Which arrhythmias require emergency room (ER) evaluation and which can be managed on an outpatient basis?

From the Guidelines

Arrhythmias requiring immediate emergency room evaluation include hemodynamically unstable arrhythmias, ventricular tachycardia, ventricular fibrillation, complete heart block, symptomatic bradycardia, new-onset atrial fibrillation with rapid ventricular response, and Wolff-Parkinson-White syndrome with rapid conduction. The decision to evaluate an arrhythmia in the emergency room versus an outpatient setting depends on several factors, including hemodynamic stability, symptom severity, and risk of sudden cardiac death 1. Some key points to consider in this decision include:

• Hemodynamic stability: Arrhythmias that cause hypotension, chest pain, altered mental status, or heart failure require immediate emergency room evaluation.
• Symptom severity: Arrhythmias that cause severe symptoms, such as syncope, severe chest pain, shortness of breath, or palpitations with dizziness, require prompt evaluation.
• Risk of sudden cardiac death: Arrhythmias that increase the risk of sudden cardiac death, such as ventricular tachycardia or ventricular fibrillation, require immediate emergency room evaluation.

In contrast, arrhythmias that can typically be managed on an outpatient basis include stable supraventricular tachycardias, chronic well-controlled atrial fibrillation, premature atrial or ventricular contractions without symptoms, first-degree AV block, and asymptomatic sinus bradycardia. For outpatient management of SVT, options include beta-blockers (metoprolol 25-100mg twice daily), calcium channel blockers (diltiazem 30-120mg three times daily), or referral for ablation 1. For stable atrial fibrillation, rate control with similar medications plus anticoagulation assessment using CHA₂DS₂-VASc score is appropriate 1. Patients should be educated about warning signs requiring emergency care, including syncope, severe chest pain, shortness of breath, or palpitations with dizziness. Any patient with concerning symptoms or uncertain diagnosis should be evaluated promptly in an emergency setting, as delayed treatment of life-threatening arrhythmias can lead to cardiac arrest.

From the Research

Arrhythmias Requiring Emergency Room (ER) Evaluation

• Life-threatening ventricular arrhythmias such as sustained ventricular tachycardia and ventricular fibrillation require immediate medical attention and ER evaluation 2, 3, 4, 5
• Atrial fibrillation and flutter can lead to stroke, heart failure, and even death, and may require ER evaluation depending on the severity of symptoms and underlying medical conditions 3, 4
• Unstable hemodynamics, such as those caused by atrial fibrillation, atrial flutter, or ventricular tachyarrhythmias, require immediate DC-cardioversion and ER evaluation 4

Arrhythmias That Can Be Managed on an Outpatient Basis

• Supraventricular tachycardia, including atrioventricular nodal reentrant tachycardia, atrioventricular reciprocating tachycardia, and atrial tachycardia, can often be managed on an outpatient basis with vagal maneuvers, adenosine, or antiarrhythmic medications 6
• Atrial fibrillation can be managed on an outpatient basis with rate-control or rhythm-control therapy, depending on the patient's symptoms and underlying medical conditions 4
• Ventricular arrhythmias that are not life-threatening can be managed on an outpatient basis with antiarrhythmic medications, catheter ablation, or implantable cardioverter-defibrillator therapy, depending on the patient's symptoms and underlying medical conditions 2, 3, 5

Factors Influencing the Need for ER Evaluation

• Presence of underlying structural heart disease or cardiac dysfunction 2, 3, 5
• Severity of symptoms, such as palpitations, light-headedness, chest discomfort, anxiety, dyspnea, or fatigue 3, 4, 6
• Presence of unstable hemodynamics or life-threatening arrhythmias 4
• Effectiveness of outpatient management and the need for closer monitoring or more aggressive treatment 2, 3, 5, 6