Acute Treatment Of Atrial Fibrillation Research Articles

Heterogeneity in the role of emergency physicians and treatment of acute atrial fibrillation in emergency departments—results of the International Atrial Fibrillation Background (AFiB) Study

The consept of emergency departments (EDs) with specialized teams of emergency physicians originated in the United Kingdom and the United States during the 1970s and was expanded across most European countries in the twenty-first century. Among the various cardiac arrhythmias encountered in EDs, atrial fibrillation (AF) is the most prevalent, contributing to ED congestion. Existing guidelines offer multiple treatment options for acute-onset AF occurring within 48 hours. The aim of The Atrial Fibrillation Background Study is to evaluate treatment strategies, practices and the role of emergency physicians in managing acute-onset AF in Western medical tradition across Europe, the United States and China (Hong Kong). The data for this nonexperimental survey were collected through a questionnaire administered to the medical director or a senior physician at each of the 12 participating EDs. We obtained information regarding the total number of physicians employed in these EDs, their respective specialties, and the patient caseloads they managed. Additionally, we gathered data on the diagnostic and treatment protocols employed for atrial fibrillation (AF). In the investigated EDs in Hong Kong, the United Kingdom and the United States, patients were treated by emergency physicians. Comparatively, many European EDs primarily relied on physicians with traditional medical specialties. Diagnostic methods employed for acute AF ranged from point-of-care testing to comprehensive laboratory panels and echocardiography. In terms of AF treatment, rate control was the preferred approach in Hong Kong and the USA EDs, while rhythm control was preferred in European settings. Regarding rhythm control, there were considerable variations in preferences between pharmacological and electrical cardioversion methods. Findings from the AFiB Study highlight the growing significance of emergency physicians in the management of acute AF, as well as the divergent treatment approaches for acute AF observed in EDs between Europe and the United States.

Association of Intravenous Potassium and Magnesium Administration With Spontaneous Conversion of Atrial Fibrillation and Atrial Flutter in the Emergency Department

Whether the simultaneous intravenous administration of potassium and magnesium is associated with the probability of spontaneous conversion to sinus rhythm (SCV) in the acute treatment of atrial fibrillation (AF) and atrial flutter (AFL) is unknown. To assess potassium and magnesium administration and SCV probability in AF and AFL in the emergency department. A registry-based cohort study was conducted in the Department of Emergency Medicine of the Medical University of Vienna, Austria. All consecutive patients with AF or AFL were screened between February 6, 2009, and February 16, 2020. Intravenous administration of potassium, 24 mEq, and magnesium, 145.8 mg. The primary outcome was the probability of SCV during the patient's stay in the emergency department. Multivariable cluster-adjusted logistic regression was used to estimate the association between potassium and magnesium administration and the probability of SCV. A total of 2546 episodes of nonpermanent AF (median patient age, 68 [IQR, 58-75] years, 1411 [55.4%] men) and 573 episodes of nonpermanent AFL (median patient age, 68 [IQR, 58-75] years; 332 [57.9%] men) were observed. In AF episodes, intravenous potassium and magnesium administration vs no administration was associated with increased odds of SCV (19.2% vs 10.4%; odds ratio [OR], 1.98; 95% CI, 1.53-2.57). In AFL episodes, in contrast, no association was noted for the probability of SCV with potassium and magnesium vs no administration (13.0% vs 12.5%; OR, 1.05; 95% CI, 0.65-1.69). The findings of this registry-based cohort study on intravenous administration of potassium and magnesium suggest an increased probability of SCV in nonpermanent AF, but not AFL, during a patients' stay in the emergency department.

The Physical Compatibility of Clinically Used Concentrations of Diltiazem Hydrochloride With Heparin Sodium.

