What is the management plan for a patient presenting to the emergency department (ED) with atrial fibrillation (a fib)?

Management of Atrial Fibrillation in the Emergency Department

For patients presenting to the emergency department with atrial fibrillation, immediate assessment of hemodynamic stability should guide management, with unstable patients requiring immediate electrical cardioversion and stable patients receiving rate or rhythm control based on duration of symptoms and risk factors. 1, 2

Initial Assessment

• Evaluate hemodynamic stability: Check for signs of shock, hypotension, acute heart failure, angina, or myocardial infarction 1
• Identify potential reversible causes: thyroid dysfunction, electrolyte abnormalities, alcohol consumption, infection 1, 3
• Determine duration of atrial fibrillation (if known): <48 hours or >48 hours/unknown duration 1
• Assess stroke risk using CHA₂DS₂-VASc score 3

Management Algorithm

Hemodynamically Unstable Patients

• Perform immediate electrical cardioversion without waiting for anticoagulation 1
• Administer heparin concurrently (if not contraindicated) via initial IV bolus followed by continuous infusion to achieve aPTT 1.5-2 times control value 1
• After stabilization, initiate oral anticoagulation (INR 2-3) for at least 3-4 weeks 1

Hemodynamically Stable Patients

Rate Control Strategy

• First-line agents: IV beta-blockers or calcium channel blockers (verapamil, diltiazem) 1
• Target heart rate <110 beats per minute in patients with preserved left ventricular function 2
• Combination therapy: Consider digoxin plus beta-blocker or calcium channel antagonist for better rate control at rest and during exercise 1
• Avoid using digoxin as sole agent for rate control in paroxysmal AF 1

Rhythm Control Strategy (for selected patients)

• Consider if AF duration <48 hours, patient is younger with first episode, or symptomatic despite rate control 2, 4
• Pharmacological cardioversion options for hemodynamically stable patients: IV amiodarone 5, 4
• For AF with accessory pathway conduction: IV procainamide, ibutilide, or amiodarone 1

Anticoagulation Management

• Administer antithrombotic therapy to all AF patients except those with lone AF 1
• For AF >48 hours or unknown duration: Anticoagulate for at least 3-4 weeks before and after cardioversion (INR 2-3) 1
• Alternative approach: Perform transesophageal echocardiography (TEE) to rule out left atrial thrombus before cardioversion 1
• Direct oral anticoagulants (e.g., rivaroxaban) are safe first-line options for anticoagulation 6, 3
• Higher intensity anticoagulation (INR 2.5-3.5) for patients with prosthetic heart valves, prior thromboembolism, or persistent atrial thrombus 1

Disposition Decisions

• Consider discharge for stable patients with:
  • Adequate rate control
  • No significant comorbidities
  • Low risk of complications based on risk scores (RED-AF, AFFORD, or AFTER) 3
• Admission criteria:
  • Hemodynamic instability
  • New-onset heart failure
  • Acute coronary syndrome
  • First episode of AF with uncertain etiology 2, 3

Common Pitfalls to Avoid

• Failing to identify and treat reversible causes of AF 1, 3
• Using digoxin as sole agent for rate control in paroxysmal AF 1
• Omitting anticoagulation in high-risk patients 1
• Attempting cardioversion without appropriate anticoagulation in AF >48 hours 1
• Inadequate follow-up planning for discharged patients 2, 3