The epidemiology and management of recent-onset atrial fibrillation and flutter presenting to the Emergency Department

Atrial fibrillation (AF) and flutter are common tachyarrhythmias seen in the Emergency Department (ED). The management of recent-onset AF remains poorly defined. Two management strategies have been proposed: rhythm control versus rate control. The aims of this study were to investigate the epidemiology and management of recent-onset AF presenting to one large tertiary ED.

Retrospective analysis of ED records was carried out using the ED PAS database to identify eligible patients presenting between 1 July 2009 and 30 June 2011 with onset of AF in the previous 7 days. Patients were included for analysis if it was their first presentation, first diagnosis or a paroxysm of atrial fibrillation.

A total of 494 patients (625 presentations) were analysed. AF (n=564; 90.2%) and flutter (n=61; 9.8%) were the presenting rhythms. In all, 374 (53.8%) presentations were paroxysmal atrial fibrillation. For patients with AF, rhythm control was attempted in 171 (55.0%) patients presenting less than 48 h after symptom onset. Pharmacotherapy was the approach in 105 (31.4%) patients, compared with direct current cardioversion (n=45; 26.3%). Twenty-one patients received both. Flecainide (n=85) and amiodarone (n=33) were the main first-line pharmacotherapies, restoring sinus rhythm in 81.3 and 81.4% of patients, respectively. The overall efficacy of direct current cardioversion in restoring sinus rhythm was similar (78.8%). Eighty-one patients presented more than 48 h after symptom onset. Of those patients managed in the ED (n=38; 71.7%) were managed with rate control. The majority of patients with atrial flutter presented less than 48 h after symptom onset (n=48; 78.7%). Sixteen of these patients were managed with rhythm control strategies in the ED.

The epidemiology of recent-onset AF in this series is comparable with previous publications. Rhythm control was only attempted in approximately half of all eligible patients. There was no single-favoured management strategy. Our results mirror the literature in emphasizing the variation in management and the lack of robust evidence guiding the management of recent-onset AF and flutter.