Impact of Emergency Department Management of Atrial Fibrillation on Hospital Charges A randomized clinical trial of early invasive intervention for atrial fibrillation (EARLY-AF) - methods and rationale. Evaluation of an individualized strategy of cavotricuspid isthmus ablation as an adjunct to atrial fibrillation ablation. Biphasic cardioversion of acute atrial fibrillation in the emergency department The AFFORD clinical decision aid to identify emergency department patients with atrial fibrillation at low risk for 30-day adverse events. Effect of a Multidisciplinary Approach for the Management of Patients With Atrial Fibrillation in the Emergency Department on Hospital Admission Rate and Length of Stay. A prospective, randomized, controlled trial of an emergency department-based atrial fibrillation treatment strategy with low-molecular-weight heparin. Efficacy and safety of intravenously administered dofetilide in acute termination of atrial fibrillation and flutter: a multicenter, randomized, double-blind, placebo-controlled trial. Danish Dofetilide in Atrial Fibrillation and Flutter Study Group. Ibutilide to expedite ED therapy for recent-onset atrial fibrillation flutter. Increased risk of sudden and non-sudden cardiovascular death in patients with atrial fibrillation/flutter following acute myocardial infarction. Thirty-day outcomes of emergency department patients undergoing electrical cardioversion for atrial fibrillation or flutter. Validation of the Risk Estimator Decision Aid for Atrial Fibrillation (RED-AF) for predicting 30-day adverse events in emergency department patients with atrial fibrillation. Impact of a practice guideline for patients with atrial fibrillation on medical resource utilization and costs. Cardioversion of acute atrial fibrillation in the short observation unit: comparison of a protocol focused on electrical cardioversion with simple antiarrhythmic treatment Ablation of atypical atrial flutter guided by the use of concealed entrainment in patients without prior cardiac surgery. An asthma management system in a pediatric emergency department An integrated chronic care program for patients with atrial fibrillation: study protocol and methodology for an ongoing prospective randomised controlled trial. Vernakalant Hydrochloride for the Rapid Conversion of Atrial Fibrillation After Cardiac Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial Cardioversion of paroxysmal atrial fibrillation in the emergency department. Treatment of Stable Atrial Fibrillation in the Emergency Department: A Population-Based Comparison of Electrical Direct-Current versus Pharmacological Cardioversion or Conservative Management A prospective, multicenter evaluation of ablating complex fractionated electrograms (CFEs) during atrial fibrillation (AF) identified by an automated mapping algorithm: acute effects on AF and efficacy as an adjuvant strategy. Emergency department use of intravenous procainamide for patients with acute atrial fibrillation or flutter. Prophylactic cavotricuspid isthmus block during atrial fibrillation ablation in patients without atrial flutter: a randomised controlled trial
Introduction Emergency department ( ED ) cardioversion ( EDCV ) and discharge of patients with recent onset atrial fibrillation or atrial flutter ( AF ) has been shown to be a safe and effective management strategy . This study examines the impact of such aggressive ED management on hospital charges . Methods : A r and om sample of 300 AF patients were identified from an ED electronic data base and screened for timing of onset of their symptoms . Patients were considered eligible for EDCV if either nursing or physician notes documented an onset of symptoms less than 48 hours prior to ED presentation and the patient was less than 85 years of age . An explicit chart review was then performed to determine patient management and disposition . Cardioversion attempts were defined as ED administration of procainamide , flecainide , propafenone , ibutilide , amiodarone or direct current cardioversion ( DCCV ) .  Total hospital charges for each patient were obtained from the hospital billing office . Differences across medians were analyzed utilizing through Wilcoxon rank sum tests and chi square . Results : A total of 51 patients were included in the study .  EDCV  was attempted on 24 ( 47 % ) patients , 22 ( 92 % ) were successfully cardioverted to normal sinus rhythm ( NSR ) . An additional 12 ( 23 % ) spontaneously converted to NSR . Twenty ( 91 % ) of those successfully cardioverted were discharged from the ED along with 4 ( 33 % ) of those spontaneously converting . Pharmacologic cardioverson was attempted in six patients and was successful in three ( 50 % ) , one after failed DCCV attempt .  Direct current cardioversion  was attempted in 21 ( 88 % ) and was successful in 19 ( 90 % ) , two after failed pharmacologic attempts . Median charges for patients cardioverted and discharged from the ED were $ 5,460 ( IQR $ 4,677–$6,190 ) . Median charges for admitted patients with no attempt at cardioversion were $ 23,202 ( IQR $ 19,663–$46,877 ) . Median charges for patients whose final ED rhythm was NSR were $ 5,641 ( IQR $ 4,638–$12,339 ) while for those remaining inAF median charges were $ 30,299 ( IQR $ 20,655 – $ 69,759 ) . Conclusion : ED cardioversion of recent onset AF patients results in significant hospital savings BACKGROUND The ideal management of patients with newly diagnosed symptomatic atrial fibrillation ( AF ) remains unknown . Current practice guidelines recommend a trial of antiarrhythmic drugs ( AAD ) prior to considering an invasive ablation procedure . However , earlier ablation offers an opportunity to halt the progressive patho-anatomical changes associated with AF , as well as impart other important clinical benefits . OBJECTIVE The aim of this study is to determine the optimal initial management strategy for patients with newly diagnosed , symptomatic atrial fibrillation . METHODS / DESIGN The EARLY-AF study ( Clinical Trials.govNCT02825979 ) is a prospect i ve , open label , multicenter , r and omized trial with a blinded assessment of outcomes . A total of 298 patients will be r and omized in a 1:1 fashion to first-line AAD therapy , or first-line cryoballoon-based pulmonary vein isolation .  