Management of patients with acute atrial fibrillation in the ED

Patients with acute atrial fibrillation with a history of mild structural heart disease could be considered for rhythm conversion.

Patients received intravenous flecainide, propafenone, or amiodarone on presentation and a second dose after 6 hours if atrial fibrillation persisted. No randomization was used, and drugs were given at the discretion of the treating physician. Primary end point was rhythm conversion within the first 6 hours from presentation. Secondary end points included rhythm conversion, time to rhythm conversion, and adverse drug effects within 24 hours.

Among the 378 patients enrolled, 37 (10%) recovered sinus rhythm before therapy was given. Of the remaining 341 patients, 43 (13%) received flecainide, 187 (55%) received propafenone, and 111 (32%) received amiodarone. Baseline clinical characteristics were homogeneous among groups. Rhythm conversion was obtained in 87% of treated patients overall. Within 6 hours, the primary end point was achieved in a higher proportion in the flecainide and propafenone groups (72% and 55%, respectively) as compared with the amiodarone group (30%; P < .001). The mean time to the end point overall was shorter in the flecainide and propafenone groups (178 ± 227 and 292 ± 285 minutes, respectively) as compared with the amiodarone group (472 ± 269 minutes; P < .001). Length of in-hospital stay in the amiodarone group was significantly higher (26.1 ± 22.4 hours) compared with the flecainide and propafenone groups (8.9 ± 10.3 and 11.0 ± 13.8 hours; respectively; P = .001). No significant differences were found in adverse drug effects.

Flecainide and propafenone achieve rhythm control in a higher proportion of patients as compared with amiodarone within a 6-hour management.