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+ IMPROVING CARE THROUGH EVIDENCE
GUIDELINES UPDATE
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Canadian
CardiovascuPAGE
Practice
Guideline:
2 |2|Clinical
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lar Society
Atrial FibrilBenign
Paroxysmal
lation Guidelines
2010:
Positional
Vertigo
Management Of RecentOnset Atrial Fibrillation/
PAGE 3 | Practice Parameter:
Flutter In the Emergency
Therapies
For Benign
Department
Paroxysmal Positional
Canadian
Journal of
Vertigo
(An Evidence-Based
Cardiology
Review): Report Of The
Quality Standards Subcom2011OfACCF/AHA/HRS
PAGE 6|mittee
The American
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his issue of EM Practice Guidelines Update reviews 2
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discomfort
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PAGE 5 | Clinical Practice Guideline:
be diagnosed
with AF,work
doubling
the
number ofincases.
Guidelines For The
elderly.
The
most
common
emergency
department
therapies
Acute Otitis Externa
Several key controversies exist in the management of AF,for
includManagement Of Patients BPPV
(antihistamines,
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and
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ing rhythm
versus rate
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versus
pharmacological
With Atrial Fibrillation
recommended
byand
specialists.
rhythm control,
if and when anticoagulation is indicated.
Circulation
Several key guidelines have been recently published to direct
The second topic for review, AOE, is a prevalent and painful
emergency clinicians in their care of patients with this most comcondition seen by emergency clinicians whose management can be
mon arrhythmia.
complicated by several common pitfalls.
PAGE13 | Editorial Comment
PAGE15 | References
PAGE15 | CME Questions
Editor’s Note: To read more about this publication
and the background and methodologies for practice
guideline development, go to:
http://www.ebmedicine.net/introduction
Practice
Guideline
Impact
Practice
Guideline
Impact:
• • Hemodynamically
Vestibular suppressant
medications
the benzodiazepine,
unstable
patients of
require
immediate directanticholinergic,
and
antihistamine
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have a limited role
current cardioversion.
in the management
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• Hemodynamically
stable
patients with onset of AF < 48 hours
undergo
cardioversion
withoutisanticoagulation.
• may
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repositioning
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the therapy of choice in
• Ifthe
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duration is ≥ of
48BPPV
hoursand
or an
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period ofintime,
the
should
be performed
the ED
patient
must from
be assessed
or arranged
the ED. for the need for thromboembolism
prophylaxis.
• • The
Systemic
antibiotics
should bemust
avoided
in most cases
patient's
risk of bleeding
be assessed
priorofto initiatdiffuse
AOE.
ing anticoagulation.
• Only symptomatic patients or patients with insufficient rate
control require hospital admission.
November
2009
May 2012
Volume
1,
Number
Volume 4, Number 25
Editor-In-Chief
Authors
Reuben
J. Strayer,
MD
Vishal
Demla,
MD
Department
of Emergency
Medicine, Mount
Sinai School of Medicine, New
Assistant Professor
of Emergency
Medicine,
York,
NYSinai School of Medicine, New York, NY
Mount
Editor-In-Chief
Editorial
Reuben
J. Board
Strayer, MD
Assistant Professor of Emergency Medicine, Mount Sinai School of Medicine,
Andy
Jagoda,
MD, FACEP
New
York,
NY
Professor and Chair, Department of Emergency Medicine
Mount Sinai
School of Medicine, New York, NY
Editorial
Board
Nicole
C. Bouchard,
MD, FRCPC
Erik Kulstad,
MD, MS
Assistant
Clinical
Professor,
Assistant
SiteMedical
Director; Center
Director of Medical
Research
Director,
Advocate
Christ
Toxicology, New York-Presbyterian Hospital, Columbia University Medical
Department
of
Emergency
Medicine,
Oak
Lawn,
IL
Center, New York, NY
EddyJagoda,
S. Lang,
MDCM,
Andy
MD,
FACEPCCFP (EM), CSPQ
Professor
and
Chair, Department
of Emergency
Medicine,
Mount
Sinai School
Associate
Professor,
McGill University,
SMBD
Jewish
General
of
Medicine,Montreal,
New York,Canada
NY
Hospital,
Erik Kulstad, MD, MS
Lewis S.
Nelson,
MD of Emergency Medicine, Advocate Christ
Research
Director,
Department
Director,
Fellowship
in Medical
Toxicology, New York City Poison
Medical
Center,
Oak Lawn,
IL
Control
Associate
Professor,
Department of Emergency
Eddy
S.Center,
Lang, MDCM,
CCFP
(EM), CSPQ
Medicine,
NYU Medical
Center,
New York,
NY Professor, University of
Senior
Researcher,
Alberta Health
Services;
Associate
Gregory M. Press, MD, RDMS
Calgary; Adjunct Professor, McGill University, Montreal, Quebec, Canada
Lewis
S. Nelson,
MD
Assistant
Professor,
Director of Emergency Ultrasound, Emergency
Associate Professor of Emergency Medicine, New York University School of
Ultrasound
Fellowship
Director, Department of Emergency Medicine,
Medicine; Director, Fellowship in Medical Toxicology, New York City Poison
University
of Texas
at Houston
Medical School, Houston, TX
Control
Center,
New York,
NY
Gregory
Press, MD,
Scott M.M.Silvers,
MDRDMS
Assistant
Professor, Director
of Emergency
Ultrasound, Emergency Ultrasound
Chair, Department
of Emergency
Medicine
Fellowship Director, Department of Emergency Medicine, University of Texas at
Mayo Clinic, Jacksonville, FL
Houston Medical School, Houston, TX
ScottS.Weingart,
MD FACEP
Maia
Rutman, MD
Assistant
Professor,
Department
Emergency
Medicine, Elmhurst
Medical
Director,
Pediatric
Emergency of
Services,
Dartmouth-Hitchcock
Medical
Center;
Assistant
of Pediatric
Emergency
Medicine,
Hospital
Center,Professor
Mount Sinai
School
of Medicine,
NewDartmouth
York, NY
Medical School, Lebanon, NH
Scott
Silvers,this
MDactivity, see “Physician CME Information” on
Prior toM.
beginning
Chair,
Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL
page 7.
Scott Weingart, MD, FACEP
Associate Professor, Director of the Division of Emergency Critical Care,
Department of Emergency Medicine, Mount Sinai School of Medicine, New
York, NY
Editor’s Note: Introduction to a New Series
EM Practice Guidelines Update is a new publication from
EB Medicine
that will help emergency department cliniResearch
Editor
cians G.
stay
current
Phillip
Blanc,
MD, with
MPH practice guidelines. To read more
Department of Emergency Medicine, Mount Sinai School of Medicine, New
about this publication and the background and methodYork, NY
ologies for practice guideline development, http://www.
ebmedicine.net/introduction
Prior to beginning this activity, see “CME Information” on page 16.