Patients with symptomatic treatment naïve AF will be included . Arrhythmia outcomes will be assessed by implantable cardiac monitor ( ICM ) . The primary outcome is time to first recurrence of AF , atrial flutter , or atrial tachycardia ( AF/AFL/AT ) between days 91 and 365 following AAD initiation or AF ablation . Secondary outcomes include arrhythmia burden , quality of life , and healthcare utilization . DISCUSSION The EARLY-AF study is a r and omized trial design ed to evaluate the optimal first management approach for patients with AF . We hypothesize that catheter ablation will be superior to drug therapy in prevention of AF recurrence OBJECTIVES To evaluate supplementary cavotricuspid isthmus ( CTI ) ablation as an adjunct to  atrial fibrillation ( AF ) ablation in selected patients . BACKGROUND It is unclear whether routine CTI ablation is beneficial in all patients undergoing AF ablation . METHODS AND RESULTS In patients undergoing AF ablation , additional CTI block was created only for those with typical atrial flutter ( Afl ) before or during the ablation . Out of 188 consecutive patients ( 108 male , 56 + /- 9 years ) , 75 underwent CTI ablation ( Group CTI+ ) and left atrial ( LA ) ablation ( circular mapping-guided extensive pulmonary vein isolation in all and linear LA ablation when required ) , while 113 underwent LA ablation alone ( Group CTI- ) . Group CTI+ patients had smaller LA and less frequently persistent/permanent AF and linear LA ablation . Over a follow-up of 30 + /- 10 months , complications ( 4 % vs 5 % , P = NS ) , typical Afl occurrence ( 1.3 % and 2.6 % , P = NS ) and AF recurrence ( 25 % and 28 % , P = NS ) were similar . Atypical Afl was more common in Group CTI- ( 4 vs 14 % , P = 0.026 ) . Eighty-two percent and 79 % of patients in Groups CTI+ and CTI- , respectively , remained arrhythmia free in stable sinus rhythm without antiarrhythmic drug treatment ( P = NS ) . CONCLUSIONS Avoiding supplementary CTI ablation in AF ablation patients without evidence of typical flutter does not result in a higher incidence of typical Afl . Despite more persistent/permanent AF and larger LA in patients without evidence of typical flutter , a strategy of selective supplementary ablation result ed in similar and low AF recurrence rates in the group without CTI ablation compared with the group with CTI ablation Introduction : There is a trend towards accelerated management of acute atrial fibrillation ( AF ) in the emergency department ( ED ) . We report our experience with biphasic cardioversion of acute AF . Methods : This was a prospect i ve , descriptive study at a tertiary hospital ED over a 6 month period . Acute AF was defined as symptoms that had been present for < 48 hours . Patients who received biphasic cardioversion for acute AF in the ED were enrolled . Data collected included : patient demographics , past medical history , details of biphasic cardioversion , outcome , complications , disposition , and length of stay . Results : There were 34 attempts at cardioversion in 33 patients . The mean ( SD ) age was 56 ( 16 ) years and 21 patients ( 64 % ) were men .  Biphasic cardioversion was successful in 31 attempts ( 91 % ) . In 24 attempts ( 71 % ) , 100 J was selected as the initial energy level . This was successful in 21 attempts ( 88 % ) . There were three minor complications related to sedation . The mean ( SD ) length of stay was 5.6 ( 2.8 ) hours in the ED and 15 ( 25 ) hours in the hospital . The three patients who failed to revert were older ( mean age 64 years ) , had underlying cardiovascular disease , and spent longer in hospital ( 50 v 12 hours , p = 0.01 ) . Telephone follow up was conducted with 32 patients ( 97 % ) at 3 months . Recurrence of AF occurred in 7 patients ( 22 % ) . Most patients ( 31 , 97 % ) were satisfied with the biphasic cardioversion . Conclusions : Biphasic cardioversion of acute AF is effective . The majority of patients can be managed as out patients , and there is very high patient satisfaction with this approach . An initial shock energy level of 100 J is usually effective There is wide variation in the management of patients with atrial fibrillation ( AF ) in the emergency department ( ED ) . We aim ed to derive and internally vali date the first prospect i ve , ED-based clinical decision aid to identify patients with AF at low risk for 30-day adverse events . We performed a prospect i ve cohort study at a university-affiliated tertiary-care ED . Patients were enrolled from June 9 , 2010 , to February 28 , 2013 , and followed for 30 days . We enrolled a convenience sample of patients in ED presenting with symptomatic AF .  