Abstract

This issue of EM Practice Guidelines Update reviews 2 guidelines that focus on the management of atrial fibrillation (AF) in the emergency department (ED). AF is the most common sustained cardiac rhythm disturbance in adults. It is a risk factor for thromboembolism and congestive heart failure (CHF), and it causes symptoms such as chest pain and shortness of breath. Prevalence increases with age, and it is predicted that by 2050, nearly 5.6 million people in the United States will be diagnosed with AF, doubling the current number of cases.¹ Several key controversies exist in the management of AF, including rhythm versus rate control, electric versus pharmacological rhythm control, and if and when anticoagulation is indicated. Several key guidelines have been recently published to direct emergency clinicians in their care of patients with this most common arrhythmia.

Practice Guideline Impact

• Hemodynamically unstable patients require immediate direct current cardioversion.
• Hemodynamically stable patients with onset of AF < 48 hours may undergo cardioversion without anticoagulation.
• If AF duration is ≥ 48 hours or an unknown period of time, the patient must be assessed for the need for thromboembolism prophylaxis.
• The patient's risk of bleeding must be assessed prior to initiating anticoagulation.
• Only symptomatic patients or patients with insufficient rate control require hospital admission.

Keywords:
atrial fibrillation, atrial flutter, cardioversion, thromboembolism