Should new-onset atrial fibrillation (AF) be referred to the Emergency Room (ER)?

From the Guidelines

New-Onset Atrial Fibrillation Referral to the Emergency Room

Yes, new-onset atrial fibrillation (AF) should be referred to the Emergency Room (ER) for immediate evaluation and treatment, as it can significantly increase the risk of stroke, heart failure, and other complications 1.

• Importance of Prompt Medical Attention: The effects of AF are variable across individual patients, but morbidity from AF remains highly concerning, with potential complications including stroke, heart failure, and thromboembolism to other organs, contributing to a higher risk of mortality 1.
• Diagnostic Tests in the ER: In the ER, patients will typically undergo an electrocardiogram (ECG), blood tests, and other diagnostic tests to determine the cause of the atrial fibrillation and to assess for any signs of cardiac or other organ damage.
• Treatment Options: Treatment may include rate control medications such as metoprolol (25-100mg orally) or diltiazem (30-120mg orally), rhythm control medications such as amiodarone (150-300mg orally), or anticoagulation medications such as aspirin (81-325mg orally) or apixaban (5mg orally twice daily) to prevent stroke.
• Individualized Treatment Approach: The ER physician will determine the best course of treatment based on the individual patient's condition and medical history, following a patient-centered, shared decision-making approach that considers the patient's unique needs and preferences 1.

From the Research

Referral to Emergency Room (ER) for New-Onset Atrial Fibrillation (AF)

• The decision to refer new-onset atrial fibrillation (AF) to the Emergency Room (ER) depends on various factors, including patient stability and the presence of underlying medical conditions 2, 3.
• Studies suggest that not all patients with new-onset AF require immediate referral to the ER, and some can be managed in an outpatient setting or with a wait-and-see approach 4, 5.
• The American Heart Association/American College of Cardiology, the European Society of Cardiology, and the Canadian Cardiovascular Society provide recommendations for the management of AF, including rate or rhythm control, cardioversion, and anticoagulation 2.
• A study published in the New England Journal of Medicine found that a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks in patients with recent-onset, symptomatic AF 4.
• Another study published in the Journal of General Internal Medicine found that hospitalization is not necessary for all patients with new-onset AF, and those in whom reversion to normal sinus rhythm occurs rapidly during digoxin therapy can be discharged 5.
• Factors that may justify referral to the ER include:
  • Hemodynamic instability 2, 3
  • Presence of underlying medical conditions such as congestive heart failure or chest pain suggestive of myocardial ischemia 3
  • Significant complications during the ED stay or during the subsequent hospitalization 3
• Studies suggest that approximately one third of patients with new-onset AF may not require admission to the hospital, and most patients for whom admission is medically justified can be reliably identified during the ED evaluation 3.