C and i date predictors were based on ED data available in the first 2 hours . The decision aid was derived using model approximation ( preconditioning ) followed by strong bootstrap internal validation . We used an ordinal outcome hierarchy defined as the incidence of the most severe adverse event within 30 days of the ED evaluation . Of 497 patients enrolled , stroke and AF-related death occurred in 13 ( 3 % ) and 4 ( < 1 % ) patients , respectively . The decision aid included the following : age , triage vitals ( systolic blood pressure , temperature , respiratory rate , oxygen saturation , supplemental oxygen requirement ) , medical history ( heart failure , home sotalol use , previous percutaneous coronary intervention , electrical cardioversion , cardiac ablation , frequency of AF symptoms ) , and ED data ( 2 hours heart rate , chest radiograph results , hemoglobin , creatinine , and brain natriuretic peptide ) . The decision aid 's c-statistic in predicting any 30-day adverse event was 0.7 ( 95 % confidence interval 0.65 , 0.76 ) . In conclusion , in patients with AF in the ED , Atrial Fibrillation and Flutter Outcome Risk Determination provides the first evidence -based decision aid for identifying patients who are at low risk for 30-day adverse events and c and i date s for safe discharge Management of  atrial fibrillation ( AF )  in the emergency department ( ED ) is variable because of the absence of universally adopted treatment guidelines . To address potentially preventable hospital admissions and prolonged length of stay , an AF treatment pathway was co-developed by physicians from the cardiac electrophysiology service and the department of emergency medicine at our institution . The impact of this AF pathway on patient outcomes was evaluated with a prospect i ve , observational study conducted in a single tertiary care center from July 1 , 2013 , to June 30 , 2014 . The primary study outcome was the rate of hospital admission . The secondary outcomes were duration of ED visit and inpatient length of stay . The 94 patients treated according to the AF pathway during the study period were less likely to be admitted than the 265 patients who received routine care ( 16 % vs 80 % , p < 0.001 ) . For admitted patients , the mean length of stay was shorter for patients treated according to the AF pathway ( 32 vs 85 hours , p = 0.002 ) . The time spent in the ED was longer for patients in the AF pathway ( 16 vs 85 hours , p < 0.001 ) . Utilization of a multidisciplinary pathway for management of AF  in the ED led to a significant reduction in the rate of hospital admission .  Patients who were admitted after receiving care according to the AF pathway had a shorter length of stay . In conclusion , utilization of a multidisciplinary AF pathway result ed in a 5-fold reduction in admission rate and > 2-fold reduction length of stay for admitted patients STUDY OBJECTIVE We assess an alternative accelerated clinical pathway approach to the management of patients with newly diagnosed or new-onset atrial fibrillation ( AF ) . METHODS A prospect i ve , r and omized pilot study of 2  AF disease-management strategies was conducted at a single university hospital . A traditional approach of hospital admission versus an accelerated emergency department-based strategy with low-molecular-weight heparin and early cardioversion to sinus rhythm was assessed in a cohort of patients with uncomplicated AF . The primary end points were length of stay and total actual direct costs . RESULTS Eighteen patients were r and omized over a 15-month period . The accelerated treatment strategy in the ED result ed in a substantial decrease in length of stay ( 2.1+/-2.3 versus < 1 day ) and a favorable trend toward mean cost reduction ( $ 1,706+/-$1,512 versus $ 879+/-$394 ; P = .15 ) . The clinical outcomes ( rate of sinus rhythm at discharge and follow-up and complications caused by AF ) related to AF were similar in the 2 groups . CONCLUSION A disease-management strategy for new , uncomplicated AF that uses an ED-outpatient treatment pathway results in a shorter length of stay at potentially lower cost . The results of this pilot study warrant further investigation BACKGROUND This study was design ed to assess the efficacy and safety of intravenous dofetilide in acute termination of atrial fibrillation ( AF ) and flutter ( AFL ) .  Dofetilide , an investigational class III antiarrhythmic agent , selectively inhibits the rapid component of the delayed rectifier potassium current , thus prolonging the effective refractory period and duration of the action potential . Dofetilide can be administered intravenously and has a rapid onset of electrophysiologic action . METHODS AND RESULTS Ninety-six patients with AF ( n = 79 ) or AFL ( n = 17 ) with a median arrhythmia duration of 62 days ( range 1 to 180 ) were r and omized to placebo ( n = 30 ) or 8 micrograms/kg IV dofetilide ( n = 66 ) over 30 minutes . Conversion was defined as termination of the atrial arrhythmia within 3 hours from the start of infusion . The conversion rate was 30.3 % after dofetilide and 3.3 % after placebo ( P < .006 ) . Conversion rate was higher in AFL than in AF : 64 % versus 24 % ( P = . 012 ) . In nonconverters , there was no statistically significant difference between the change in heart rate among the dofetilide-treated compared with the placebo-treated patients ( P = . 42 ) . Torsade de pointes ventricular tachycardia developed in 2 patients ( 3 % ) . In both patients , drug infusion was discontinued before the event because of prolongation of the QT interval . CONCLUSIONS Intravenous dofetilide is effective in acute termination of AF and AFL of medium duration , with a particularly high efficacy rate in AFL . A small but serious risk of proarrhythmia must be anticipated OBJECTIVE Ibutilide is a type III antiarrhythmic agent approved for the pharmacologic conversion of atrial fibrillation ( AF ) and atrial flutter ( AFl ) . Previous studies conducted outside the ED setting have demonstrated conversion rates of 60 % to 80 % . This response has been highest in patients with recent-onset AF-AFl . These observations and the 4-hour half-life of ibutilide suggest that it may be an excellent drug with which to treat AF-AFl in the ED . The purpose of the study was to examine the efficacy and safety of ibutilide in terminating AF-AFl in patients who present to the ED with symptoms of less than 3 days ' duration , neither angina nor heart failure , and no comorbid conditions that require admission . METHODS Among 36 enrolled patients , the admission electrocardiogram demonstrated AF in 26 and AFl in 10 .  