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Current Guidelines On Atrial Fibrillation In The Emergency Department
Canadian Cardiovascular Society Atrial Fibrillation Guidelines
2010: Management Of Recent-Onset Atrial Fibrillation/Flutter In
The Emergency Department2-5
Canadian Journal of Cardiology. 2011;27(1):38-46.
Link: http://www.ccs.ca/guidelines/cc_library_e.aspx
T
had a connection with the presented content. Evidence and recommendations were classified according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.3
(http://www.onlinecjc.ca/article/S0828-282X(10)00004-8/fulltext) (See
Tables 1 and 2.) This approach separates the quality of evidence from
the strength of recommendations. Only recommendations pertinent to
emergency clinicians are abstracted here.
he Canadian Cardiovascular Society (CCS) convened a primary
panel of experts to undertake a comprehensive review of current
knowledge and management strategies in the field of AF and to
develop an evidence-based set of recommendations on the diagnosis
and management of patients with AF. The target is primary care physicians, emergency physicians, internists, and cardiologists. The working
groups undertook a review of the English language literature, using Ovid
MEDLINE® and Cochrane Library searches and a critical appraisal of the
evidence, focusing predominantly on the results of randomized clinical
trials and systematic reviews. In the absence of such data, recommendations were based on the results of large cohort studies or smaller clinical studies. Writing group disclosures were listed and revealed that most
authors had an affiliation with a commercial organization that may have
Table 2. GRADE Classifications, Factors Determining Strength of Evidence3
Factors
Description
Quality of evidence
The higher the quality of evidence, the greater the probability that a strong recommendation is indicated; eg, strong
recommendation that patients with AF at moderate to high
risk of stroke be treated with oral anticoagulants.
Difference between
desirable and undesirable effects
The greater the difference between desirable and undesirable effects, the greater the probability that a strong
recommendation is indicated; eg, strong recommendation
that patients with AF ≥ 48-hour duration receive oral anticoagulation therapy for at least 3 weeks prior to planned
cardioversion and 4 weeks following.
Table 1. GRADE Classifications, Quality Of Evidence3
Classification
Evidence
High
Future research unlikely to change confidence in estimate of
effect; eg, multiple well-designed, well-conducted clinical trials.
Multiple populations evaluated. Data derived from multiple randomized controlled trials or meta-analyses.
Moderate
Further research likely to have an important impact on confidence
in estimate of effect and may change the estimate; eg, limited
clinical trials, inconsistency of results, or study limitations.
Low
Further research very likely to have a significant impact on the
estimate of effect and is likely to change the estimate; eg, small
number of clinical studies or cohort observations.
Very low
Values and preferences The greater the variation or uncertainty in values and
preferences, the higher the probability that a conditional
recommendation is indicated; eg, aspirin may be a reasonable alternative to oral anticoagulant therapy in patients at
low risk of stroke.
Cost
The higher the cost, the lower the likelihood that a strong
recommendation is indicated; eg, conditional recommendation for catheter ablation as first-line therapy for AF.
Abbreviation: AF, atrial fibrillation.
The estimate of effect is very uncertain; eg, case studies, consensus opinion.
EM Practice Guidelines Update © 2012
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Current Guidelines On Atrial Fibrillation In The Emergency Department
3. Atrioventricular (AV) nodal blocking agents (digoxin, calcium channel blockers, beta-blockers, adenosine) are contraindicated (Strong
Recommendation, Low-Quality Evidence).
Canadian Cardiovascular Society Atrial Fibrillation Guidelines
2010: Management Of Recent-Onset Atrial Fibrillation And Flutter
In The Emergency Department2
Link: http://www.onlinecjc.ca/article/S0828-282X(10)00015-2/fulltext
Overall Approach
1. We recommend that in stable patients with recent-onset AF/ atrial
flutter (AFL), a strategy of rate control or rhythm control could be
selected (Strong Recommendation, High-Quality Evidence).
2. We recommend for patients with acute hemodynamic instability secondary to rapid recent-onset AF/AFL, immediate electrical conversion
to sinus rhythm (Strong Recommendation, Low-Quality Evidence).
Prevention Of Thromboembolism
We recommend that hemodynamically stable patients with AF/AFL of
≥ 48 hours' or uncertain duration for whom a strategy of rhythm control has been selected should have rate control optimized and receive
therapeutic oral anticoagulant (OAC) therapy (warfarin [international
normalized ratio (INR) 2-3] or dabigatran) for 3 weeks before and at
least 4 weeks postcardioversion. Following attempted cardioversion:
1. If AF/AFL persists or recurs or if symptoms suggest that the presenting AF/AFL has been recurrent, the patient should have antithrombotic therapy continued indefinitely (using either OAC or
aspirin as appropriate).
2. If sinus rhythm is achieved and sustained for 4 weeks, the need for
ongoing antithrombotic therapy should be determined based on the
risk of stroke, and, in selected cases, expert consultation may be
required (Strong Recommendation, Moderate-Quality Evidence).
3. We recommend that hemodynamically stable patients with AF/AFL
of known duration < 48 hours for whom a strategy of rhythm control
has been selected may generally undergo cardioversion without
prior or subsequent anticoagulation. However, if the patient is at
particularly high risk of stroke (eg, mechanical valve, rheumatic
heart disease, recent stroke, or transient ischemic attack [TIA]),
cardioversion should be delayed and the patient should receive
OAC for 3 weeks before and at least 4 weeks postcardioversion.
Rhythm Control
In hemodynamically stable patients with AF/AFL of known duration
< 48 hours in whom a strategy of rhythm control has been selected:
1. We recommend that rate-slowing agents alone are acceptable
while awaiting spontaneous conversion (Strong Recommendation,
Moderate-Quality Evidence).
2. We recommend that synchronized electrical cardioversion or pharmacologic cardioversion may be used when a decision is made to
cardiovert patients in the ED (Strong Recommendation, ModerateQuality Evidence).
3. We suggest that antiarrhythmic drugs may be used to pretreat patients before electrical cardioversion in the ED in order to decrease
early recurrence of AF and to enhance cardioversion efficacy (Conditional Recommendation, Low-Quality Evidence).
Electrical Cardioversion
1. We recommend that electrical cardioversion may be conducted in
the ED with 150-200 joules biphasic waveform as the initial energy
setting (Strong Recommendation, Low-Quality Evidence).
Disposition And Follow-Up
1. We recommend hospital admission for highly symptomatic patients
with decompensated heart failure or myocardial ischemia (Strong
Recommendation, Low-Quality Evidence).
2. We suggest limiting hospital admission to highly symptomatic
patients in whom adequate rate control cannot be achieved (Conditional Recommendation, Low-Quality Evidence).
3. We suggest that after conversion to sinus rhythm has been
achieved, whether antiarrhythmic drug therapy is indicated should
be based on the estimated probability of recurrence and the symptoms during AF. Long-term therapy will need to be determined by
Rapid Pre-excitation During Atrial Fibrillation
We recommend, in patients with rapid ventricular pre-excitation during
AF (Wolff-Parkinson-White syndrome):
1. Urgent electrical cardioversion if the patient is hemodynamically
unstable (Strong Recommendation, Low-Quality Evidence).
