What is the treatment for atrial fibrillation in the Emergency Department (ED)?

From the Guidelines

The primary treatment for atrial fibrillation in the emergency department should focus on rate control, anticoagulation, and potential cardioversion if appropriate, as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1. For rate control:

• Start with intravenous beta-blockers (e.g., metoprolol 5mg IV every 5 minutes, up to 3 doses) or calcium channel blockers (e.g., diltiazem 0.25 mg/kg IV over 2 minutes), as these are recommended as first-choice drugs in patients with AF and LVEF >40% to control heart rate and reduce symptoms 1.
• If ineffective, consider adding digoxin 0.5mg IV, as beta-blockers and/or digoxin are recommended in patients with AF and LVEF ≤40% to control heart rate and reduce symptoms 1. For anticoagulation:
• Assess stroke risk using CHA2DS2-VASc score, as recommended by the 2024 ESC guidelines 1.
• If score ≥2, initiate anticoagulation with heparin or low molecular weight heparin, and plan for long-term oral anticoagulation (e.g., warfarin, direct oral anticoagulants) if AF persists, as oral anticoagulants are recommended for all eligible patients, except those at low risk of incident stroke or thromboembolism 1. Consider cardioversion:
• If AF duration <48 hours or patient is already anticoagulated, perform electrical cardioversion (start at 200J biphasic), as electrical cardioversion is recommended in cases of haemodynamic instability, and otherwise choose electrical or pharmacological cardioversion based on patient characteristics and preferences 1.
• If chemical cardioversion is preferred, use ibutilide or amiodarone, as these are options for pharmacological cardioversion. Additional considerations:
• Correct electrolyte imbalances, particularly potassium and magnesium, as recommended by the 2024 ESC guidelines 1.
• Treat underlying causes (e.g., hyperthyroidism, infection), as comorbidities and risk factors should be thoroughly evaluated and managed to avoid recurrence and progression of AF, improve success of AF treatments, and prevent AF-related adverse outcomes 1.
• Monitor oxygen saturation and provide supplemental oxygen if needed, as part of the general management of AF. This approach aims to control heart rate, prevent thromboembolism, and potentially restore normal sinus rhythm, with the goal of improving symptoms, cardiac function, and quality of life, while reducing stroke risk and morbidity, as recommended by the 2024 ESC guidelines 1.

From the FDA Drug Label

In a study in healthy volunteers, intravenous infusions of ibutilide fumarate injection resulted in prolongation of the QT interval that was directly correlated with ibutilide plasma concentration during and after 10-minute and 8-hour infusions. Clinical Studies Treatment with intravenous ibutilide fumarate for acute termination of recent onset atrial flutter/fibrillation was evaluated in 466 patients participating in two randomized, double-blind, placebo-controlled clinical trials Among patients with atrial flutter, 53% receiving 1 mg ibutilide fumarate and 70% receiving 2 mg ibutilide fumarate converted, compared to 18% of those receiving sotalol In patients with atrial fibrillation, 22% receiving 1 mg ibutilide fumarate and 43% receiving 2 mg ibutilide fumarate converted compared to 10% of patients receiving sotalol.

The treatment for atrial fibrillation in the Emergency Department (ED) with ibutilide (IV) is:

• A single 10-minute infusion of 1 mg ibutilide fumarate, with the option for a second infusion of 0.5 or 1.0 mg 10 minutes after completion of the first infusion.
• The dose of ibutilide fumarate injection is directly correlated with the QT interval prolongation, which is associated with its antiarrhythmic activity.
• Conversion of atrial fibrillation usually occurs within 30 minutes of the start of infusion and is dose-related.
• Patients should be monitored with continuous ECG monitoring for at least 4 hours following infusion or until QTc has returned to baseline 2.
• Diltiazem (IV) may also be used to control the ventricular rate in atrial fibrillation, but the provided text does not specify its use for conversion of atrial fibrillation to normal sinus rhythm 3.

From the Research

Treatment Options for Atrial Fibrillation in the Emergency Department

The treatment for atrial fibrillation in the Emergency Department (ED) involves several options, including:

• Rate control with medications, such as beta blockers and calcium channel blockers 4
• Rhythm control, which is an option for patients with longer life expectancy and those with AF onset <48 hours before presentation, anticoagulated for 3-4 weeks, or with transesophageal echocardiography demonstrating no intracardiac thrombus 4
• Cardioversion, which is indicated in hemodynamically unstable patients 4, 5, 6
• Anticoagulation, which is pivotal in AF to prevent cardioembolic stroke and is considered a primary objective after an accurate assessment of antithrombotic treatment risks and benefits 4, 7, 6

Management Strategies

The management of atrial fibrillation in the ED involves two main strategies:

• Rate control: aiming to control the heart rate to <110 beats per minute in patients with intact left ventricular function 4
• Rhythm control: aiming to restore and maintain sinus rhythm, which can be achieved through cardioversion or antiarrhythmic drugs 4, 7, 5, 6

Disposition and Follow-up

Clinical judgment regarding disposition is recommended, but literature supports discharging stable patients who do not have certain comorbidities 4. The decision to discharge or admit a patient with atrial fibrillation should be based on their clinical status, the presence of underlying conditions, and the risk of thromboembolic events 4, 6.