Acute Management Of Atrial Fibrillation Research Articles

Modern management of acute atrial fibrillation and atrial flutter.

This clinical review is intended to assist emergency physicians manage patients who present to the emergency department (ED) with acute/recent-onset atrial fibrillation (AF) or flutter (AFL). This article is based primarily on the 2021 Canadian Association of Emergency Physicians (CAEP) Acute Atrial Fibrillation/Flutter Best Practices Checklist. We encourage readers to download the open access CAEP Checklist article (https://link.springer.com/article/10.1007/s43678-021-00167-y) and the free smartphone app (CAEP Atrial Fibrillation Guide). We focus on four key elements of ED care: assessment and risk stratification, rate and rhythm control, short-term and long-term stroke prevention, and disposition and follow-up. It is important to determine if AF/AFL with rapid ventricular response is a primary arrhythmia or secondary to medical causes. While it is unusual for patients with primary AF to be unstable, urgent cardioversion is occasionally required. The criteria for when cardioversion is safe have recently changed and it is essential that physicians are well versed in them. When rhythm control is not safe, provide effective and safe IV rate control. When rhythm control is safe, either pharmacological or electrical cardioversion acceptable, per patient and physician preference. Rapid ventricular pre-excitation (Wolff-Parkinson-White Syndrome) usually, but not always, requires urgent electrical cardioversion. ED physicians should prescribe oral anticoagulants at discharge if indicated. No specific direct oral anticoagulant is preferred, and references should be freely consulted for optimal dosing. Hospital admission is rarely required for acute AF/AFL patients, who should be given good discharge instructions.

Safety of Diltiazem for Acute Management of Atrial Fibrillation (AF) in Patients with Heart Failure and Reduced Ejection Fraction in the Emergency Department

BackgroundDiltiazem is an effective rate control agent for atrial fibrillation with rapid ventricular rate (AF RVR). However, its negative inotropic effects may increase the risk for worsening heart failure in patients with a reduced ejection fraction (EF). ObjectivesThis observational study aims to describe the incidence of worsening heart failure in patients who receive intravenous diltiazem for acute atrial fibrillation management. MethodsAdult patients that received diltiazem in the emergency department (ED) for AF RVR (heart rate ≥ 100 beats/min) from 2021 to 2022 and had a prior documented EF were included. The primary outcome is worsening heart failure within 24 h of diltiazem administration. Secondary outcomes include return ED visits and death within 7 days. EF percentage was compared across outcomes using Wilcoxon rank-sum tests. Outcomes were compared by reduced EF (< 50%) and preserved EF (≥ 50%). Continuous data were summarized with medians and interquartile ranges, and categorical features were summarized with frequency counts and percentages. Wilcoxon rank-sum tests were used for numeric outcomes and chi-squared tests or Fisher's exact tests for categorical outcomes, with a p-value < 0.05 considered statistically significant. ResultsThere were 674 patients with AF RVR that received diltiazem, and 386 patients met the inclusion criteria for analysis. Baseline demographics included a median age of 72 (64–81) years, with 14.5% of patients having a prior diagnosis of congestive heart failure. EF < 50% was identified in 13.7% of patients (n = 53), of which approximately 30% of these patients safely discharged home after receiving i.v. diltiazem. The primary outcome of worsening heart failure occurred in 7/41 (17%) and 10/207 (4.8%) patients with reduced and preserved ejection fractions, respectively, who were admitted to the hospital (p = 0.005). ConclusionThe development of worsening heart failure is multifactorial and may include the use of diltiazem in critically ill patients requiring hospital admission.

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.

Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association

Acute atrial fibrillation is defined as atrial fibrillation detected in the setting of acute care or acute illness; atrial fibrillation may be detected or managed for the first time during acute hospitalization for another condition. Atrial fibrillation after cardiothoracic surgery is a distinct type of acute atrial fibrillation. Acute atrial fibrillation is associated with high risk of long-term atrial fibrillation recurrence, warranting clinical attention during acute hospitalization and over long-term follow-up. A framework of substrates and triggers can be useful for evaluating and managing acute atrial fibrillation. Acute management requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient's underlying substrate and acute condition. Key components of acute management include identification and treatment of triggers, selection and implementation of rate/rhythm control, and management of anticoagulation. Acute rate or rhythm control strategy should be individualized with consideration of the patient's capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient's ability to tolerate the risk of the therapeutic strategy. Given the high risks of atrial fibrillation recurrence in patients with acute atrial fibrillation, clinical follow-up and heart rhythm monitoring are warranted. Long-term management is guided by patient substrate, with implications for intensity of heart rhythm monitoring, anticoagulation, and considerations for rhythm management strategies. Overall management of acute atrial fibrillation addresses substrates and triggers. The 3As of acute management are acute triggers, atrial fibrillation rate/rhythm management, and anticoagulation. The 2As and 2Ms of long-term management include monitoring of heart rhythm and modification of lifestyle and risk factors, in addition to considerations for atrial fibrillation rate/rhythm management and anticoagulation. Several gaps in knowledge related to acute atrial fibrillation exist and warrant future research.