Ibutilide 1 mg was administered intravenously for 10 minutes . If sinus rhythm was not present 10 minutes after the infusion concluded , a second infusion of 1 mg was given . Successful conversion was defined as restoration of sinus rhythm within 1 hour after the last dose of ibutilide . RESULTS Sixteen ( 61.5 % ) of 26 patients with AF and 9 ( 90 % ) of 10 patients with AFl converted to sinus rhythm ( overall conversion rate=69 % ) . The mean time to arrhythmia termination was 19+/-9 minutes . The mean stay in the ED was 16.2 hours . No significant complications occurred . CONCLUSION We conclude that ibutilide is an excellent therapy option for restoring sinus rhythm in the ED . Its use may obviate the need for admission , avoid the risks and inconveniences of general anesthesia to perform electrical cardioversion , and reduce the ED length of stay in selected patients with recent-onset atrial arrhythmias AIMS Atrial fibrillation ( AF ) is a common complication in patients with acute myocardial infa rct ion and is associated with an increase in the risk of death . The excess mortality associated with AF complicating acute myocardial infa rct ion has not been studied in detail . Observations indicate that AF facilitates induction of ventricular arrhythmias , which may increase the risk of sudden cardiovascular death ( SCD ) . A close examination of the mode of death could potentially provide useful knowledge to guide further investigations and treatments . METHODS AND RESULTS We analysed the relation between AF/atrial flutter ( AFL )  and modes of death in 5983 consecutive patients discharged alive after an acute myocardial infa rct ion screened in the TR And olapril Cardiac Evaluation registry . This cohort of patients with an enzyme-verified acute myocardial infa rct ion was admitted to 27 centres in 1990 - 92 .  Survival status was obtained 2 years after screening of the last patient . An independent endpoint committee assessed the modes of death . Left ventricular ejection fraction was determined in all the screened patients and information about presence or absence of AF/AFL was prospect ively collected . Sustained or paroxysmal AF/AFL was observed in 1149 patients ( 19 % ) during hospitalization . During follow-up , 1659 patients ( 34 % ) died : 482 ( 50 % ) patients with AF/AFL and 1177 ( 30 % ) patients without AF/AFL , P<0.001 . SCD occurred in 536 , non-SCD occurred in 725 , and 398 died of non-cardiovascular causes ( includes 142 unclassifiable cases ) . The adjusted risk ratio of AF/AFL for total mortality was 1.33 ( 95 % CI : 1.19 - 1.49 ; P<0.0001 ) and the risk ratio for SCD was 1.31 ( 95 % CI : 1.07 - 1.60 ; P<0.009 ) . The adjusted risk ratio of AF/AFL for non-SCD was 1.43 ( 95 % CI : 1.21 - 1.70 ; P<0.0001 ) . CONCLUSION The excess mortality observed in patients with AF/AFL following acute myocardial infa rct ion is due to a significant increase in both SCD and non-SCD OBJECTIVES While the short-term ( < 7-day ) safety and efficiency of electrical cardioversion for emergency department ( ED ) patients with atrial fibrillation or flutter have been established , the 30-day outcomes with respect to stroke , thromboembolic events , or death have not been investigated . METHODS A two-center cohort of consecutive ED patients undergoing cardioversion for atrial fibrillation or flutter between January 1 , 2000 , and September 30 , 2007 , was retrospectively investigated . This cohort was probabilistically linked with both a regional ED data base and the provincial health registry to determine which patients had a subsequent ED visit or hospital admission , stroke , or thromboembolic event or died within 30 days . In addition , trained review ers performed a detailed chart abstract ion on 150 r and omly selected patients , with emphasis on demographics , vital signs , medical treatment , and predefined adverse events . Hemodynamically unstable patients or those whose condition was the result of an underlying acute medical diagnosis were excluded . Data were analyzed by descriptive methods . RESULTS During the study period , 1,233 patients made 1,820 visits for atrial fibrillation or flutter to the ED . Of the 400 eligible patients undergoing direct-current cardioversion ( DCCV ) , no patients died , had a stroke , or had a thromboembolic event in the following 30 days ( 95 % confidence interval [ CI ] = 0.0 to 0.8 % for all outcomes ) . A total of 141 patients were included in the formal chart review , with five patients ( 3.5 % , 95 % CI = 0.5 % to 6.6 % ) failing cardioversion , six patients ( 4.3 % , 95 % CI = 0.9 % to 7.6 % ) having a minor adverse event that did not change disposition , and five patients ( 3.5 % , 95 % CI = 0.5 % to 6.6 % ) admitted to hospital at the index visit . CONCLUSIONS Cardioversion of patients with atrial fibrillation or flutter in the ED appears to have a very low rate of long-term complications STUDY OBJECTIVE In the United States , nearly 70 % of emergency department ( ED ) visits for atrial fibrillation result in hospitalization . The incidence of serious 30-day adverse events after an ED evaluation for atrial fibrillation remains low . This study 's goal was to prospect ively vali date our previously reported Risk Estimator Decision Aid for Atrial Fibrillation ( RED-AF ) model for estimating a patient 's risk of experiencing a 30-day adverse event . METHODS This was a prospect i ve cohort study , which enrolled a convenience sample of ED patients presenting with atrial fibrillation .  