Background: Acute treatment of atrial fibrillation often requires concomitant intravenous (IV) continuous infusions of unfractionated heparin and diltiazem. Concomitantly infusing these medications through the same IV line minimizes multiple IV sites. Diltiazem and heparin visual compatibility have been previously investigated but with limited drug dwell times and differing drug concentrations leading to inconsistent published results. Objective: To investigate the physical compatibility of diltiazem hydrochloride at concentrations of 5 and 1 mg/mL combined with an equal volume of heparin sodium 100 units/mL. Methods: Using a 0.22-µm filter, 15 mL of heparin sodium were placed into a polyvinyl chloride infusion bag followed by 15 mL of either diltiazem hydrochloride 5 or 1 mg/mL. Admixtures were prepared in triplicate. Each admixture was investigated for visual precipitation, spectrophotometric absorbance, and pH change at baseline and 1, 5, 8, and 24 hours after mixing. Physical incompatibility was determined by visual observation, increased spectrophotometric absorbance, and demonstrative pH changes. Results: Each diltiazem 5 mg/mL admixture exhibited a slight haze and enhanced absorbance readings indicating turbidity while none revealed a demonstrative pH change. None of the diltiazem 1 mg/mL assessments revealed visual precipitation or suggested turbidity. Only one pH reading at 5 hours revealed a demonstrative change from baseline. Conclusions: Our findings indicate that infusing diltiazem hydrochloride 5 mg/mL with heparin sodium 100 units/mL in the same IV line cannot be advocated. In contrast, our findings suggest that heparin sodium 100 units/mL infused with diltiazem hydrochloride 1 mg/mL is physically compatible but chemical stability was not assessed.

Treating arrhythmias with adjunctive magnesium: identifying future research directions.

Magnesium is the fourth most abundant cation in the human body and is the second most prevalent cation in intracellular tissues. Myocardial cell action potentials are mediated by voltage-dependent Na+, K+, and Ca2+ channels which, when their function is altered, can lead to the genesis of cardiac dysrythmias. Magnesium regulates the movement of ions through these channels within myocardial tissues. The potential ability of magnesium supplementation to prevent and/or treat arrhythmias has been recognized in clinical medicine for years. This includes termination of torsade de pointes, prevention of post-operative atrial fibrillation, acute treatment of atrial fibrillation, and improving the efficacy and safety of antiarrhythmic drugs. Despite what is currently known about magnesium's therapeutic potential, a number of limitations and gaps to the literature exist. This includes an unclear link between correction of intracellular magnesium concentrations and both mechanistic and clinical outcomes, small sample sizes, varying routes of administration and doses, as well as short follow-up periods. This review highlights these gaps and recommends areas of need for future research.

Oral carvedilol in escalating doses in the acute treatment of atrial fibrillation.

Objective:To study the efficacy of oral carvedilol in acute treatment of atrial fibrillation (AF) with fast ventricular rate.Materials and Methods:In an open-label, single-arm trial, oral carvedilol was administered to 35 patients of AF in escalating doses from 3.125 mg o.d. to 12.5 mg b.i.d.Results:A successful result was seen in 25 patients (71.4%) with 4 converting to sinus rhythm, rate control to less than 90 bpm in 16 and a 20% rate reduction in 5 patients. Two patients developed hypotension needing withdrawal of the drug.Conclusion:Escalating doses of oral carvedilol can be effectively and safely used in the acute treatment of AF with fast ventricular rate.