Acute rate control with metoprolol versus diltiazem in atrial fibrillation with heart failure with reduced ejection fraction

ObjectiveCompare heart rate control between parenteral metoprolol and diltiazem and identify safety outcomes in the acute management of atrial fibrillation (AFib) with rapid ventricular response (RVR) in patients with heart failure with reduced ejection fraction (HFrEF). MethodsThis retrospective, single-center, cohort study included adult patients with HFrEF who received intravenous (IV) metoprolol or diltiazem for AFib RVR in the emergency department (ED). The primary outcome was rate control defined as HR <100 bpm or a HR reduction ≥20% within 30 min of first dose administration. The secondary outcomes included rate control within 60 min and 120 min from first dose, need for repeat dosing, and disposition. Safety outcomes included hypotensive and bradycardic events. ResultsOut of 552 patients, 45 patients met the inclusion criteria with 15 in the metoprolol group and 30 in the diltiazem group. Using bootstrapping method, patients treated with metoprolol were equally able to reach the primary outcome as those treated with diltiazem (BCa 95% CI: 0.14, 4.31). Hypotensive and bradycardia events remained zero in both groups. ConclusionOur study provides further evidence that short term use of diltiazem is likely as safe and effective as metoprolol in the acute management of HFrEF patients with AFib RVR and provides support for the use of non-dihydropyridine calcium channel blockers (non-DHP CCBs) in this patient population.

Abstract 9933: Shifting Paradigms in Rhythm versus Rate Control in Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials

Introduction: Atrial fibrillation is the most common cardiac arrhythmia and is an independent risk factor for mortality across a wide age range in both men and women. Management methods of atrial fibrillation have been thoroughly investigated through numerous trials exploring various treatment modalities. There has been a preference for rate control as the initial approach, but recent studies, particularly the EAST-AFNET 4 trial, point out several clinical settings in which rhythm control is preferable. To evaluate new paradigms in the acute management of atrial fibrillation, our meta-analysis provides a current, curated examination of the major landmark trials in the management of atrial fibrillation along with the most recent randomized controlled trials that have been published since 2022. Methods: A literature search was performed on May 2022 using PubMed and OVID Medline databases for study identification. Combinations of the search terms atrial fibrillation, rate control, adrenergic beta antagonists, rhythm control, anti-arrhythmia drugs, and catheter ablation were combined to conduct the literature search. Boolean operators AND and OR were used to combine terms. Results: There were no significant differences in the effects of rate and rhythm control on any outcome: all-cause mortality (RR: 0.996; CI: 0.674-1.376), cardiovascular mortality (RR: 0.957; CI: 0.601-1.413), arrhythmic/sudden death mortality (RR: 0.954; CI: 0.445-1.816), stroke/transient ischemic attack (RR: 1.011; CI: 0.535-1.78), and systemic embolism (RR: 1.275; CI: 0.541-2.625). Conclusions: Updated data pooled from randomized control trials in patients with atrial fibrillation suggests that rhythm and rate control strategies have no statistically significant differences on major clinical outcomes. Additional studies will be required to investigate factors favorable for rhythm-control strategies and to determine contemporary best clinical practices.

PATIENT PERCEPTIONS AFTER EMERGENCY DEPARTMENT VISITS FOR ATRIAL FIBRILLATION: UNNECESSARY FEAR?

Guidelines suggest rate or rhythm control are both appropriate for acute management of atrial fibrillation (AF) in the emergency department (ED). However, patient perceptions after ED visit are not well documented or understood.

Acute management of atrial fibrillation in congestive heart failure with reduced ejection fraction in the emergency department

IntroductionAcute heart rate control for atrial fibrillation (AF) with rapid ventricular response (RVR) in the emergency department (ED) is often achieved utilizing intravenous (IV) non-dihydropyridine calcium channel blockers (CCB) or beta blockers (BB). For patients with concomitant heart failure with a reduced ejection fraction (HFrEF), the American Heart Association and other clinical groups note that CCB should be avoided due to their potential negative inotropic effects. However, minimal evidence exists to guide this current recommendation. The primary objective of this study was to compare the incidence of adverse effects in the HFrEF patient population whose AF with RVR was treated with IV diltiazem or metoprolol in the ED. MethodsThis single center, retrospective review included patients ≥18 years old with HFrEF who presented in AF with RVR and received IV diltiazem or metoprolol in the ED. The primary outcome was adverse effects of therapy defined as: 1) hypotension (systolic blood pressure < 90 mmHg requiring fluid bolus or vasopressors) or bradycardia (heart rate < 60 beats/min) within 60 min of medication administration 2) worsening heart failure symptoms defined as increased oxygen requirements within four hours or inotropic support within 48 h. Secondary outcomes included the incidence of rate control failure, patient disposition, ED length of stay, hospital length of stay, and in-hospital mortality. ResultsOne hundred and twenty-five patients met inclusion criteria, with 57 receiving diltiazem and 68 receiving metoprolol. Overall adverse effects for diltiazem and metoprolol were similar (32% vs. 21%, P = 0.217). However, there was a significantly higher incidence of worsening heart failure symptoms within the diltiazem group (33% vs 15%, P = 0.019). Rate control failure at 60 min did not differ significantly between diltiazem and metoprolol (51% vs 62%, P = 0.277). ConclusionsIn HFrEF patients with AF, there was no difference in total adverse events in patients treated with IV diltiazem compared to metoprolol. However, the diltiazem group had a higher incidence of worsening CHF symptoms defined as increased oxygen requirement within four hours or initiation of inotropic support within 48 h.