2. Intravenous (IV) antiarrhythmic agents procainamide or ibutilide in
stable patients (Strong Recommendation, Low-Quality Evidence).
EM Practice Guidelines Update © 2012
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Current Guidelines On Atrial Fibrillation In The Emergency Department
an appropriate outpatient consultation (Conditional Recommendation, Low-Quality Evidence).
3. We recommend that the goal of rhythm control therapy should be
improvement in patient symptoms and clinical outcomes and not
necessarily the elimination of all AF (Strong Recommendation,
Moderate-Quality Evidence).
Canadian Cardiovascular Society Atrial Fibrillation Guidelines
2010: Rate And Rhythm Management4
Link: http://www.onlinecjc.ca/article/S0828-282X(10)00002-4/fulltext
Drugs For Heart Rate Control
1. We recommend beta-blockers or nondihydropyridine calcium channel blockers as initial therapy for rate control of AF or AFL in most
patients without a past history of myocardial infarction or left ventricular dysfunction (Strong Recommendation, Moderate-Quality
Evidence).
2. We suggest that digoxin not be used as initial therapy for active
patients and be reserved for rate control in patients who are sedentary or who have left ventricular systolic dysfunction (Conditional
Recommendation, Moderate-Quality Evidence).
3. We suggest that digoxin be added to therapy with beta-blockers or
calcium channel blockers in patients whose heart rate remains uncontrolled (Conditional Recommendation, Moderate-Quality Evidence).
4. We suggest that dronedarone may be added for additional rate
control in patients with uncontrolled ventricular rates despite
therapy with beta-blockers, calcium channel blockers, or digoxin
(Conditional Recommendation, Moderate-Quality Evidence).
5. We suggest that amiodarone for rate control should be reserved
for exceptional cases in which other means are not feasible or are
insufficient (Conditional Recommendation, Low-Quality Evidence).
6. We recommend beta-blockers as initial therapy for rate control of AF
or AFL in patients with myocardial infarction or left ventricular systolic
dysfunction (Strong Recommendation, High-Quality Evidence).
Antiarrhythmic Drug Therapy To Maintain Sinus Rhythm
1. We recommend use of maintenance oral antiarrhythmic therapy as
first-line therapy for patients with recurrent AF in whom long-term
rhythm control is desired (Strong Recommendation, ModerateQuality Evidence).
2. We recommend that oral antiarrhythmic drug therapy should be
avoided in patients with AF or AFL and advanced sinus or AV nodal
disease unless the patient has a pacemaker or implantable defibrillator (Strong Recommendation, Low-Quality Evidence).
3. We recommend that an AV blocking agent should be used in patients with AF or AFL being treated with a class I antiarrhythmic drug
(eg, propafenone or flecainide) in the absence of advanced AV nodal
disease (Strong Recommendation, Low-Quality Evidence).
Canadian Cardiovascular Society Atrial Fibrillation Guidelines
2010: Prevention Of Stroke And Systemic Thromboembolism In
Atrial Fibrillation And Flutter5
Link: http://www.onlinecjc.ca/article/S0828-282X(10)00008-5/fulltext
Assessing Risk
1. We recommend that all patients with AF or AFL (paroxysmal,
persistent, or permanent) should be stratified using a predictive
index for stroke (eg, CHADS2) and for the risk of bleeding (eg,
HAS-BLED) and that most patients should receive antithrombotic
therapy (Strong Recommendation, High-Quality Evidence).
2. We recommend that patients at very low risk of stroke (CHADS2 =
0) should receive aspirin (75-325 mg/day) (Strong Recommendation, High-Quality Evidence).
3. We recommend that patients at low risk of stroke (CHADS2 = 1)
should receive OAC therapy (either warfarin [INR 2-3] or dabigatran) (Strong Recommendation, High-Quality Evidence).
4. We suggest, based on individual risk benefit considerations, that
aspirin is a reasonable alternative for some (Conditional Recommendation, Moderate-Quality Evidence).
Rhythm Control
1. We recommend the optimal treatment of precipitating or reversible
predisposing conditions of AF prior to attempts to restore or maintain
sinus rhythm (Strong Recommendation, Low-Quality Evidence).
2. We recommend a rhythm control strategy for patients with AF or
AFL who remain symptomatic with rate-control therapy or in whom
rate-control therapy is unlikely to control symptoms (Strong Recommendation, Moderate-Quality Evidence).
EM Practice Guidelines Update © 2012
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Current Guidelines On Atrial Fibrillation In The Emergency Department
mechanical valve, rheumatic heart disease, recent stroke, or TIA),
the patient should receive IV unfractionated heparin (UFH) or lowmolecular-weight heparin (LMWH) before cardioversion, if possible,
or immediately thereafter if even a brief delay is unacceptable, and
then be converted to OAC for at least 4 weeks postcardioversion.
2. If the AF or AFL is ≥ 48 hours' or of uncertain duration, we suggest
the patient receive IV UFH or LMWH before cardioversion if possible, or immediately thereafter if even a brief delay is unacceptable. Such a patient should then be converted to OAC for at least 4
weeks postcardioversion.
3. Following attempted cardioversion, the guidelines for subsequent
antithrombotic therapy are identical to those for the management of
hemodynamically stable patients undergoing cardioversion (Conditional Recommendation, Low-Quality Evidence). ■
Emergency Cardioversion
We recommend that hemodynamically stable patients with AF or AFL
of ≥ 48 hours' or uncertain duration for whom electrical or pharmacologic cardioversion is planned should receive therapeutic OAC therapy
(warfarin [INR 2-3] or dabigatran) for 3 weeks before and at least 4
weeks postcardioversion. Following attempted cardioversion:
1. If AF or AFL persists or recurs or if symptoms suggest that the
presenting AF or AFL has been recurrent, the patient should have
antithrombotic therapy continued indefinitely (using either OAC or
aspirin, as appropriate).
2. If sinus rhythm is achieved and sustained for 4 weeks, the need
for ongoing antithrombotic therapy should be determined on the
basis of the risk of stroke, and, in selected cases, expert consultation may be required (Strong Recommendation, Moderate-Quality
Evidence).
We recommend that hemodynamically stable patients with AF or AFL
of known duration < 48 hours may undergo cardioversion without prior
or subsequent anticoagulation. However, if the patient is at particularly
high risk of stroke (eg, mechanical valve, rheumatic heart disease, recent stroke, or TIA), cardioversion should be delayed, and the patient
should receive OAC for 3 weeks before and at least 4 weeks postcardioversion. Following attempted cardioversion,
1. If AF or AFL persists or recurs or if symptoms suggest that the
presenting AF or AFL has been recurrent, antithrombotic therapy
(OAC or aspirin, as appropriate) should be commenced and continued indefinitely.
