II. Precautions

  1. Complex patients with Atrial Fibrillation with rapid ventricular rate
    1. Secondary cause for Atrial Fibrillation (Alcohol Withdrawal, decompensated COPD, Sepsis, CHF exacerbation)
    2. In these cases, serious active comorbidity is resulting in rapid rate and Atrial Fibrillation is incidental in these cases
    3. Focus on treating the underlying severe illness (e.g. Sepsis, CHF, COPD, Alcohol Withdrawal)
    4. High rate of adverse events when Atrial Fibrillation rate or rhythm control are used in these patients
    5. Scheuermeyer (2014) Ann Emerg Med S0196-0644(14)01298-0 +PMID:25441768 [PubMed]

III. Management: Hemodynamically Unstable

  1. Criteria
    1. Rapid Heart Rate over 150 beats per minute
    2. Symptoms or signs of cardiovascular compromise
      1. Angina Pectoris
      2. Acute Myocardial Infarction
      3. Hypotension
      4. Congestive Heart Failure
      5. Shortness of Breath
      6. Decreased Level of Consciousness
      7. Pulmonary edema
  2. Atrial Fibrillation Cardioversion
    1. See Synchronized Cardioversion
    2. Consider Adenosine 6-12 mg rapid IV (if no delay)
      1. Use only if regular rate and unclear diagnosis (possible PSVT)
      2. Not effective in PSVT
    3. Synchronized Cardioversion
      1. Monophasic dose: 200 joules synchronized (up to 360 joules)
      2. Biphasic dose: 150 joules synchronized (up to 200 joules)
    4. Anticoagulation
      1. Indications
        1. Atrial Fibrillation of unknown duration or >48 hours or
        2. Emergent, unstable cases requiring immediate cardioversion or
        3. High risk for CVA (e.g. prior TIA or CVA, Rheumatic Heart Disease, Mechanical Heart Valve)
        4. Many cardiologists recommend Anticoagulation after any electrical cardioversion
      2. Protocol
        1. Unfractionated Heparin or Low Molecular Weight Heparin at the time of cardioversion
        2. Warfarin (or other Anticoagulant such as Rivaroxaban) for 2-3 weeks after cardioversion

IV. Management: Hemodynamically Stable

  1. Asymptomatic, hemodynamically stable patients with Heart Rate <110 to 120
    1. No emergency management required
    2. Manage precipitating conditions (e.g. holiday heart)
    3. Initiate or adjust Atrial Fibrillation Rate Control
    4. See Atrial Fibrillation Anticoagulation
  2. Symptomatic patients or Heart Rate >110 to 120
    1. Initiate Atrial Fibrillation Rate Control
  3. Atrial Fibrillation Cardioversion to sinus rhythm
    1. See Atrial Fibrillation Cardioversion
      1. See Electrical Synchronized Cardioversion of Atrial Fibrillation
        1. See Synchronized Cardioversion
        2. See Conscious Sedation
      2. See Atrial Fibrillation Pharmacologic Cardioversion
        1. See Ottawa Aggressive Protocol in Atrial Fibrillation Cardioversion
    2. Atrial Fibrillation less than 48 hours (acute Atrial Fibrillation)
      1. See Atrial Fibrillation Cardioversion for precautions
      2. Consider other CVA risks (e.g. CVA/TIA in last 6 months, Mechanical Heart Valve, rheumatic heart)
      3. Consider Heparin while considering cardioversion
      4. Consider early Atrial Fibrillation Cardioversion (esp. if age <65 years old)
        1. Many patients prefer this when presenting with recurrence of Atrial Fibrillation to the ED
        2. Atrial Fibrillation is uncomfortable (Dyspnea, light headedness)
        3. Rate control medications have adverse effects
    3. Atrial Fibrillation more than 48 hours
      1. See Atrial Fibrillation Anticoagulation
      2. Protocol
        1. Warfarin (or other approved Anticoagulant/DOAC) for 3 weeks before cardioversion
        2. Atrial Fibrillation Cardioversion
        3. Continue Warfarin (or other approved Anticoagulant) for 4 weeks after cardioversion
      3. Early cardioversion may be acceptable if cleared with Transesophageal Echocardiogram (TEE) first
        1. Normal TEE does not exclude all Thromboembolism risk in anticoagulated patients
        2. See Atrial Fibrillation Cardioversion for precautions

V. Disposition: Hospitalization Indications

  1. Atrial Fibrillation with rapid ventricular rate
    1. Requiring continuous intravenous Atrial Fibrillation Rate Control (e.g. Diltiazem infusion)
  2. Congestive Heart Failure (CHF)
  3. Angina, Acute Coronary Syndrome or Myocardial Infarction
  4. Hypotension
  5. Serious comorbidity
    1. Acute Renal Failure
    2. Pulmonary Embolism
    3. Hyperthyroidism
  6. Other possible indications for hospitalization
    1. Elderly
    2. Unreliable follow-up
    3. Structural heart disease
  7. New onset Atrial Fibrillation hospitalization indications
    1. Acute Coronary Syndrome symptoms (typical symptoms)
      1. Coronary Artery Disease suspected as cause of Atrial Fibrillation trigger
    2. Patients at higher risk of coronary disease who present with atypical ACS symptoms
      1. Elderly
      2. Diabetes Mellitus

