Outcomes of transesophageal echocardiogram guided electrical cardioversion in patients with atrial fibrillation greater than 48 hours treated in the emergency department versus the cardiology ward: A retrospective comparison study

2021 ◽  
Author(s):  
Baha Zaro ◽  
Evan Avraham Alpert ◽  
Nechama Kaufman ◽  
David Rosenmann
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Electrical Cardioversion ◽  
Comparison Study ◽  
Transesophageal Echocardiogram ◽  
Retrospective Comparison

scholarly journals A clinical pathway for safely and effectively cardioverting emergency department patients with atrial fibrillation greater than 48 hours

2021 ◽  
Author(s):  
Baha Zaro ◽  
Evan Avraham Alpert ◽  
Nechama Kaufman ◽  
David Rosenmann
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Hospital Stay ◽  
Clinical Pathway ◽  
Group Versus ◽  
Length Of Hospital Stay ◽  
Electrical Cardioversion ◽  
Transesophageal Echocardiogram ◽  
Cardiology Department ◽  
Emergency Department Patients

Background: The current emergency medicine literature on cardioversion for atrial fibrillation (AF), describes its performance on those who are hemodynamically unstable, present within 48 hours of the onset of the arrhythmia, or are on long term anticoagulants. This article describes a clinical pathway comparing patients presenting to the emergency department (ED) with atrial fibrillation (AF) of more than 48 hours who underwent a transesophageal echocardiogram (TEE) and subsequent cardioversion in the ED. The objective of this study is to evaluate such a pathway looking at the time to cardioversion, length of hospital stay, rate of successful cardioversion, and the rate of complications compared to the traditional pathway of admitting patients directly to the cardiology department for evaluation and treatment. Methods: This was a retrospective observational study of patients who presented to the ED with AF for more than 48 hours, underwent a transesophageal echocardiogram, and then were electrically cardioverted either in the emergency department versus the cardiology ward. Results: Electrical cardioversion was performed in the ED on 92 patients (61%) and the cardiology department on 59 (39%). Over 90% of cardioversions were successful in both groups. Time to cardioversion was significantly less in the ED group versus the cardiology group (1.03 ± 0.8 days versus 4.17 ± 1.9; p<0.001). Similarly, the mean length of hospital stay was less for the ED group (1.5± 1.5 days versus 7.2 ± 3.5; p<0.001). Conclusion: Patients who present in atrial fibrillation for more than 48 hours and then have a TEE, undergo electrical cardioversion faster in the ED compared to the cardiology ward. This clinical pathway also results in a shorter length of hospital stay without having more side effects.

Treatment of Acute Atrial Fibrillation: Ventricular Rate Control and Restoration of Sinus Rhythm

2000 ◽  
Vol 7 (2) ◽  
pp. 85-95
Author(s):  
Ht Fung ◽  
Cw Kam
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Cardiac Output ◽  
General Population ◽  
Sinus Rhythm ◽  
Rate Control ◽  
Electrical Cardioversion ◽  
Ventricular Rate ◽  
The Past ◽  
Definite Risk

Atrial fibrillation (AF) is a familiar arrhythmia seen in the emergency department and the general population. In the past it was treated in the majority of cases by controlling the ventricular rate, whether the AF is acute or chronic. However, ventricular rate control alone does not address the underlying problem and the patients still remain in AF, cardiac output and symptoms have not been optimally corrected. There is definite risk of thromboembolism. Restoration of sinus rhythm is the only way of resuming the normal conduction physiology of the heart and correcting these problems This article provides a review of the two major principles of rhythm treatment of acute AF: rate control and restoration of sinus rhythm. Transthoracic electrical cardioversion is the mainstay of treatment in haemodynamically unstable AF, whereas in stable AF, there is a choice between rate control and restoration of sinus rhythm, or they can be carried out in conjunction with each other.

scholarly journals “Wait and See” Approach to the Emergency Department Cardioversion of Acute Atrial Fibrillation

2011 ◽  
Vol 2011 ◽  
pp. 1-4 ◽  
Author(s):  
Brian Doyle ◽  
Mark Reeves
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Sinus Rhythm ◽  
Normal Sinus Rhythm ◽  
Routine Care ◽  
Spontaneous Resolution ◽  
Electrical Cardioversion ◽  
Normal Sinus ◽  
Degree Of Satisfaction ◽  
Wait And See