2. If normal sinus rhythm is achieved and sustained for 4 weeks, the
need for ongoing antithrombotic therapy should be determined on
the basis of the risk of stroke according to CHADS2 score, and in
selected cases expert consultation may be required (Strong Recommendation, Moderate-Quality Evidence).
We suggest that hemodynamically unstable patients with AF or AFL
who require emergency cardioversion be managed as follows:
1. If the AF or AFL is of known duration < 48 hours, the patient may
generally undergo cardioversion without prior anticoagulation.
However, if the patient is at particularly high risk of stroke (eg,
EM Practice Guidelines Update © 2012
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Current Guidelines On Atrial Fibrillation In The Emergency Department
2011 ACCF/AHA/HRS Focused Updates Incorporated Into The
ACC/AHA/ESC 2006 Guidelines For The Management Of Patients With Atrial Fibrillation: A Report Of The ACCF/AHA Task
Force On Practice Guidelines6
Circulation. 2011;123:e269-e367.
Link: http://circ.ahajournals.org/content/123/10/e269.full.pdf
T
were recused from voting on recommendations for which they had a
relevant conflict.
his is a focused update to the 2006 guidelines.6-9 The guidelines
were created by a committee composed of members representing the American College of Cardiology (ACC), the American
Heart Association (AHA), the European Society of Cardiology (ESC),
the European Heart Rhythm Association (EHRA), and the Heart
Rhythm Society (HRS). This document was reviewed by 2 official
reviewers nominated by the ACC, 2 official reviewers nominated by the
AHA, and 2 official reviewers nominated by the ESC, as well as by the
American College of Cardiology Foundation (ACCF) Clinical Electrophysiology Committee, the AHA ECG and Arrhythmias Committee, the
AHA Stroke Review Committee, the EHRA, the HRS, and numerous
additional content reviewers nominated by the writing committee. The
document was approved for publication by the governing bodies of
the ACC, AHA, and ESC and officially endorsed by
the EHRA and the
HRS. The ACC/AHA/ESC Writing Committee to Revise the
2001 Guidelines for the Management of Patients With Atrial Fibrillation conducted a
comprehensive review of the relevant literature from 2001 to 2006.
Recommendations were sorted into 4 classes based on predefined
categories representing their benefit-to-risk ratios (I, IIa, IIb, III). In addition, the level of evidence for each of these recommendations was
evaluated for quality and graded based on predefined criteria (A, B, C).
(See Table 3.)
Only recommendations pertinent to emergency medicine are excerpted
here. Section numbering has been retained from the original guidelines.
Table 3. American Heart Association Classification Of Levels And Classes Of
Evidence6
Levels of Evidence
Literature searches were conducted in the PubMed/MEDLINE® database and the Cochrane Library (including the Cochrane Database of
Systematic Reviews and the Cochrane Controlled Trials Registry). In
an effort to respond promptly to new evidence, the ACCF/AHA Task
Force on Practice Guidelines has created a “focused update” process
to revise the existing guideline recommendations that are affected by
evolving data or opinion. Evidence will be reviewed at least twice per
year, and updates will be initiated on an as-needed basis. All authors
disclosed conflicts of interest and relationships with industry; authors
EM Practice Guidelines Update © 2012
Level A
Multiple populations evaluated. Data derived from multiple randomized controlled trials or meta-analyses.
Level B
Limited populations evaluated. Data derived from a single randomized trial or nonrandomized studies.
Level C
Very limited populations evaluated; only consensus opinion of experts, case studies, or standard of care
Classes of Evidence
6
Class I
Benefit >>> Risk; procedure SHOULD be performed/administered
Class IIa
Benefit >> Risk; IT IS REASONABLE to perform procedure/administer treatment
Class IIb
Benefit ≥ Risk; procedure/treatment MAY BE CONSIDERED
Class III
No proven benefit/harmful to patients
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Current Guidelines On Atrial Fibrillation In The Emergency Department
Class III
1. Digitalis should not be used as the sole agent to control the rate
of ventricular response in patients with paroxysmal AF. (Level of
evidence: B)
3. In patients with decompensated HF and AF, IV administration of a
nondihydropyridine calcium channel antagonist may exacerbate
hemodynamic compromise and is not recommended. (Level of
evidence: C)
4. IV administration of digitalis glycosides or nondihydropyridine
calcium channel antagonists to patients with AF and pre-excitation
syndrome may paradoxically accelerate the ventricular response
and is not recommended. (Level of evidence: C)
[Editor’s note: beta-blockers should also be avoided in this setting.]
8.1.3.1 Pharmacological Rate Control During Atrial Fibrillation
Recommendations:
Class I
2. In the absence of pre-excitation, IV administration of beta-blockers
(esmolol, metoprolol, or propranolol) or nondihydropyridine calcium
channel antagonists (verapamil, diltiazem) is recommended to
slow the ventricular response to AF in the acute setting, exercising
caution in patients with hypotension or heart failure (HF). (Level of
evidence: B)
3. IV administration of digoxin or amiodarone is recommended to
control the heart rate in patients with AF and HF who do not have
an accessory pathway. (Level of evidence: B)
5. Digoxin is effective following oral administration to control the heart
rate at rest in patients with AF and is indicated for patients with HF,
LV dysfunction, or for sedentary individuals. (Level of evidence: C)
8.1.4 Preventing Thromboembolism
Recommendations:
Class I
1. Antithrombotic therapy to prevent thromboembolism is recommended for all patients with AF, except those with lone AF or contraindications. (Level of Evidence: A)
2. The selection of the antithrombotic agent should be based upon
the absolute risks of stroke and bleeding and the relative risk and
benefit for a given patient. (Level of Evidence: A)
3. For patients without mechanical heart valves at high risk of stroke,
chronic oral anticoagulant therapy with a vitamin K antagonist is
recommended in a dose adjusted to achieve the target intensity
INR of 2.0 to 3.0, unless contraindicated. Factors associated with
highest risk for stroke in patients with AF are prior thromboembolism (stroke, TIA, or systemic embolism) and rheumatic mitral
stenosis. (Level of Evidence: A)
4. Anticoagulation with a vitamin K antagonist is recommended for
patients with more than 1 moderate risk factor. Such factors include
age 75 years or greater, hypertension, HF, impaired left ventricle
systolic function (ejection fraction 35% or less or fractional shortening less than 25%), and diabetes mellitus. (Level of Evidence: A)
6. Aspirin, 81 to 325 mg daily, is recommended as an alternative to
vitamin K antagonists in low-risk patients or in those with contraindications to oral anticoagulation. (Level of Evidence: A)
Class IIa
1. A combination of digoxin and either a beta-blocker or a nondihydropyridine calcium channel antagonist is reasonable to control the
heart rate both at rest and during exercise in patients with AF. The
choice of medication should be individualized and the dose modulated to avoid bradycardia. (Level of evidence: B)
3. IV amiodarone can be useful to control the heart rate in patients
with AF when other measures are unsuccessful or contraindicated.