VI. Disposition: Emergency Department Observation Unit

  1. Indications
    1. Atrial Fibrillation onset within last 48 hours AND
    2. Normotensive patients (SBP > 90 mmHg) AND
    3. No Acute Coronary Syndrome, Heart Failure or other comorbidity AND
    4. Heart Rate <130 after IV rate control
  2. Contraindications
    1. Chest Pain
    2. Ischemic EKG changes
    3. Respiratory distress
    4. Fluid Overload
    5. Hypoxia
    6. Hypotension
    7. Decompensated significant condition (e.g. Sepsis, GI Bleed)
    8. New onset Acute Kidney Injury
    9. Pregnancy
    10. Lack of close follow-up
    11. Unable to comply with medication management
  3. Discharge goals (choose one of three options)
    1. Spontaneous cardioversion on rate control agent OR
    2. Electrical Cardioversion (consider TEE first) OR
    3. Rate control on oral nodal blockade agent (e.g. Metoprolol, Diltiazem) for at least 1-2 hours
      1. Heart Rate <100-100 bpm at rest (<110-120 bpm with activity)
  4. Anticoagulation
    1. CHADS2-VASc Score 2 or more indicates oral Anticoagulants (Warfarin or DOAC)
    2. HAS-BLED Score 3 or more suggests high risk of bleeding
    3. Expert opinion: Anticoagulation (Warfarin or DOAC) for 3 weeks after electrical cardioversion
    4. Factor comorbidity (hepatic or renal disease) into Anticoagulant selection
      1. ED observation unit protocol should include decision tools for Anticoagulant selection
  5. Education
    1. Medication Compliance
    2. Drug Interactions (and dietary restrictions)
    3. Anticoagulant Safety
      1. Avoiding Trauma and identifying signs, symptoms of bleeding
  6. Discharge from observation
    1. Established follow-up within 3-5 days
    2. Prescriptions for 30 day supply for lowest effective dose of rate control agent
    3. Anticoagulation agent prescription and follow-up with Anticoagulation clinic
  7. Efficacy
    1. Successful discharge to home in 80% of cases (20% require inpatient care)
    2. Shortens mean hospital stay from 50 hours to 13 hours
  8. References
    1. Davenport and Baugh (2018) Crit Dec Emerg Med 32(7): 15-24
    2. Decker (2008) Ann Emerg Med 52(4): 322-8 [PubMed]

VII. Disposition: Emergency Discharge Plan

  1. Interventions
    1. See Atrial Fibrillation Anticoagulation
    2. See Atrial Fibrillation Rate Control
    3. Anticoagulation, if indicated is often initiated prior to ED discharge
    4. Abstain from Alcohol, Caffeine and other potential exacerbating factors
    5. Consider cardiology Consultation (see indications below)
  2. Discharge Indications
    1. Asymptomatic (or CCS-SAF Scale 0-3) AND
    2. Heart Rate <110 beats per minute AND
    3. Hemodynamically stable (e.g. systolic Blood Pressure >90/60) AND
    4. No indications for hospitalization (see above)
  3. Follow-up
    1. Consider arranging cardiology follow-up
    2. Primary care follow-up
    3. Anticoagulation clinic follow-up
  4. Safety of emergency department discharge after cardioversion
    1. Discharge rates after cardioversion: 86-100%
    2. Return rate within 1 week: 10%
    3. Burton (2004) Ann Emerg Med 44(1): 20-30 [PubMed]
    4. Jacoby (2005) J Emerg Med 28(1): 27-30 [PubMed]
    5. Lo (2006) Emerg Med J 23(1): 51-3 [PubMed]
    6. von Besser (2011) Ann Emerg Med 58(6):517-20 +PMID:22098994 [PubMed]

VIII. Disposition: Cardiology Consultation indications

  1. Patient chronically managed with Atrial Fibrillation Rhythm Control
  2. Atrial Fibrillation with refractory rapid ventricular rate
  3. Structural heart disease (e.g. valvular heart disease, Congenital Heart Disease)
  4. Wolff-Parkinson-White Syndrome (WPW Syndrome) or other accessory pathway
  5. Decompensated Congestive Heart Failure or Coronary Artery Disease

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window

Ontology: Atrial Fibrillation (C0004238)

Definition (CHV) rapid tremor and shake of upper chambers of the heart
Definition (CHV) rapid tremor and shake of upper chambers of the heart
Definition (CHV) rapid tremor and shake of upper chambers of the heart
Definition (CHV) rapid tremor and shake of upper chambers of the heart
Definition (CHV) rapid tremor and shake of upper chambers of the heart
Definition (CHV) rapid tremor and shake of upper chambers of the heart
Definition (MEDLINEPLUS)

An arrhythmia is a problem with the speed or rhythm of the heartbeat. Atrial fibrillation (AF) is the most common type of arrhythmia. The cause is a disorder in the heart's electrical system.