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Introduction: Approximately 84% of patients have an acute deterioration within 8 to 48 hours of cardiac arrest, most often manifested as hypotension or tachypnea. Accordingly, the Institute for Healthcare Improvement recommends implementation of rapid response teams as a part of their 100,000 Lives Campaign to reduce preventable hospital deaths. Currently at Froedtert Hospital, ACLS trained pharmacists respond to medical emergencies 24/7, but do not have a formal role on the rapid response team (RRT). Prior studies investigating pharmacist presence only evaluated interventions and team perceptions, but have not evaluate outcomes. Methods: This was a retrospective, pre-post interventional study that evaluated 161 patients before and 175 patients after pharmacist implementation on a rapid response team. Patients who were admitted as inpatients between August and October 2012 or between March and May 2013 were included in either the pre-interventional or pilot arm, respectively. Patients were excluded if they were an outpatient, a visitor, a clinic patient, an intensive care unit or emergency department patient or had a rapid response that progressed immediately into a medical emergency. The primary outcome was turnaround time for medication administration, with a goal turnaround time of less than 30 minutes. Pertinent descriptive secondary outcomes consisted of the most frequently administered medications, the indications for RRT, and the number of rapid responses that result in subsequent ICU admission and medical emergencies. RRT calls within 24 hours of admission or 48 hours of ICU discharge, total and post RRT call hospital length of stay, survival to hospital discharge, and pharmacist interventions on the RRT were also evaluated. Results: The addition of a pharmacist decreased medication turnaround time (mean = 45 min +/- 5 vs. 3 min +/- 4; median = 31 vs. 28 min, p = 0.278) and trended towards more patients with an acceptable turnaround time of under 30 minutes (49.1% vs. 57.1%, p = 0.155). The most frequently administered classes of medications were for the acute treatment of atrial fibrillation (22.1% vs. 15.1%), acute treatment of seizures (5.3% vs. 9.2%), analgesics (8.4% vs. 5.9%), antibiotics (8.4% vs. 12.6 %), reversal agents (14.7% vs. 17.6%), and other medications (41.1% vs. 39.5%, p = 0.52). No other variables were different between the two groups besides number of medication changes post-RRT, which were greater in the pre-interventional arm (43.4% vs. 56.1%, p = 0.002). Pharmacists documented on only 90/162 patients (55.5%), while 18/90 patients (20%) had documented a pharmacist intervention on dosing, preparing emergent medications, and drug/patient information. Conclusions: The addition of a pharmacist to a rapid response team reduced time to medication administration and helped improve the medication use process by identifying areas for improvement.

RHYTHM-AF: design of an international registry on cardioversion of atrial fibrillation and characteristics of participating centers

BackgroundAtrial fibrillation is a serious public health problem posing a considerable burden to not only patients, but the healthcare environment due to high rates of morbidity, mortality, and medical resource utilization. There are limited data on the variation in treatment practice patterns across different countries, healthcare settings and the associated health outcomes.Methods/designRHYTHM-AF was a prospective observational multinational study of management of recent onset atrial fibrillation patients considered for cardioversion designed to collect data on international treatment patterns and short term outcomes related to cardioversion. We present data collected in 10 countries between May 2010 and June 2011. Enrollment was ongoing in Italy and Brazil at the time of data analysis. Data were collected at the time of atrial fibrillation episode in all countries (Australia, Brazil, France, Germany, Italy, Netherlands, Poland, Spain, Sweden, United Kingdom), and cumulative follow-up data were collected at day 60 (±10) in all but Spain. Information on center characteristics, enrollment data, patient demographics, detail of atrial fibrillation episode, medical history, diagnostic procedures, acute treatment of atrial fibrillation, discharge information and the follow-up data on major events and rehospitalizations up to day 60 were collected.DiscussionA total of 3940 patients were enrolled from 175 acute care centers. 70.5% of the centers were either academic (44%) or teaching (26%) hospitals with an overall median capacity of 510 beds. The sites were mostly specialized with anticoagulation clinics (65.9%), heart failure (75.1%) and hypertension clinics (60.1%) available. The RHYTHM-AF registry will provide insight into regional variability of antiarrhythmic and antithrombotic treatment of atrial fibrillation, the appropriateness of such treatments with respect to outcomes, and their cost-efficacy. Observations will help inform strategies to improve cardiovascular outcomes in patients with atrial fibrillation.Trial registrationClinical trials NCT01119716

A 2-year survey of treatment of acute atrial fibrillation in an ED

A 2-year survey of treatment of acute atrial fibrillation in an ED

Identifying Temporal Changes to the Prescribing of Anti‐Arrhythmics for Atrial Fibrillation