RED-AF , previously derived from a retrospective cohort of 832 patients , assigns points according to age , sex , coexisting disease ( eg , heart failure , hypertension , chronic obstructive pulmonary disease ) , smoking , home medications ( eg , β-blocker , diuretic ) , physical examination findings ( eg , dyspnea , palpitations , peripheral edema ) , and adequacy of ED ventricular rate control . Primary outcome was occurrence of greater than or equal to 1 atrial fibrillation-related adverse outcome ( ED visits , rehospitalization , cardiovascular complications , death ) within 30 days . We identified a clinical ly relevant threshold and measured RED-AF 's performance in this prospect i ve cohort , assessing its calibration , discrimination , and diagnostic accuracy . RESULTS The study enrolled 497 patients between June 2010 and February 2013 . Of these , 120 ( 24 % ) had greater than or equal to 1 adverse event within 30 days . A RED-AF score of 87 was identified as an optimal threshold , result ing in sensitivity and specificity of 96 % ( 95 % confidence interval [ CI ] 91 % to 98 % ) and 19 % ( 95 % CI 15 % to 23 % ) , respectively . Positive and negative predictive values were 27 % ( 95 % CI 23 % to 32 % ) and 93 % ( 95 % CI 85 % to 97 % ) , respectively . The c statistic for RED-AF was 0.65 ( 95 % CI 0.59 to 0.71 ) . CONCLUSION In this separate validation cohort , RED-AF performed moderately well and similar to the original derivation cohort for identifying the risk of short-term atrial fibrillation-related adverse events in ED patients receiving a diagnosis of atrial fibrillation Health care re source utilization is high for patients presenting with acute atrial fibrillation ( AF ) . The potential for treatment algorithms to safely reduce re source consumption in this setting has not been prospect ively evaluated . We design ed and implemented a practice guideline for the management of patients presenting to the emergency department ( ED ) with the primary diagnosis of AF , with emphasis on appropriate cardioversion , use of oral rate-controlling medications , and expedited referral to an outpatient AF clinic . We prospect ively collected clinical and re source utilization data on all such patients for 14 months before and after institution of the guideline . Institution of the guideline was associated with a decreased rate of hospital admission ( from 74 % to 38 % ) , with no differences in ED return visits or hospital readmission within 30 days . No strokes or deaths were observed . This large decrease in re source utilization during the intervention phase of the study translated to an average decrease in 30-day total direct health care costs of approximately $ 1,400 US dollars per patient . Our clinical and cost outcomes were minimally affected after statistical adjustment for baseline differences between study groups . We conclude that the implementation of our practice guideline was feasible , safe , and effective . Widespread adoption of such practice s may have large financial implication s for the health care system Background Direct current cardioversion ( DCC ) has been shown to be effective for the management of  atrial fibrillation ( AF )  in the emergency department ( ED ) . Pharmacological cardioversion was compared with a strategy including DCC on patients with uncomplicated , recent-onset ( < 48 h ) AF managed in a short observation unit ( SOU ) . Methods A prospect i ve observational study was undertaken over a period of 13 months in two institutions . A DCC-centred protocol was applied to 171 AF cases in a hospital ( DCC-cohort ) and pharmacological cardioversion to 151 AF cases in another hospital ( P-cohort ) . Patients remaining in AF after 24 h were admitted . The outcomes were rate of discharge in sinus rhythm , length of stay in the ED-SOU , rate of hospitalisation and complications of treatment . Data collected were analysed according to Student t test and χ2 statistics . Results Discharge in sinus rhythm was achieved in 159/171 cases in the DCC-cohort and 77/151 cases in the P-cohort ( 93 % vs 51 % ; number needed to treat ( NNT ) 2.4 ; 95 % CI 2.0 to 3.1 , p<0.001 ) , whereas mean length of stay was 7 + 7 h in the DCC-cohort and 9 + 6 h in the P-cohort ( p=0.43 ) . Eleven cases from the DCC-cohort and 67 from the P-cohort were admitted ( admission rate 6 % vs 44 % ; NNT 2.6 ; 95 % CI 2.2 to 3.5 , p<0.001 ) . Three short-term complications occurred in the DCC-cohort and five in the P-cohort ( 2 % vs 3 % , p=0.59 ) . Two strokes were registered in the DCC-cohort during 6-month follow-up ( p undefined ) . Conclusions Electrical cardioversion of recent-onset AF in the SOU is safe , effective and reduces hospitalisations . Further studies are needed to identify the most cost-effective strategy for the management of AF patients in emergency setting INTRODUCTION Mapping techniques have not been systematic ally evaluated with respect to atypical atrial flutter ( AF ) not involving the inferior vena cava isthmus . The purpose of this study was to assess prospect ively the use of concealed entrainment ( CE ) in mapping of AF and to assess the clinical benefit of ablation of clinical ly relevant atypical AF . METHODS AND RESULTS In seven consecutive patients without prior cardiac surgery presenting with atypical AF , mapping was performed in the right and , if necessary , left atrium . At sites with CE , radiofrequency energy was delivered . In a posthoc analysis , the endocardial activation time , stimulus-flutter wave ( F ) interval , presence of split potentials and diastolic potentials , and postpacing interval were assessed , and effective sites were compared to ineffective sites . A total of 22 forms of atypical AF either