(Level of evidence: C)
4. When electrical cardioversion is not necessary in patients with AF
and an accessory pathway, IV procainamide or ibutilide is a reasonable alternative. (Level of evidence: C)
Class IIb
1. When the ventricular rate cannot be adequately controlled both at
rest and during exercise in patients with AF using a beta-blocker,
nondihydropyridine calcium channel antagonist, or digoxin, alone
or in combination, amiodarone may be administered to control the
heart rate. (Level of evidence: C)
2. IV procainamide, disopyramide, ibutilide, or amiodarone may be
considered for hemodynamically stable patients with AF involving
conduction over an accessory pathway. (Level of evidence: B)
EM Practice Guidelines Update © 2012
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2. When surgical procedures require interruption of oral anticoagulant
therapy for longer than 1 week in high-risk patients, UFH may be
administered or LMWH given by subcutaneous injection, although the
efficacy of these alternatives in this situation is uncertain. (Level of
Evidence: C)
4. In patients undergoing percutaneous coronary intervention, anticoagulation may be interrupted to prevent bleeding at the site of
peripheral arterial puncture, but the vitamin K antagonist should
be resumed as soon as possible after the procedure and the dose
adjusted to achieve an INR in the therapeutic range. Aspirin may
be given temporarily during the hiatus, but the maintenance regimen should then consist of the combination of clopidogrel, 75 mg
daily, plus warfarin (INR 2.0 to 3.0). Clopidogrel should be given for
a minimum of 1 month after implantation of a bare metal stent, at
least 3 months for a sirolimus-eluting stent, at least 6 months for a
paclitaxel-eluting stent, and 12 months or longer in selected patients, following which warfarin may be continued as monotherapy
in the absence of a subsequent coronary event. When warfarin is
given in combination with clopidogrel or low-dose aspirin, the dose
intensity must be carefully regulated. (Level of Evidence: C)
7. For patients with AF who have mechanical heart valves, the target
intensity of anticoagulation should be based on the type of prosthesis, maintaining an INR of at least 2.5. (Level of Evidence: B)
8. Antithrombotic therapy is recommended for patients with AFL as for
those with AF. (Level of Evidence: C)
Class IIa
1. For primary prevention of thromboembolism in patients with nonvalvular AF who have just 1 of the following validated risk factors,
antithrombotic therapy with either aspirin or a vitamin K antagonist
is reasonable, based upon an assessment of the risk of bleeding
complications, ability to safely sustain adjusted chronic anticoagulation, and patient preferences: age ≥ 75 years (especially in female
patients), hypertension, HF, impaired left ventricular function, or
diabetes mellitus. (Level of Evidence: A)
2. For patients with nonvalvular AF who have 1 or more of the following less well-validated risk factors, antithrombotic therapy with
either aspirin or a vitamin K antagonist is reasonable for prevention
of thromboembolism: age 65 to 74 years, female gender, or coronary artery disease (CAD). The choice of agent should be based
upon the risk of bleeding complications, ability to safely sustain
adjusted chronic anticoagulation, and patient preferences. (Level
of Evidence: B)
3. It is reasonable to select antithrombotic therapy using the same
criteria irrespective of the pattern (ie, paroxysmal, persistent, or
permanent) of AF. (Level of Evidence: B)
4. In patients with AF who do not have mechanical prosthetic heart
valves, it is reasonable to interrupt anticoagulation for up to 1 week
without substituting heparin for surgical or diagnostic procedures
that carry a risk of bleeding. (Level of Evidence: C)
Class III
Long-term anticoagulation with a vitamin K antagonist is not recommended for primary prevention of stroke in patients below the age of
60 years without heart disease (lone AF) or any risk factors for thromboembolism. (Level of Evidence: C)
8.1.5 Cardioversion Of Atrial Fibrillation
Recommendations For Pharmacological Cardioversion Of Atrial
Fibrillation:
Class I
Administration of flecainide, dofetilide, propafenone, or ibutilide is
recommended for pharmacological cardioversion of AF. (Level of Evidence: A)
Class IIb
1. In patients 75 years of age and older at increased risk of bleeding
but without frank contraindications to oral anticoagulant therapy,
and in other patients with moderate risk factors for thromboembolism who are unable to safely tolerate anticoagulation at the standard intensity of INR 2.0 to 3.0, a lower INR target of 2.0 (range
1.6 to 2.5) may be considered for primary prevention of ischemic
stroke and systemic embolism. (Level of Evidence: C)
EM Practice Guidelines Update © 2012
Class IIa
1. Administration of amiodarone is a reasonable option for pharmacological cardioversion of AF. (Level of Evidence: A)
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2. Patient preference is a reasonable consideration in the selection of
infrequently repeated cardioversions for the management of symptomatic or recurrent AF. (Level of Evidence: C)
3. Administration of amiodarone can be beneficial on an outpatient
basis in patients with paroxysmal or persistent AF when rapid
restoration of sinus rhythm is not deemed necessary. (Level of
Evidence: C)
Class III
1. Frequent repetition of direct-current cardioversion is not recommended for patients who have relatively short periods of sinus
rhythm between relapses of AF after multiple cardioversion procedures despite prophylactic antiarrhythmic drug therapy. (Level of
Evidence: C)
2. Electrical cardioversion is contraindicated in patients with digitalis
toxicity or hypokalemia. (Level of Evidence: C)
Class IIb
Administration of quinidine or procainamide might be considered for
pharmacological cardioversion of AF, but the usefulness of these
agents is not well established. (Level of Evidence: C) [Editor’s note:
there are high-quality data attesting to the safety and efficacy of procainamide for pharmacologic cardioversion of AF.2]
Class III
1. Digoxin and sotalol may be harmful when used for pharmacological cardioversion of AF and are not recommended. (Level of
Evidence: A)
8.2.6 Pharmacological Enhancement Of Direct-Current
Cardioversion
Recommendations:
Class IIa
1. Pretreatment with amiodarone, flecainide, ibutilide, propafenone,
or sotalol can be useful to enhance the success of direct-current
cardioversion and prevent recurrent AF. (Level of Evidence: B)
2. In patients who relapse to AF after successful cardioversion, it can
be useful to repeat the procedure following prophylactic administration of antiarrhythmic medication. (Level of Evidence: C)
8.2 Direct-Current Cardioversion Of Atrial Fibrillation And Flutter
Recommendations:
Class I
1. When a rapid ventricular response does not respond promptly to
pharmacological measures for patients with AF with ongoing myocardial ischemia, symptomatic hypotension, angina, or HF, immediate R-wave synchronized direct-current cardioversion is recommended. (Level of Evidence: C)
2. Immediate direct-current cardioversion is recommended for patients with AF involving pre-excitation when very rapid tachycardia
or hemodynamic instability occurs. (Level of Evidence: B)
3. Cardioversion is recommended in patients without hemodynamic
instability when symptoms of AF are unacceptable to the patient. In
case of early relapse of AF after cardioversion, repeated direct-current cardioversion attempts may be made following administration
of antiarrhythmic medication. (Level of Evidence: C)
Class IIb
1. For patients with persistent AF, administration of beta-blockers,
disopyramide, diltiazem, dofetilide, procainamide, or verapamil may
be considered, although the efficacy of these agents to enhance
the success of direct-current cardioversion or to prevent early recurrence of AF is uncertain. (Level of Evidence: C)
8.2.7 Prevention Of Thromboembolism In Patients With Atrial
Fibrillation Undergoing Cardioversion
Recommendations:
Class I
1. For patients with AF of 48-hour duration or longer, or when the duration of AF is unknown, anticoagulation (INR 2.0 to 3.0) is recommended for at least 3 weeks prior to and 4 weeks after cardiover-
Class IIa
1. Direct-current cardioversion can be useful to restore sinus rhythm
as part of a long-term management strategy for patients with AF.