ABSTRACTBackgroundThere are a paucity of data on the use of anti‐arrhythmics for atrial fibrillation (AF), particularly in view of new treatment guidelines recommending rate control over rhythm control.AimTo investigate the use of anti‐arrhythmics for AF in the local clinical setting.MethodA retrospective clinical audit of the medical records of 174 adult patients with primary or secondary AF was conducted at a large Sydney teaching hospital. Data were collected on patients' characteristics, medical history, factors affecting treatment choice and clinical outcomes.ResultsFor acute treatment of AF, 38 (22%) patients received rhythm control only, 30 (17%) received rate control only, and 42 (24%) received rate control plus rhythm control. For long‐term management of AF, 24 (14%) patients received rhythm control only, 42 (24%) received rate control only, and 28 (16%) received rate control plus rhythm control. The number of patients who attained sinus rhythm was higher in those receiving rhythm control drugs versus rate control drugs (84% vs 31%; p < 0.05). A decrease was observed in the number of patients on digoxin (41% vs 6%; p < 0.01) and amiodarone (26% vs 6%; p < 0.001). Factors identified as influencing treatment choice were age, heart rate, AF characteristics and comorbidities.ConclusionThere has been a temporal change in the use of anti‐arrhythmics for AF, reflecting changes to recommendations on the use of rhythm versus rate control drugs. These changes in prescribing patterns are reflective of current guidelines and evidence‐based practice.

A 2-year survey of treatment of acute atrial fibrillation in an ED

Objective Pharmacologic cardioversion of atrial fibrillation (AF) is a reasonable mode of treatment if the arrhythmia is of recent onset. Results concerning the response rates of different drugs, respectively, in daily clinical practice and data with regard to the parameters associated with successful cardioversion are not very prevalent. Methods Three-hundred seventy-six patients who were admitted to the emergency department with acute AF and a duration of shorter than 48 hours were enrolled into the AF registry. Results The most effective drugs were flecainide and ibutilide (95% and 76%). Low response rates were observed with amiodarone (36%) and the individual use of digoxin or diltiazem (19% and 18%). Factors associated with a successful cardioversion were a lower blood pressure on admission ( P = .002), a shorter time interval between the onset of AF and admission to the ED ( P = .003), and adherence to treatment guidelines ( P < .0001). Conclusion The use of flecainide and ibutilide is associated with a much higher rate of cardioversion than other drugs we studied.

Accelerated AV Nodal Conduction with Use of Procainamide in Atrial Fibrillation

Background: Atrial fibrillation is a common dysrhythmia seen in the emergency department (ED). Chemical or electrical cardioversion may be performed on patients who have had atrial fibrillation for < 48 h duration and who are at low risk for thromboembolic events. Multiple studies suggest that intravenous procainamide is an appropriate agent in the treatment of acute atrial fibrillation due to its relatively low risk profile and high conversion rate. Objectives: A case is presented that demonstrates an adverse reaction to the use of intravenous procainamide for chemical cardioversion of atrial fibrillation in an otherwise hemodynamically stable patient. Case Report: We report a case of lone paroxysmal atrial fibrillation in a patient with a structurally normal heart who suffered paradoxical accelerated atrioventricular nodal conduction and secondary hypotension in response to procainamide administration. Conclusion: When administering procainamide for chemical cardioversion of atrial fibrillation, a low threshold should be maintained for administration of a complementary rate-controlling agent, and facilities for immediate electrical cardioversion always must be available.

