Can early management in the emergency department of patients with acute onset atrial fibrillation decrease hospital admissions?

An 8-hour protocol for the management of acute onset atrial fibrillation (AF) in the emergency department will result in most patients being sent home rather than being admitted. However, this study only evaluated patients who were hemodynamically stable and not in need of hospitalization for other reasons, which applied to only 7.3% of patients with acute AF seeking care. (LOE = 1b)

Decker WW, Smars PA, Vaidyanathan L, et al. A prospective, randomized trial of an emergency department observation unit for acute onset atrial fibrillation. Ann Emerg Med 2008;52(4):322-28.  [PMID:18339449]

Randomized controlled trial (nonblinded)

Foundation

Concealed

Emergency department

These researchers enrolled 153 patients with AF of less than 48 hours' duration. The patients presented to an emergency department and did not have hemodynamic instability; that is, low blood pressure or a pulse greater than 129 beats per minute after rate control. These criteria eliminated many patients with AF: Over a 39-month period, only 7.3% of the total number of patients with AF were eligible for this study. After giving consent, the patients were randomized, using concealed allocation, to immediate admission and routine care, or to management in the emergency department for up to 8 hours. Emergency department care consisted of initial assessment and pulse rate control using either a calcium channel blocker or beta-blocker with an aim of less than 100 beats per minute. After 6 hours, patients in sinus rhythm for at least 2 hours were discharged to home. Patients with continued AF were electrically cardioverted and observed for a further 2 hours before either being discharged to home or admitted. Eighty-five percent of patients managed in the emergency department were discharged to home. The median length of stay for patients managed in the emergency department was 10.1 hours versus 25.2 hours for hospitalized patients (P <.001). Recurrence of AF over 30 days following the study was similar in both groups.