(Level of Evidence: B)
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b. For patients in whom thrombus is identified by TEE, oral anticoagulation (INR 2.0 to 3.0) is reasonable for at least 3 weeks
prior to and 4 weeks after restoration of sinus rhythm, and a
longer period of anticoagulation may be appropriate even after
apparently successful cardioversion, because the risk of thromboembolism often remains elevated in such cases. (Level of
Evidence: C)
3. For patients with AFL undergoing cardioversion, anticoagulation
can be beneficial according to the recommendations as for patients
with AF. (Level of Evidence: C)
sion, regardless of the method (electrical or pharmacological) used
to restore sinus rhythm. (Level of Evidence: B)
2. For patients with AF of more than 48-hours' duration requiring immediate cardioversion because of hemodynamic instability, heparin
should be administered concurrently (unless contraindicated) by an
initial IV bolus injection followed by a continuous infusion in a dose
adjusted to prolong the activated partial thromboplastin time to 1.5
to 2 times the reference control value. Thereafter, oral anticoagulation (INR 2.0 to 3.0) should be provided for at least 4 weeks, as for
patients undergoing elective cardioversion. Limited data support
subcutaneous administration of LMWH in this indication. (Level of
Evidence: C)
3. For patients with AF of less than 48 hours' duration associated with
hemodynamic instability (angina pectoris, myocardial infarction,
shock, or pulmonary edema) cardioversion should be performed
immediately without delay for prior initiation of anticoagulation.
(Level of Evidence: C)
8.3 Maintenance Of Sinus Rhythm
Recommendations:
Class I
Before initiating antiarrhythmic drug therapy, treatment of precipitating
or reversible causes of AF is recommended. (Level of Evidence: C)
Class IIa
1. Pharmacological therapy can be useful in patients with AF to maintain sinus rhythm and prevent tachycardia-induced cardiomyopathy. (Level of Evidence: C)
2. Infrequent, well-tolerated recurrence of AF is reasonable as a successful outcome of antiarrhythmic drug therapy. (Level of Evidence: C)
Class IIa
1. During the first 48 hours after onset of AF, the need for anticoagulation before and after cardioversion may be based on the patient’s
risk of thromboembolism. (Level of Evidence: C)
2. As an alternative to anticoagulation prior to cardioversion of AF, it
is reasonable to perform transesophageal echocardiography (TEE)
in search of thrombus in the left atrium or left atrium appendage.
(Level of Evidence: B)
a. For patients with no identifiable thrombus, cardioversion is
reasonable immediately after anticoagulation with UFH (eg,
initiate by IV bolus injection and an infusion continued at a dose
adjusted to prolong the activated partial thromboplastin time to
1.5 to 2 times the control value until oral anticoagulation has
been established with a vitamin K antagonist (eg, warfarin), as
evidenced by an INR ≥ 2.0). (Level of Evidence: B)
Thereafter, oral anticoagulation (INR 2.0 to 3.0) is reasonable
for a total anticoagulation period of at least 4 weeks, as for patients undergoing elective cardioversion. (Level of Evidence: B)
Limited data are available to support the subcutaneous administration of a LMWH in this indication. (Level of Evidence: C)
EM Practice Guidelines Update © 2012
Class III
1. Antiarrhythmic therapy with a particular drug is not recommended
for maintenance of sinus rhythm in patients with AF who have welldefined risk factors for proarrhythmia with that agent. (Level of
Evidence: A)
2. Pharmacological therapy is not recommended for maintenance of
sinus rhythm in patients with advanced sinus node disease or AV
node dysfunction unless they have a functioning electronic cardiac
pacemaker. (Level of Evidence: C)
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8.4.3 Wolff-Parkinson-White Pre-excitation Syndromes
Recommendations:
Class I
2. Immediate direct-current cardioversion is recommended to prevent
ventricular fibrillation in patients with a short anterograde bypass
tract refractory period in whom AF occurs with a rapid ventricular
response associated with hemodynamic instability. (Level of Evidence: B)
3. IV procainamide or ibutilide is recommended to restore sinus
rhythm in patients with Wolff-Parkinson-White (WPW) syndromes
in whom AF occurs without hemodynamic instability in association
with a wide QRS complex on the electrocardiogram (ECG) (greater
than or equal to 120-ms duration) or with a rapid pre-excited ventricular response. (Level of Evidence: C)
8.4.2 Acute Myocardial Infarction
Recommendations:
Class I
1. Direct-current cardioversion is recommended for patients with
severe hemodynamic compromise or intractable ischemia or when
adequate rate control cannot be achieved with pharmacological
agents in patients with acute myocardial infarction and AF. (Level
of Evidence: C)
2. IV administration of amiodarone is recommended to slow a rapid
ventricular response to AF and improve left ventricular (LV) function
in patients with acute myocardial infarction. (Level of Evidence: C)
3. IV beta-blockers and nondihydropyridine calcium antagonists are
recommended to slow a rapid ventricular response to AF in patients with acute myocardial infarction who do not display clinical
LV dysfunction, bronchospasm, or atrioventricular block. (Level of
Evidence: C)
4. For patients with AF and acute myocardial infarction, administration
of UFH by either continuous IV infusion or intermittent subcutaneous injection is recommended in a dose sufficient to prolong the
activated partial thromboplastin time to 1.5 to 2.0 times the control
value, unless contraindications to anticoagulation exist. (Level of
Evidence: C)
Class IIa
IV flecainide or direct-current cardioversion is reasonable when very
rapid ventricular rates occur in patients with AF involving conduction
over an accessory pathway. (Level of Evidence: B)
Class IIb
It may be reasonable to administer IV quinidine, procainamide, disopyramide, ibutilide, or amiodarone to hemodynamically stable patients
with AF involving conduction over an accessory pathway. (Level of
Evidence: B)
Class IIa
IV administration of digitalis is reasonable to slow a rapid ventricular
response and improve LV function in patients with acute myocardial
infarction and AF associated with severe LV dysfunction and heart
failure. (Level of Evidence: C)
Class III
IV administration of digitalis glycosides or nondihydropyridine calcium
channel antagonists is not recommended in patients with WPW syndromes who have pre-excited ventricular activation during AF. (Level
of Evidence: B)
Class III
The administration of class IC antiarrhythmic drugs is not recommended in patients with AF in the setting of acute myocardial infarction.