could be induced or were present at the time of the study . Eleven of the 13 targeted atypical AFs ( 85 % ) were successfully ablated . The positive predictive value of CE increased from 45 % to 75 % in the presence of matching electrogram-F and stimulus-F intervals or if flutter terminated during entrainment pacing , and to 88 % in the presence of split atrial electrograms or diastolic potentials . During short-term clinical follow-up , none of the patients had recurrence of the ablated AF . However , the majority of patients required either medication for atrial fibrillation or repeated interventions for new forms of AF . CONCLUSION Mapping and ablation of atypical AF is feasible if sites with CE can be identified . However , the clinical benefit of successful ablations in patients with atypical flutter appears to be limited INTRODUCTION Pediatric asthma exacerbations account for > 1.8 million emergency department ( ED ) visits annually . Asthma guidelines are intended to guide time-dependent treatment decisions that improve clinical outcomes ; however , guideline adherence is inadequate . We examined whether an automatic disease detection system increases clinicians ' use of paper-based guidelines and decreases time to a disposition decision . METHODS We evaluated a computerized asthma detection system that triggered NHLBI-adopted , evidence -based practice to improve care in an urban , tertiary care pediatric ED in a 3-month ( 7/09 - 9/09 ) prospect i ve , r and omized controlled trial . A probabilistic system screened all ED patients for acute asthma . For intervention patients , the system generated the asthma protocol at triage for intervention patients to guide early treatment initiation , while clinicians followed st and ard processes for control patients . The primary outcome measures included time to patient disposition . RESULTS The system identified 1100 patients with asthma exacerbations , of which 704 had a final asthma diagnosis determined by a physician-established reference st and ard . The positive predictive value for the probabilistic system was 65 % . The median time to disposition decision did not differ among the intervention ( 289 min ; IQR = ( 184 , 375 ) ) and control group ( 288 min ; IQR = ( 185 , 375 ) ) ( p=0.21 ) . The hospital admission rate was unchanged between intervention ( 37 % ) and control groups ( 35 % ) ( p = 0.545 ) . ED length of stay did not differ among the intervention ( 331 min ; IQR = ( 226 , 581 ) ) and control group ( 331 min ; IQR = ( 222 , 516 ) ) ( p = 0.568 ) . CONCLUSION Despite a high level of support from the ED leadership and staff , a focused education effort , and implementation of an automated disease detection , the use of the paper-based asthma protocol remained low and time to patient disposition did not change BACKGROUND Adherence to guidelines for the management of atrial fibrillation ( AF ) is often poor , although this is associated with improved morbidity and mortality in such patients . Increasing numbers of programs are design ed to enhance appropriate counselling , treatment and coordinated care delivery including the nurse-led , guidelines -based , software-supported integrated chronic care program ( ICCP ) for patients with AF reported here . OBJECTIVES This paper outlines the study protocol and methodology currently being used to evaluate the effectiveness of a newly developed nurse-led , guideline -based , software-supported ICCP for patients with AF . DESIGN AND METHODS Evaluation of the ICCP is currently being carried out in the outpatient care setting known as the AF-Clinic . A prospect i ve r and omised controlled trial is currently underway in the outpatient AF-Clinic of a University Hospital in the Netherl and s in cooperation with the collaborating university . The primary outcome measures are cardiovascular hospitalisation and /or death . Secondary outcome measures include guideline adherence , patient knowledge about their condition , quality of life , satisfaction and other outcome measurements such as cost-effectiveness . PARTICIPANTS It was calculated that 698 participants are needed to demonstrate discernible outcomes in relation to the primary endpoint ( 349 patients in each group ) with follow-up after 1 year . RESULTS The study started in January 2007 and the first results are expected in the beginning of 2010 . CONCLUSIONS It is hypothesised that the ICCP may contribute towards closing the gap between guideline recommendations and current practice in the management of atrial fibrillation . Furthermore , it is hypothesised that the program has the potential to optimise the management of AF patients and improve the efficiency and coordination of patient care . This may lead to better patient outcomes including improved quality of life and patient satisfaction in such patients Background —Postoperative atrial arrhythmias are common and are associated with considerable morbidity . This study was design ed to evaluate the efficacy and safety of vernakalant for the conversion of  atrial fibrillation ( AF ) or  atrial flutter ( AFL ) after cardiac surgery . Methods and Results —This was a prospect i ve , r and omized , double-blind , placebo-controlled trial of vernakalant for the conversion of AF or AFL  after coronary artery bypass graft , valvular surgery , or both . Patients were r and omly assigned 2:1 to receive a 10-minute infusion of 3 mg/kg vernakalant or placebo . If AF or AFL was present after a 15-minute observation period , then a second 10-minute infusion of 2 mg/kg vernakalant or placebo was given . The primary end point was the conversion of postcardiac surgery AF or AFL to sinus rhythm within 90 minutes of dosing . In patients with AF , 47 of 100 ( 47 % ) who received vernakalant