF Icon Protocol Definitions Criteria
PDF Icon Protocol Suggested Metrics

Additional Links

For further background, details and discussion please refer to this
NCBI Page

Acknowledgments

AFIB:

Developed by the ACEP Expert Panel on Atrial Fibrillation

Contributors:
Christopher Baugh, MD, MBA (Chair) Karen Pate, PhD (Moderator) Jo Ann Brooks, PhD, RN, FAAN, FCCP Carol L. Clark, MD, MBA, FACEP Abraham G. Kocheril, MD, FACC, FACP, FHRS Dhanunjaya Lakkireddy, MD Krista Luck, PharmD, CACP, CPP Troy Myers, MD, FACEP Brian Patel, MD Jesse Pines, MD Charles V. Pollack, Jr. MA, MD, FACEP, FAAEM, FAHA, FESC, FCPP Steven Roumpf, MD Matthew Shaw, PA-C Ian Stiell, MD, MSc, FRCPC Gery Tomassoni, MD, FHRS, FACC James Williams , MS, DO, FACEP Jason W. Wilson , MD, MA, FACEP, FAAEM Fred Wu, MHS, PA-C GilAnthony Ungab, MD

 

ACEP Staff
Sandy Schneider, MD Lori Vega Riane Gay, MPA Travis Schulz, MLIS

 

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