(Level of Evidence: C)
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8.4.4 Hyperthyroidism
Recommendations:
Class I
1. Administration of a beta-blocker is recommended to control the rate
of ventricular response in patients with AF complicating thyrotoxicosis, unless contraindicated. (Level of Evidence: B)
2. In circumstances when a beta-blocker cannot be used, administration of a nondihydropyridine calcium channel antagonist (diltiazem
or verapamil) is recommended to control the ventricular rate in
patients with AF and thyrotoxicosis. (Level of Evidence: B)
3. In patients with AF associated with thyrotoxicosis, oral anticoagulation (INR 2.0 to 3.0) is recommended to prevent thromboembolism,
as recommended for AF patients with other risk factors for stroke.
(Level of Evidence: C)
4. Once a euthyroid state is restored, recommendations for antithrombotic prophylaxis are the same as for patients without hyperthyroidism. (Level of Evidence: C)
8.4.7 Pulmonary Diseases
Recommendations:
Class I
1. Correction of hypoxemia and acidosis is the recommended primary
therapeutic measure for patients who develop AF during an acute
pulmonary illness or exacerbation of chronic pulmonary disease.
(Level of Evidence: C)
2. A nondihydropyridine calcium channel antagonist (diltiazem or
verapamil) is recommended to control the ventricular rate in patients with obstructive pulmonary disease who develop AF. (Level
of Evidence: C)
3. Direct-current cardioversion should be attempted in patients with
pulmonary disease who become hemodynamically unstable as a
consequence of AF. (Level of Evidence: C)
Class III
1. Theophylline and beta-adrenergic agonist agents are not recommended in patients with bronchospastic lung disease who develop
AF. (Level of Evidence: C)
2. Beta-blockers, sotalol, propafenone, and adenosine are not recommended in patients with obstructive lung disease who develop AF.
(Level of Evidence: C) ■
8.4.5 Pregnancy
Recommendations:
Class I
1. Digoxin, a beta-blocker, or a nondihydropyridine calcium channel
antagonist is recommended to control the rate of ventricular response in pregnant patients with AF. (Level of Evidence: C)
2. Direct-current cardioversion is recommended in pregnant patients
who become hemodynamically unstable due to AF. (Level of Evidence: C)
3. Protection against thromboembolism is recommended throughout
pregnancy for all patients with AF (except those with lone AF and/
or low thromboembolic risk). Therapy (anticoagulant or aspirin)
should be chosen according to the stage of pregnancy. (Level of
Evidence: C)
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Editorial Comment
Unstable Patients
According to AHA/CCS/ESC/JCS, unstable patients (hypotension,
heart failure, ischemic chest pain, altered mentation) not responding
to pharmacotherapy should receive immediate R-wave synchronized
direct-current cardioversion. Biphasic waveform is preferred for its
lower energy requirement and greater success rates. Initial electrical
doses should be 150 to 200 J for biphasic devices in order to increase
likelihood of initial success and limit the cumulative dose from multiple
attempts. These recommendations also apply to patients who are
pregnant or have pulmonary disease, cardiomyopathy, or thyrotoxicosis. Both the AHA and CCS recommend that in unstable patients with
AF of > 48 hours' (or unknown) duration requiring prompt cardioversion, heparin should be administered concurrently with bolus followed
by infusion to achieve prothrombin time (PTT) 2x reference control,
with OAC started thereafter.
Pharmacological Rate Control Of Atrial Fibrillation In The Absence Of Pre-excitation Syndrome
Rate-slowing agents such as beta-blockers or nondihydropyridine
calcium channel antagonists are recommended for rate control of
stable patients with AF or AFL. The CCS recommends beta-blockers
as the initial agent in patient with myocardial infarction. If the patient
has concomitant HF, digoxin or amiodarone is recommended. Digoxin
can be given in combination with a calcium channel antagonist or betablocker; digoxin monotherapy is not recommended. If these agents
fail to adequately control rate, amiodarone can be administered. This
recommendation is similar across all societies except CCS, which
recommends dronedarone instead of amiodarone when additional
rate control is needed due to the ATHENA trial, which demonstrated
that drondedarone was associated with reduced hospitalizations and
cardiac mortality.
Electrical cardioversion is not as effective at converting AF to normal
sinus rhythm as it is with other arrhythmias. Although electrical cardioversion is the recommended first-line therapy in the unstable patient,
emergency clinicians should be prepared for failure of this modality and
be prepared with other strategies, which may include vasopressors in
combination with AV nodal blocking agents, calcium in combination with
calcium channel blockers, amiodarone, and magnesium.
Preventing Thromboembolism
For patients with AF/AFL of an unknown period of time or > 48 hours,
antithrombotic therapy to prevent thromboembolism is recommended.
The selection of antithrombotic agent is based on risk of stroke using CHADS2 (cardiac failure, hypertension, age, diabetes, and prior
stroke); the ESC/CCS recommends an expanded acronym CHA2DS2VASc (congestive heart failure, hypertension, age > 75 years, diabetes, stroke, vascular disease, age 65-74, and female sex). Scoring
is similar to CHADS2. Anticoagulation should be continued at least 3
weeks before and at least 4 weeks postcardioversion.
Rate Versus Rhythm Control
The decision regarding rate versus rhythm control is controversial.
There is no evidence showing mortality benefit or decreased risk of
thromboembolism using rhythm control over rate control.4 The decision
should be based on onset of symptoms, severity of symptoms, comorbidities, results of past treatments (if applicable), and physician comfort
and preference. The more confidently the onset of symptoms can be
established to be < 48 hours, and the younger and more active the
patient, the stronger is the indication for primary rhythm control over
rate control.
EM Practice Guidelines Update © 2012
For patients with AF duration < 48 hours, CCS generally recommends
cardioversion without prior or subsequent anticoagulation unless at
significant risk, ie, mechanical valve, rheumatic heart disease, recent
stroke, or TIA. The AHA has similar recommendations.
Editorial Comment continued on page 14 >>
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Agents For Thromboembolism
Based on risk score, either a Vitamin K antagonist or aspirin can
be used. CCS and ESC describe the use of newer agents for OAC,
including dabigatran. CCS updated its guideline, giving dabigatran a
Class I recommendation as an alternative to warfarin in patients who
do not have a prosthetic heart valve, hemodynamically significant
valve disease, severe renal failure (creatinine clearance < 15 mL/min),
or advanced liver disease (impaired baseline clotting function).