Vernakalant

Vernakalant is an atrial-selective antiarrhythmic drug discovered by Cardiome Pharma (formerly Nortran Pharmaceuticals). Vernakalant may have potential in the treatment of atrial arrhythmias, including acute atrial fibrillation and atrial flutter. Vernakalant is a mixed sodium/potassium channel blocker and selectively blocks ion channels in the heart that are known to be active during episodes of atrial fibrillation. An IV formulation of vernakalant is awaiting registration in the US for the acute conversion of atrial fibrillation. Also, an oral formulation of the compound is in phase II clinical development as a chronic-use product for the maintenance of normal heart rhythm following termination of atrial fibrillation. Cardiome is seeking co-development partners for intravenous vernakalant in the treatment of atrial arrhythmia, atrial fibrillation and atrial flutter in Europe and Japan. In October 2003, Cardiome Pharma and Fujisawa Healthcare, the US subsidiary of Fujisawa Pharmaceutical Co., Ltd (now Astellas Pharma), executed a $US68 million strategic partnership agreement for the co-development of vernakalant. On 1 April 2005, Fujisawa merged with Yamanouchi to form Astellas Pharma. The partnership grants Astellas Pharma exclusive commercialisation rights for vernakalant. Under the terms of the agreement, Cardiome and Astellas Pharma will co-develop vernakalant as an intravenous formulation for the treatment of atrial fibrillation and atrial flutter for North American markets. Astellas Pharma will be financially responsible for 75% of all future clinical development costs, with Cardiome responsible for the remaining 25% of costs. Astellas Pharma will be responsible for the development plan, NDA application (and NDA re-submission costs) and registration, along with the commercial manufacturing, marketing and sale of vernakalant. Cardiome will manage the phase III trials ACT 1 and ACT 2 and will also be responsible for the continued manufacturing of clinical supplies of vernakalant. Cardiome will receive royalties on end-user sales of vernakalant reflective of Cardiome's 25% share of development costs and other financial considerations. Product rights to the IV formulation of vernakalant for markets outside of North America and world rights to the oral formulation of vernakalant for chronic atrial fibrillation are not included within the scope of this partnership. Cardiome intends to form future additional alliances for these product opportunities or maintain such opportunities for commercialisation on its own. Cardiome and Astellas amended their agreement for vernakalant in relation to the re-submission of the NDA with the US FDA. Under the terms of the new agreement, Astellas agreed to fund 100% of the costs associated with re-submission, including engagement and external consultants. Astellas also agreed to modify the timing of the $US10 million NDA milestone to the date of resubmission. In February 2005, Cardiome Pharma received a $US6 million milestone payment from its co-development partner, Fujisawa Healthcare Inc. This milestone payment was triggered by the successful completion of ACT 1.A pivotal phase II trial demonstrated in September 2002 that vernakalant rapidly and effectively terminated recent onset atrial fibrillation and the study met both primary and secondary study endpoints. Following discussions with the FDA, Cardiome initiated three separate phase III clinical trials in order to enable Cardiome to apply for marketing approval for vernakalant. In August 2003, Cardiome Pharma commenced patient dosing in its first phase III efficacy study of vernakalant for the acute treatment of atrial fibrillation. This initial study, called ACT 1 (Atrial fibrillation Conversion Trial 1), measured the safety and efficacy of vernakalant in 416 patients with atrial arrhythmias. The placebo-controlled study was carried out in 45 centers in the US, Canada and Scandinavia. The ACT 1 study included two substudies of 60 patients with atrial flutter and 119 patients with longer term atrial fibrillation. The primary efficacy endpoint was acute conversion of atrial arrhythmia to normal heart rhythm. Cardiome commenced its second phase III efficacy study in March 2004, known as ACT 2. The ACT 2 study in post-cardiac surgery (coronary artery bypass graft) patients with atrial fibrillation, evaluated the safety and efficacy of vernakalant (IV) in the termination of atrial arrhythmias in patients after cardiac surgery. Around 210 patients from 25 centres in the US, Canada and Europe were enrolled in this study. The primary efficacy endpoint was acute conversion of atrial arrhythmias to normal heart rhythm. The ACT 2 study is ongoing. The third phase III study, known as ACT 3 (Atrial arrhythmia Conversion Trial 3), was initiated by Cardiome Pharma in July 2004. In September 2005, Cardiome and Astellas reported that ACT 3 had been completed, achieving its primary endpoint, with over half of the 170 patients with recent-onset atrial fibrillation (AF) who received vernakalant intravenously converting to normal heart rhythm, compared with only 4% in the placebo group. The study was being conducted by co-development partner Astellas Pharma and measured the safety and efficacy of intravenous vernakalant in recent onset atrial arrhythmia patients. The placebo-controlled study was being carried out in 276 patients in more than 50 centres throughout the world.ACT 4, a phase III safety study evaluating safety of IV vernakalant in approximately 120 AF patients from 30 centres in the US, Canada and Europe, was initiated in October 2005. Results from this trial are expected to supplement trial results from the pivotal ACT 1 and 3 trials. This study is ongoing. Cardiome Pharma successfully completed phase I studies for its controlled-release oral formulation of vernakalant in 2005. The oral, controlled-release formulation of vernakalant is expected to help prevent or slow the recurrence of atrial fibrillation, and will be used as a follow-on therapy to intravenous vernakalant.

