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Atrial Fibrillation: An Approach to Diagnosis and Management in the Emergency Department
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Publication Date: May 2021 (Volume 23, Number 5)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 05/01/2024.

Authors

Brian Milman, MD
Assistant Professor, Department of Emergency Medicine, University of Oklahoma School of Community Medicine, Tulsa, OK
Boyd D. Burns, DO, FACEP
Professor and George Kaiser Family Foundation Chair in Emergency Medicine, University of Oklahoma School of Community Medicine, Tulsa, OK

Peer Reviewers

Corey M. Slovis, MD, FACP, FACEP
Professor and Chairman Emeritus, Department of Emergency Medicine, Vanderbilt University Medical Center; Medical Director, Metro Nashville Fire Department and International Airport, Nashville, TN
Douglas L. Robinson, DO, MS
Assistant Professor, Mercer University School of Medicine; Columbus, GA; Emergency Medicine Physician, Piedmont Regional Medical Center, Columbus, GA

Abstract

Atrial fibrillation is the most common dysrhythmia encountered in the emergency department. In patients aged >65 years, the incidence approaches 10%, and the number of patients with atrial fibrillation is expected to almost double in the next 30 years. Atrial fibrillation and its associated comorbidities also carry significant healthcare cost. Electrocardiogram findings may be subtle at times, but prompt diagnosis is needed to maximize good outcomes, especially when patients are cardiovascularly compromised. This review includes evidence-based recommendations on rate versus rhythm control, discusses pharmacologic versus electrical cardioversion, evaluates thromboembolic risk, and provides options for anticoagulation.

Case Presentations

CASE 1
A 58-year-old man with a history of atrial fibrillation and diabetes on rivaroxaban is complaining of palpitations that started after a bike ride…
  • On physical exam, he is afebrile, has a blood pressure of 165/82 mm Hg, and a wide complex irregular heart rate at 160 beats/min.
  • You suspect AF with aberrancy or a pre-existing bundle branch block and begin thinking about the best strategy for rate control.
  • You wonder whether this anticoagulated patient can be safely cardioverted and discharged home...
CASE 2
A 28-year-old woman arrives via EMS after an episode of syncope…
  • She has experienced multiple episodes of syncope in the past, but reports no other medical problems.
  • She is usually asymptomatic after episodes and has never been evaluated, but this time, she had persistent chest pain and called EMS.
  • ECG shows a wide complex irregular tachycardia with a rate of 200 beats/min.
  • You wonder whether this is supraventricular or ventricular and the best way to stabilize her would be...
CASE 3
A 67-year-old woman with no cardiac history presents with increasing fatigue for the past 5 days, but is otherwise asymptomatic…
  • Her ECG shows AF at a rate of 158 beats/min and her blood pressure is 84/58 mm Hg.
  • Your colleague tells you that cardioverting these patients makes him nervous and he asks you how you manage rapid AF in the setting of hypotension…

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