Often, people who have AF may not even feel symptoms. But you may feel

  • Palpitations -- an abnormal rapid heartbeat
  • Shortness of breath
  • Weakness or difficulty exercising
  • Chest pain
  • Dizziness or fainting
  • Fatigue
  • Confusion

AF can lead to an increased risk of stroke. In many patients, it can also cause chest pain, heart attack, or heart failure.

Doctors diagnose AF using family and medical history, a physical exam, and a test called an electrocardiogram (EKG), which looks at the electrical waves your heart makes. Treatments include medicines and procedures to restore normal rhythm.

NIH: National Heart, Lung, and Blood Institute

Definition (NCI_CTCAE) A disorder characterized by a dysrhythmia without discernible P waves and an irregular ventricular response due to multiple reentry circuits. The rhythm disturbance originates above the ventricles.
Definition (NCI_FDA) An arrhythmia in which minute areas of the atrial myocardium are in various uncoordinated stages of depolarization and repolarization; instead of intermittently contracting, the atria quiver continuously in a chaotic pattern, causing a totally irregular, often rapid ventricular rate.
Definition (NCI) A disorder characterized by an electrocardiographic finding of a supraventricular arrhythmia characterized by the replacement of consistent P waves by rapid oscillations or fibrillatory waves that vary in size, shape and timing and are accompanied by an irregular ventricular response. (CDISC)
Definition (CSP) disorder of cardiac rhythm characterized by rapid, irregular atrial impulses and ineffective atrial contractions.
Definition (MSH) Abnormal cardiac rhythm that is characterized by rapid, uncoordinated firing of electrical impulses in the upper chambers of the heart (HEART ATRIA). In such case, blood cannot be effectively pumped into the lower chambers of the heart (HEART VENTRICLES). It is caused by abnormal impulse generation.
Concepts Pathologic Function (T046)
MSH D001281
ICD9 427.31
SnomedCT 155364009, 266306001, 49436004
LNC LA17084-7
English Atrial Fibrillations, Auricular Fibrillation, Auricular Fibrillations, Fibrillations, Atrial, Fibrillations, Auricular, FIBRILLATION ATRIAL, AURICULAR FIBRILLATION, Auricular fibrillation, Fibrillation, Atrial, Fibrillation, Auricular, AF, atrial fibrillation, atrial fibrillation (diagnosis), Afib, AFib, Fibrillation atrial, Atrial Fibrillation [Disease/Finding], Fibrillation;atrial, afib, atrial fibrillation (AF), auricular fibrillations, atrial fibrillations, Familial Atrial Fibrillation, Fibrillation - atrial, ATRIAL FIBRILLATION, Atrial fibrillation, AF - Atrial fibrillation, Atrial fibrillation (disorder), atrium; fibrillation, auricular; fibrillation, fibrillation; atrial or auricular, Atrial Fibrillation, auricular fibrillation
French FIBRILLATION AURICULAIRE, FA, AFib, Fibrillation auriculaire, Fibrillation atriale
German VORHOFFLIMMERN, AF, Afib, Flimmern Vorhof, Herzohrflimmern, HERZVORHOFFLIMMERN, Vorhofflimmern, Aurikuläres Flimmern
Portuguese FIBRILACAO AURICULAR, FA, FIBRILHACAO AURICULAR, Fibrilhação auricular, Fibrilação Atrial, Fibrilação Auricular
Spanish FIBRILACION AURICULAR, FA, Fibrilación atrial, AURICULAR, FIBRILACION, fibrilación auricular (trastorno), fibrilación auricular, Fibrilación auricular, Fibrilación Atrial, Fibrilación Auricular
Dutch AFib, AF, atriumfibrillatie, hartoorfibrilleren, atrium; fibrilleren, auriculair; fibrilleren, fibrilleren; atrium of auriculair, atriale fibrillatie, Atriumfibrillatie, Boezemfibrillatie, Fibrillatie, atrium-, Fibrillatie, boezem-, Fibrilleren, boezem-
Swedish Förmaksflimmer
Japanese シンボウサイドウ, 心房細動, 心房性細動
Finnish Eteisvärinä
Russian USHKA PREDSERDIIA FIBRILLIATSIIA, PREDSERDII FIBRILLIATSIIA, ПРЕДСЕРДИЙ ФИБРИЛЛЯЦИЯ, УШКА ПРЕДСЕРДИЯ ФИБРИЛЛЯЦИЯ
Czech Fibrilace ouška, Fibrilace síní, fibrilace síní, síňová fibrilace, FiS
Italian Fibrillazione auricolare, Fibrillazione atriale
Croatian ATRIJ, FIBRILACIJA
Polish Migotanie przedsionków
Hungarian AFib, Fibrillatio atrialis, Pitvarfibrillatio
Norwegian Forkammerflimmer, Hjerteflimmer, Artrieflimmer