Efficacy and Safety of RSD1235 in the Treatment of Acute Atrial Fibrillation

Efficacy and Safety of RSD1235 in the Treatment of Acute Atrial Fibrillation

Acute Conversion of Atrial Fibrillation in Two Dogs by Intravenous Amiodarone Administration

Journal of Veterinary Internal MedicineVolume 20, Issue 5 p. 1224-1227 Open Access Acute Conversion of Atrial Fibrillation in Two Dogs by Intravenous Amiodarone Administration Mark A. Oyama DVM, DACVIM-Cardiology, Mark A. Oyama DVM, DACVIM-Cardiology Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana, IL. Department of Clinical Sciences, MJR-VHUP-Cardiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA. Department of Clinical Sciences, MJR-VHUP-Cardiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104; e-mail: [email protected]Search for more papers by this authorRobert Prosek, Robert Prosek Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana, IL. Department of Small Animal Clinical Sciences, Veterinary Medical Center, University of Florida, Gainesville, FL.Search for more papers by this author Mark A. Oyama DVM, DACVIM-Cardiology, Mark A. Oyama DVM, DACVIM-Cardiology Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana, IL. Department of Clinical Sciences, MJR-VHUP-Cardiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA. Department of Clinical Sciences, MJR-VHUP-Cardiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104; e-mail: [email protected]Search for more papers by this authorRobert Prosek, Robert Prosek Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana, IL. Department of Small Animal Clinical Sciences, Veterinary Medical Center, University of Florida, Gainesville, FL.Search for more papers by this author First published: 05 February 2008 https://doi.org/10.1111/j.1939-1676.2006.tb00727.xCitations: 15 AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL References 1 Fuster V., Ryden LE, Asinger RW, et al. ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: Executive Summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients with Atrial Fibrillation) Developed in Collaboration with the North American Society of Pacing and Electrophysiology. Circulation 2001; 104: 2118– 2150. 2 Nattel S., Shiroshita-Takeshita A., Brundel BJ, et al. Mechanisms of atrial fibrillation: Lessons from animal models. Prog Cardiovasc Dis 2005; 48: 9– 28. 3 Auer J., Weber T., Berent R., et al. Risk factors of postoperative atrial fibrillation after cardiac surgery. J Card Surg 2005; 20: 425– 431. 4 Martinez EA, Bass EB, Zimetbaum P. Pharmacologic control of rhythm: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery. Chest 2005; 128: 48S– 55S. 5 Slavik RS, Zed PJ. 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Lack of a hypotensive effect with rapid administration of a new aqueous formulation of intravenous amiodarone. Am J Cardiol 2004; 93: 576– 581. 11 Boriani G., Diemberger I., Biffi M., et al. Pharmacological cardioversion of atrial fibrillation: Current management and treatment options. Drugs 2004; 64: 2741– 2762. 12 Fransi S., Briedis J. Anaphylaxis to intravenous amiodarone. Anaesth Intens Care 2004; 32: 578– 579. 13 Stroke Prevention in Atrial Fibrillation Study, Final results. Circulation 1991; 84: 527– 539. 14 Stellbrink C., Schimpf T. Anticoagulation during cardioversion in patients with atrial fibrillation: Current clinical practice. Am J Cardiovasc Drugs 2005; 5: 155– 162. Citing Literature Volume20, Issue5September 2006Pages 1224-1227 ReferencesRelatedInformation