Wolf-Parkinson-White Pre-excitation Syndromes
If hemodynamically unstable, direct-current cardioversion is recommended. IV procainamide or ibutilide is recommended for cardioversion in patients with WPW syndromes who have AF without hemodynamic instability, associated with wide QRS complex (> 120 ms) or
rapid ventricular response. AV nodal blocking agents such as digoxin,
beta-blockers, adenosine, or calcium channel antagonists are contraindicated, as these agents will increase atrial conduction through the
accessory pathway, which, without the dromotropic effect of the AV
node, will conduct to ventricles at unstainably high rates and potentially
cause degeneration into ventricular fibrillation.
Risk Of Bleeding
An assessment of bleeding risk should be made prior to starting anticoagulation. ESC/CCS discussed a newly derived risk score using a
cohort of European patients with AF called HAS-BLED (hypertension,
abnormal renal/liver function, stroke, bleeding history or predisposition,
labile INR, elderly (> 65 years of age), and use of drugs/alcohol) where
a score > 3 indicated high risk, and caution is needed when administering warfarin or aspirin.
Disposition
Disposition from the ED is only discussed in CCS guidelines. CCS recommends that only symptomatic patients or patients with insufficient
rate control be admitted. Otherwise, patients can be discharged in 6 to
12 hours with urgent cardiology follow-up. While this recommendation
is primarily informed by a single trial10 and must be adapted to individual practice environments, this practice has the potential to reduce
resource utilization in many American centers which routinely admit all
patients with new AF. ■
Pharmacological Conversion Of Atrial Fibrillation In Absence Of
Pre-excitation Syndrome
Propafenone or flecainide (Class I antiarrhythmic) are recommended
for cardioversion in the absence of structural heart disease/AV nodal
disease; as mentioned earlier, procainamide is also well-supported
in this setting. Amiodarone should be considered if structural disease
is present. This distinction is not discussed in AHA guidelines, but is
recommended by the ESC/CCS.
Direct-Current Cardioversion
Antiarrythmic drugs may be used to pretreat patients in order to decrease recurrence of AF and enhance cardioversion efficacy. If normal
sinus rhythm is achieved, the need for OAC should be determined
using aforementioned risk scores for thromboembolism and early
consultant follow-up should be arranged. Electrical cardioversion is
contraindicated in patients with digoxin toxicity or hypokalemia. Refer
to the previous section on unstable patients for further comments on
direct-current cardioversion.
EM Practice Guidelines Update © 2012
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References
CME Questions
1. Khoo CW, Lip GY. Burden of atrial fibrillation. Curr Med Res Opin.
2009;25:1261-1263. (Editorial commentary)
2. Steill IG, Macle L, CCS Atrial Fibrillation Guidelines Committee. Canadian
Cardiovascular Society atrial fibrillation guidelines 2010: management of
recent-onset atrial fibrillation and flutter in the emergency department. Can J
Cardiol. 2011;27(1):38-46. (Clinical guidelines)
To take the CME test, visit: www.ebmedicine.net/CME
1. Immediate electrical cardioversion is most appropriate for which of
the following patients presenting with rapid AF?
a. 91-year-old man with improved symptoms after IV diltiazem
b. 42-year-old woman with spontaneous conversion to normal
sinus rhythm
c. 68-year-old woman with unstable vital signs
d. 53-year-old man with rate control achieved after IV metoprolol
3. Gillis AM, Skanes AC, CCS Atrial Fibrillation Guidelines Committee. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: implementing
GRADE and achieving consensus. Can J Cardiol. 2011;27(1):27-30. (Clinical
guidelines)
4. Gillis AM, Verma A, Talajic M, et al. Canadian Cardiovascular Society atrial
fibrillation guidelines 2010: rate and rhythm management. Can J Cardiol.
2011;27(1):47-59. (Clinical guidelines)
2. Which of the following is indicated prior to initiating cardioversion in
a hemodynamically stable patient with AF of > 48 hours’ duration?
a. Rate control
b. Anticoagulation for 3 weeks
c. INR of 2 to 3
d. All of the above
e. None of the above
5. Cairns JA, Connolly S, McMurtry S, et al. Canadian Cardiovascular Society
atrial fibrillation guidelines 2010: prevention of stroke and systemic thromboembolism in atrial fibrillation and flutter. Can J Cardiol. 2011;27:74-90. (Clinical guidelines)
6. Fuster V, Ryden LE, Cannom DS, et al. 2011 ACCF/AHA/HRS focused
updates incorporated into the ACC/AHA ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of
Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines. Circulation. 2011;123(10):e269-e367. (Clinical guidelines)
3. A 51-year-old man with no prior cardiac disease presents with rapid
AF. His blood pressure is stable and he is asymptomatic. There
is no accessory pathway indicated on ECG. Which of the following medications should be administered first in order to control the
patient's rate?
a. Amiodarone
c. Procainamide
b. Ibutilide
d. Verapamil
7. European Heart Rhythm Association; European Association for Cardio-Thoracic Surgery, Camm AJ, et al. Guidelines for the management of atrial fibrillation. Eur Heart J. 2010;31(19):2369-2429. (Clinical guidelines) Erratum in
Eur Heart J. 2011;32(9):1172.
8. JCS Joint Working Group. Guidelines for pharmacotherapy of atrial fibrillation (JCS 2008): digest version. Circ J. 2010;74(11): 2479-2500. (Clinical
guidelines)
4. After multiple failed attempts at rate-controlling a patient's AF, a
strategy to convert the patient's rhythm by pharmacological cardioversion is considered. Which of the following medications is most
appropriate to administer in order to achieve conversion to sinus
rhythm?
a. Digoxin
c. Dofetilide
b. Diltiazem
d. Dronedarone
9. 2011 Writing Group Members, Wann LS, Curtis AB, et al. 2011 ACCF/AHA/
HRS Focused Update on the management of patients with atrial fibrillation
(updating the 2006 guideline): a report of the American College of Cardiology
Foundation/American Association Task Force on Practice Guidelines. Circulation. 2011;123(1):104-123. (Clinical guidelines)
10. Stiell IG, Clement CM, Symington C, et al. Emergency department use of intravenous procainamide for patients with acute atrial fibrillation or flutter. Acad
Emerg Med. 2007;14(12):1158-1164. (Cohort study, 341 patients)
EM Practice Guidelines Update © 2012
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CME information for EM Practice Guidelines Update
To take the CME test, visit: www.ebmedicine.net/cme
To write a letter to the editor, email Reuben Strayer, MD, Editor-In-Chief, at:
[email protected]
Date of Original Release: May 1, 2012. Date of most recent review: April 10, 2012. Termination date: May
1, 2015.
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In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity
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Evidence-B
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ToEv
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Number 7
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EM Practice
Practice Guidelines Update
Update © 2012
EM
EM Practice Guidelines
Guidelines Update ©© 2009
2009
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• May 2012
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•• November
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