Objective. Acute atrial fibrillation often spontaneously resolves. This study aimed to investigate the outcomes and satisfaction of an evidence-based ED protocol employing a “wait and see” approach.Methods. A prospective observational cohort study of adult patients presenting to the Emergency Department with stable acute atrial fibrillation was performed. Patients were excluded if they were considered to be unstable, need hospitalization, or poor candidates for ED procedural sedation. Routine care was provided on the index visit, and suitable candidates were discharged and asked to return to the ED the following day for possible electrical cardioversion. Outcome measures included spontaneous reversion to sinus rhythm, success of cardioversion, length of stay, adverse event and return visits for AF within 30 days, and patient satisfaction.Results. Thirty five patient encounters were analysed over a 21-month period. Twenty two of the 35 patients (63%) had spontaneous resolution of atrial fibrillation upon presentation for potential cardioversion. All of the remaining patients underwent successful cardioversion to normal sinus rhythm without significant adverse events recorded. No patients required hospitalization. Three patients (9%) returned to the ED within 30 days for recurrence of atrial fibrillation. All patients were reported to be “very satisfied” with this approach.Conclusion. A “wait and see” approach to the ED electrical cardioversion of atrial fibrillation showed that almost two-thirds of patients had spontaneous resolution without requiring cardioversion or observation in the ED or hospital. All patients were successfully reverted to normal sinus rhythm and had a high degree of satisfaction.

Electrical cardioversion of emergency department patients with atrial fibrillation

2004 ◽  
Vol 44 (1) ◽  
pp. 20-30 ◽  
Author(s):  
John H. Burton ◽  
David R. Vinson ◽  
Kate Drummond ◽  
Tania D. Strout ◽  
Henry C. Thode ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Electrical Cardioversion ◽  
Emergency Department Patients

scholarly journals LO07: Procainamide for the acute management of atrial fibrillation and flutter in the emergency department: a systematic review

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S9-S9
Author(s):  
F. Tran ◽  
D. Junqueira ◽  
M. Tan ◽  
B. Rowe
Keyword(s):  
Atrial Fibrillation ◽  
Systematic Review ◽  
Emergency Department ◽  
Adverse Events ◽  
Cohort Studies ◽  
Normal Sinus Rhythm ◽  
Grey Literature ◽  
Electrical Cardioversion ◽  
Chemical Agent ◽  
Serious Adverse Events

Introduction: Management of acute atrial fibrillation or flutter (AFF) in the emergency department (ED) can be performed with chemical or electrical cardioversion. Procainamide is the most common chemical agent used in Canada; however, there is substantial practice variation. The objective of this systematic review was to provide comparative evidence on return to normal sinus rhythm (NSR) and adverse events to better support clinical decisions. Methods: Systematic search of five electronic databases and grey literature. Randomized controlled trials (RCTs) and prospective controlled cohort studies including adults (≥17 years) with recent-onset of AFF comparing intravenous procainamide with other cardioversion strategies (e.g., electrical cardioversion, placebo or other antiarrhythmic drugs) were eligible. Two independent reviewers performed study selection and data extraction. Relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random-effects model. The protocol was registered with PROSPERO (CRD42019142080). Results: From 4060 potentially relevant citations, 7 studies were considered eligible and three RCTs and two cohort studies included in the analysis. Procainamide was less effective in promoting return to NSR at 1st attempt compared to other chemical (RR 0.76; 95% CI: 0.65 to 0.90) and electrical (RR 0.58; 95% CI: 0.53 to 0.64) options. Electrical cardioversion was more effective in restoring NSR compared to procainamide when used as 2nd attempt in one RCT (RR 0.46; 95% CI: 0.23 to 0.92). Pre-specified serious adverse events were assessed and reported by two studies showing that hypotension was more common in patients receiving procainamide in comparison with electrical cardioversion (RR 20.57; 95% CI: 1.59 to 265.63). Treatment discontinuation due to adverse events was infrequently reported with only two studies reporting that no patients withdrew from the study following treatment with procainamide. The remaining studies provided incomplete data reporting on adverse events. Conclusion: Shared decision-making for patients with acute AFF in the ED requires knowledge of the effectiveness and safety of comparative interventions. Overall, procainamide is less effective than other chemical options and electrical cardioversion strategies to restore NSR. Evidence shows that hypotension is a concern when procainamide is administered; however, the overall adverse events information provided from the studies is suboptimal.

Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter

CJEM ◽  
2010 ◽  
Vol 12 (03) ◽  
pp. 181-191 ◽  
Author(s):  
Ian G. Stiell ◽  
Catherine M. Clement ◽  
Jeffrey J. Perry ◽  
Christian Vaillancourt ◽  
Cheryl Symington ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Hospital Admissions ◽  
Torsades De Pointes ◽  
Electrical Cardioversion ◽  
University Hospital ◽  
Recent Onset ◽  
Lengths Of Stay ◽  
Atrial Fibrillation And Flutter ◽  
Onset Atrial Fibrillation

ABSTRACTObjective:There is no consensus on the optimal management of recent-onset episodes of atrial fibrillation or flutter. The approach to these conditions is particularly relevant in the current era of emergency department (ED) overcrowding. We sought to examine the effectiveness and safety of the Ottawa Aggressive Protocol to perform rapid cardioversion and discharge patients with these arrhythmias.Methods:This cohort study enrolled consecutive patient visits to an adult university hospital ED for recent-onset atrial fibrillation or flutter managed with the Ottawa Aggressive Protocol. The protocol includes intravenous chemical cardioversion, electrical cardioversion if necessary and discharge home from the ED.Results:A total of 660 patient visits were included, 95.2% involving atrial fibrillation and 4.9% involving atrial flutter. The mean age of patients enrolled was 64.5 years. In total, 96.8% were discharged home and, of those, 93.3% were in sinus rhythm. All patients were initially administered intravenous procaïnamide, with a 58.3% conversion rate. A total of 243 patients underwent subsequent electrical cardioversion with a 91.7% success rate. Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3% and 7-day relapse 8.6%. There were no cases of torsades de pointes, stroke or death. The median lengths of stay in the ED were as follows: 4.9 hours overall, 3.9 hours for those undergoing conversion with procaïnamide and 6.5 hours for those requiring electrical conversion.Conclusion:This is the largest study to date to evaluate the Ottawa Aggressive Protocol, a unique approach to cardioversion for ED patients with recent-onset episodes of atrial fibrillation and flutter. Our data demonstrate that the Ottawa Aggressive Protocol is effective, safe and rapid, and has the potential to significantly reduce hospital admissions and expedite ED care.

scholarly journals Procainamide for the acute management of atrial fibrillation and flutter in the emergency department: a systematic review

2020 ◽  
Vol 43 (2) ◽  
pp. 21
Author(s):  
Fiona Tran ◽  
Daniela Junqueira ◽  
Jillian Meyer ◽  
Kevin Zhou ◽  
Maria Tan ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Cohort Studies ◽  
Normal Sinus Rhythm ◽  
Data Extraction ◽  
Grey Literature ◽  
Electrical Cardioversion ◽  
Chemical Agent ◽  
Relative Risks ◽  
Normal Sinus

Introduction: Chemical or electrical cardioversion are utilized for acute atrial fibrillation or flutter (AFF) management in the emergency department (ED). Procainamide is a common chemical agent used in Canada; however, there are substantial practice variations. Method: Systematic search of five databases and grey literature completed. Randomized controlled trials (RCTs) and prospective controlled cohort studies including adults with acute AFF comparing procainamide with other cardioversion strategies were eligible. Two independent reviewers performed study selection and data extraction. Relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random-effects model. The protocol was registered with PROSPERO (CRD42019142080). Results: From 3847 potential citations, 6 studies were included (four RCTs and two cohort studies). Procainamide was less effective in achieving conversion to normal sinus rhythm (NSR) at 1st attempt compared to other chemical (RR 0.76; 95% CI: 0.65 to 0.90) and electrical (RR 0.72; 95% CI: 0.56 to 0.92) options. Procainamide in a drug-shock approach was as effective as electrical cardioversion alone in restoring NSR (RR 1.04; 95% CI 1.00 to 1.08). The occurrence of hypotension was higher in patients receiving procainamide compared to electrical cardioversion (RR 1.87; 95% CI: 1.14 to 3.06). Deaths and strokes were not well-reported. Conclusion: Procainamide is less effective than other chemical options and electrical cardioversion strategies to restore NSR. The efficacy of procainamide in a drug-shock approach is similar to electrical alone at restoring NSR. The evidence shows that hypotension is a common procainamide adverse effect suggesting that electrical cardioversion as a first approach is preferable.

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