converted to SR compared with 7 of 50 ( 14 % ) patients who received placebo ( P<0.001 ) . The median time to conversion was 12 minutes . Vernakalant was not effective in converting postoperative AFL to sinus rhythm . Two serious adverse events occurred within 24 hours of vernakalant administration ( hypotension and complete atrioventricular block ) . There were no cases of torsades de pointes , sustained ventricular tachycardia , or ventricular fibrillation . There were no deaths . Conclusions —Vernakalant was safe and effective in the rapid conversion of AF to sinus rhythm in patients who had AF after cardiac surgery . Clinical Trial Registration — clinical trials.gov . Identifier : NCT00125320 STUDY OBJECTIVE Patients presenting to the emergency department with acute atrial fibrillation are traditionally admitted to hospital . The objective of this study was to review the success and safety of ED cardioversion and discharge of patients with acute atrial fibrillation . METHODS This health records survey included a cohort sample of consecutive patients presenting with acute atrial fibrillation to the ED of a university-affiliated tertiary hospital . Patients who were in unstable condition on presentation , who had a complicating cardiac diagnosis , or those with other medical or surgical conditions requiring admission were excluded from the study analysis . Patient visit information was entered into a data base that included demographics and clinical presentation , investigations , ED therapy , complications , consultations , disposition , and follow up . Patient visits were then categorized into the following groups : no ED intervention , spontaneous resolution , heart rate control , attempted chemical cardioversion , or electrical cardioversion . The data were analyzed using descriptive methods . RESULTS Of the 289 eligible patients seen during an 18-month period , 62 % ( 180 ) underwent attempted chemical cardioversion with a 50 % success rate and 28 % ( 80 ) had attempted electrical cardioversion with a 89 % success rate . Ninety-three percent of electrical cardioversions were performed by emergency physicians . There was an overall 6 % ( 19 ) complication rate , 95 % of which were regarded as minor . One patient had a complication caused by a rate control medication , which necessitated hospital admission . Ninety-seven percent ( 280 ) of the patients were discharged home directly from the ED . CONCLUSION Cardioversion and immediate discharge of patients who present to the ED with acute atrial fibrillation appears to be both safe and effective . This management approach should be prospect ively evaluated in multiple setting Objective : To compare the success rates and short-term complications of three treatment approaches , pharmacological and direct-current cardioversion ( DCC ) , or ‘ wait- and -watch ’ among stable atrial fibrillation ( AF ) patients in the emergency department ( ED ) . Methods : All AF-related ED admissions during a 1-year period were retrospectively review ed , and those meeting criteria of eligibility for immediate cardioversion , based on clinical stability , AF duration and adequacy of anticoagulation , were included . The propensity score approach generalized for the three groups was used to adjust for the observational non-r and omized study nature . Results : Among 374 eligible patients , the rate of successful cardioversion was higher in DCC than in pharmacological or wait- and -watch groups ( 78.2 , 59.2 and 37.9 % respectively , p < 0.001 ) , with corresponding percentages of patients discharged from ED ( 52.9 , 47.9 and 32.1 % , p < 0.01 ) and respective odds ratios of 6.00 , 2.47 and 1 , adjusting for seniority of the treating physician , age , gender and patient comorbidities . DCC was 2.43 times more effective than pharmacological treatment in achieving sinus rhythm ( 95 % confidence interval = 1.36–4.33 , p = 0.003 ) . Rehospitalization within 14 days due to probable AF-treatment-related complications of home-discharged patients was 3.4 % . Conclusions : DCC was found to be the most effective treatment , with few short-term complications following conversion of stable AF patients to sinus rhythm in the ED BACKGROUND Complex fractionated electrograms ( CFEs ) are continuous electrograms ( EGMs ) of very short cycle length ( CL ) representing substrate for atrial fibrillation ( AF ) perpetuation . Ablation of CFEs may result in AF slowing , termination , and prevention , but identifying them can be subjective . OBJECTIVE The purpose of this study was to prospect ively assess ( 1 ) whether an automated algorithm can identify CFE regions , ( 2 ) the acute effects of ablating these regions on AF , and ( 3 ) the long-term efficacy as an adjuvant strategy to pulmonary vein antrum isolation ( PVAI ) . METHODS Thirty-five patients ( three centers , 61 + /- 9 years , left atrium [ LA ] 43 + /- 9 mm , ejection fraction 53 % + /- 7 % ) with symptomatic paroxysmal ( n = 21 ) or persistent ( n = 14 ) AF were studied . A decapolar lasso ( 2-mm spacing ) was used for mapping . A three-dimensional shell of the LA and pulmonary veins ( PVs ) was created . If not already in AF , AF was induced by burst pacing ( with or without isoproterenol ) . Atrial EGMs during AF were mapped/analyzed using an automated CFE algorithm . The algorithm measures the time between discrete deflections in a local EGM over 5 seconds ( based on selectable width and peak-to-peak [ > 0.03 mV ] criteria ) . The mean CL of the local EGM is projected onto the LA shell as a color-coded display . Regions of CL < 120 ms ( published criteria ) were targeted for ablation/elimination . Atrial fibrillation cycle length ( AFCL ) and regularity were measured from the CS . After CFE ablation , further