A Randomized Controlled Trial of a Novel Anti-arrhythmic Agent, RSD1235, in the Treatment of Acute Atrial Fibrillation

A Randomized Controlled Trial of a Novel Anti-arrhythmic Agent, RSD1235, in the Treatment of Acute Atrial Fibrillation

Cost-effective management of acute atrial fibrillation: role of rate control, spontaneous conversion, medical and direct current cardioversion, transesophageal echocardiography, and antiembolic therapy

Management strategies for the acute treatment of atrial fibrillation (AF) include: (1) the use of intravenous drugs for rate control, (2) drug termination, or (3) direct current (DC) cardioversion. Delays in cardioversion can promote atrial remodeling and add thromboembolic risk. Rate control awaiting spontaneous or pharmacologic conversion may be a cost-effective strategy in patients presenting with recent onset of symptoms. Early DC cardioversion can be cost-effective and minimize antiembolic therapy issues in the acute setting. In patients presenting with AF of unknown or >48 hours’ duration, rate control and therapeutic warfarin for 3–4 weeks followed by medical or DC cardioversion is standard practice. However, delays in conversion promote atrial remodeling that makes restoration of sinus rhythm more difficult and increases the likelihood of postcardioversion AF recurrence. Transesophageal echocardiography can identify patients at low risk for a cardioversion-related embolic event and allows cardioversion to be performed earlier, thereby minimizing atrial remodeling.

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

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.

Comparison of propafenone versus procainamide for the acute treatment of atrial fibrillation after cardiac surgery

A prospective, randomized, double-blind study to compare the efficacy in terminating postoperative atrial fibrillation of the class Ic drug propafenone versus class Ia drug procainamide was conducted. Intravenous propafenone was superior to procainamide in achieving rapid cardioversion and a better rate control with a lower incidence of symptomatic hypotension.

Acute treatment of atrial fibrillation: spontaneous conversion rates and cost of care

Acute treatment of atrial fibrillation is costly although spontaneous conversion rates are high. We reviewed 114 patients admitted to our inpatient service via the emergency department with a principal diagnosis of atrial fibrillation and found the spontaneous conversion rate was 50% in 48 hours, the average length of stay was 3.9 +/- 5.2 days, and the average cost was $6,692 +/- $4,928.

Acute Treatment of Atrial Fibrillation

Atrial fibrillation (AFib) is a common clinical entity, responsible for significant morbidity and mortality, but it also accounts for a large percentage of healthcare dollar expenditures. Efforts to treat this arrhythmia in the past have focused on subacute antithrombotic therapy and eventually use of antiarrhythmic drugs for maintenance of sinus rhythm. However, there has been a growing interest in the concept of acute electrical and pharmacologic conversion. This treatment strategy has a number of benefits, including immediate alleviation of patient symptoms, avoidance of antithrombotic therapy, and prevention of electrophysiologic remodeling, which is thought to contribute to the perpetuation of the arrhythmia. There is also increasing evidence that this is a cost-effective strategy in that it may obviate admission to the hospital and the cost of long-term therapy. This article represents a summary of the treatments that may be used acutely to control the ventricular response to AFib, prevent thromboembolic events, and provide for acute conversion either pharmacologically or electrically. It includes information on modalities that are currently available and those that are under active development. We anticipate that an active, acute treatment approach to AFib and atrial flutter will become the therapeutic norm in the next few years, especially as the benefits of these interventions are demonstrated in clinical trials.