ablation was done to achieve complete PVAI . RESULTS AF was spontaneous ( n = 20 ) or induced ( n = 15 ) in all patients . CFEs were most commonly found along the septum ( 97 % ) , anterior LA ( 97 % ) , PV antra ( 83 % ) , base of appendage ( 83 % ) , and annulus ( 71 % ) . CFE ablation alone prolonged the AFCL ( 171 + /- 27 vs. 304 + /- 41 ms ; P = .03 ) and regularized AF to left/right flutter ( AFL ) in 74 % of patients . CFE ablation terminated AF/AFL in 19 patients (54%)-the other 16 were cardioverted- and AF became noninducible in 77 % . CFE ablation alone did not cause PV isolation ( 0.1 + /- 0.3 PV isolated/patient ) . After combined CFE and PVAI ablation , the single-procedure , off-drug success rate was 83 % ( follow-up 13 + /- 4 months ) versus 71 % in matched controls who had PVAI alone ( P = .045 ) . CONCLUSIONS CFE ablation guided by an automated algorithm result ed in AFCL prolongation , regularization , and noninducibility in most patients . AF terminated in 54 % of cases . PVAI with adjuvant CFE ablation has a high efficacy and may be superior to PVAI alone OBJECTIVES Acute atrial fibrillation and flutter are very common arrhythmias seen in emergency department ( ED ) patients , but there is no consensus for their optimal management . The objective of this study was to examine the efficacy and safety of intravenous ( IV ) procainamide for acute atrial fibrillation or flutter . METHODS This health records review included a consecutive cohort of ED patients with acute-onset atrial fibrillation or atrial flutter who received IV procainamide at one university hospital ED during a five-year period . The st and ard clinical protocol involved IV infusion of 1 g of procainamide over 60 minutes , followed by electrical cardioversion if necessary . A trained observer extracted data from the original clinical records . Outcome measurements included conversion to sinus rhythm , adverse events , and relapse up to seven days . RESULTS The 341 study patients had a mean age of 63.9 years ( SD + /- 15.5 years ) , and 56.6 % were male . The conversion rates were 52.2 % ( 95 % confidence interval = 47 % to 58 % ) for 316 atrial fibrillation cases and 28.0 % ( 95 % confidence interval = 13 % to 46 % ) for 25 atrial flutter cases . Mean dose given was 860.7 mg ( SD + /- 231.2 mg ) , and median time to conversion was 55 minutes . Adverse events occurred in 34 cases ( 10.0 % ) : hypotension , 8.5 % ; bradycardia , 0.6 % ; atrioventricular block , 0.6 % ; and ventricular tachycardia , 0.3 % . There were no cases of torsades de pointes , cerebrovascular accident , or death . Most patients ( 94.4 % ) were discharged home , but 2.9 % of patients returned with a recurrence of atrial fibrillation within seven days . CONCLUSIONS This study of acute atrial fibrillation or flutter patients treated in the ED with IV procainamide suggests that this treatment is safe and effective in this setting . Procainamide should be prospect ively compared with other ED strategies Objectives : This r and omised trial evaluated if patients with atrial fibrillation ( AF ) and no history of atrial flutter ( AFL ) had any benefit of prophylactic cavotricuspid isthmus block ( CTIB ) in addition to circumferential pulmonary vein ablation ( CPVA ) . Methods : 149 patients with AF ( 54 % paroxysmal ) were r and omised to CPVA and CTIB  ( group CTIB+ , n = 73 ) or  CPVA alone  ( group CTIB− , n = 76 ) . Patients were followed for 12 months with repetitive 7-day Holter monitoring after 3 , 6 and 12 months . Results : Six patients ( 4 % ) had cardiac tamponade , and one patient had a stroke . No difference was found in the cumulative AFL-free rate between the two treatment groups ( CTIB+ : 88 % vs CTIB− : 84 % , hazard ratio ( HR ) 0.80 , 95 % CI ( 0.34 to 1.90 ) , p = 0.61 ) . There was no difference in the cumulative AF-free rate between the groups ( CTIB+ : 34 % vs CTIB− : 32 % , HR 0.93 , 95 % CI ( 0.63 to 1.38 ) , p = 0.71 ) . Overall , 33 % of the patients were free of AF after a single procedure . Including re procedures , a complete or partial beneficial effect was noted in 62 % of the patients at 12 months . At 12-month follow-up , 24 ( 50 % ) patients with documented AF or AFL in the Holter recordings were asymptomatic . Conclusions : It was not possible to demonstrate any beneficial effect of CTIB in addition to CPVA with regard to AFL or AF recurrences during follow-up . Repetitive long-term Holter monitoring demonstrated a 33 % rate of freedom from AF during a 1-year follow-up . Including additional CPVA procedures , a clinical effect was noted in 62 % of the patients at 12 months . Patients with AF or AFL recurrences were often asymptomatic
The articles were grouped into four main categories : decision aids and outcome predictors , electrical cardioversion-based protocol s , antiarrhythmic-based protocol s , and general management protocol s. Conclusion This systematic review is the first study to our knowledge to evaluate the optimal management of symptomatic AF/AFLin  the ED with a direct impact on ED disposition .
There are several viable management strategies that can result in safe discharge from the ED in the right patient population , and decision aids can be utilized to guide selection of appropriate patients for discharge
Introduction Management of  atrial fibrillation ( AF ) and atrial flutter ( AFL )  in the emergency department ( ED ) varies greatly , and there are currently no United States guidelines to guide management with regard to patient disposition after ED treatment .
The aim of this systematic review was to evaluate the literature for decision aids to guide disposition of patients with AF/AFLin the ED , and assess potential outcomes associated with different management strategies in the ED .