Management of acute atrial fibrillation in the intensive care unit: An international survey.

Atrial fibrillation (AF) is common in intensive care unit (ICU) patients and is associated with poor outcomes. Different management strategies exist, but the evidence is limited and derived from non-ICU patients. This international survey of ICU doctors evaluated the preferred management of acute AF in ICU patients. We conducted an international online survey of ICU doctors with 27 questions about the preferred management of acute AF in the ICU, including antiarrhythmic therapy in hemodynamically stable and unstable patients and use of anticoagulant therapy. A total of 910 respondents from 70 ICUs in 14 countries participated in the survey with 24%-100% of doctors from sites responding. Most ICUs (80%) did not have a local guideline for the management of acute AF. The preferred first-line strategy for the management of hemodynamically stable patients with acute AF was observation (95% of respondents), rhythm control (3%), or rate control (2%). For hemodynamically unstable patients, the preferred strategy was observation (48%), rhythm control (48%), or rate control (4%). Overall, preferred antiarrhythmic interventions included amiodarone, direct current cardioversion, beta-blockers other than sotalol, and magnesium in that order. A total of 67% preferred using anticoagulant therapy in ICU patients with AF, among whom 61% preferred therapeutic dose anticoagulants and 39% prophylactic dose anticoagulants. This international survey indicated considerable practice variation among ICU doctors in the clinical management of acute AF, including the overall management strategies and the use of antiarrhythmic interventions and anticoagulants.

Intravenous Metoprolol Versus Diltiazem for Rate Control in Atrial Fibrillation.

Currently, it remains unclear whether β-blockers or nondihydropyridine calcium channel blockers are preferred for the acute management of atrial fibrillation (AF). The objective of this study was to compare the efficacy and safety of intravenous (IV) metoprolol and diltiazem for rate control. This was a single-center, retrospective cohort study of patients who presented to the emergency department between 2015 and 2019 with AF with rapid ventricular rate (RVR) and received IV metoprolol or diltiazem. The primary outcome was the percentage of patients who achieved rate control (defined as heart rate < 100 beats per minute). Secondary outcomes included time to rate control, percentage of patients requiring additional agents for rate control, and incidence of cardioversion, bradycardia, and hypotension. A total of 200 patients were included in this study. Rate control was achieved in 35% and 41% of the metoprolol and diltiazem groups, respectively (P = 0.38). Mean time to rate control was not significantly different between the metoprolol and diltiazem groups (35 vs 21 minutes, P = 0.23). One patient developed hypotension, no patient developed bradycardia, and 4 patients required electric cardioversion. No adverse events were observed in patients with ejection fraction ≤40%. There was no difference in the achievement of rate control between IV metoprolol and diltiazem. This is the largest study to date comparing the two classes of agents for acute rate control in AF. No patient-specific factors were identified that would influence the preferential use of one medication over the other.

Impact of COVID-19 pandemic on the clinical activities related to arrhythmias and electrophysiology in Italy: results of a survey promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing).

COVID-19 outbreak had a major impact on the organization of care in Italy, and a survey to evaluate provision of for arrhythmia during COVID-19 outbreak (March–April 2020) was launched. A total of 104 physicians from 84 Italian arrhythmia centres took part in the survey. The vast majority of participating centres (95.2%) reported a significant reduction in the number of elective pacemaker implantations during the outbreak period compared to the corresponding two months of year 2019 (50.0% of centres reported a reduction of > 50%). Similarly, 92.9% of participating centres reported a significant reduction in the number of implantable cardioverter-defibrillator (ICD) implantations for primary prevention, and 72.6% a significant reduction of ICD implantations for secondary prevention (> 50% in 65.5 and 44.0% of the centres, respectively). The majority of participating centres (77.4%) reported a significant reduction in the number of elective ablations (> 50% in 65.5% of the centres). Also the interventional procedures performed in an emergency setting, as well as acute management of atrial fibrillation had a marked reduction, thus leading to the conclusion that the impact of COVID-19 was disrupting the entire organization of health care, with a massive impact on the activities and procedures related to arrhythmia management in Italy.Electronic supplementary materialThe online version of this article (10.1007/s11739-020-02487-w) contains supplementary material, which is available to authorized users.

Procainamide for the acute management of atrial fibrillation and flutter in the emergency department: a systematic review

Introduction: Chemical or electrical cardioversion are utilized for acute atrial fibrillation or flutter (AFF) management in the emergency department (ED). Procainamide is a common chemical agent used in Canada; however, there are substantial practice variations.&#x0D; Method: Systematic search of five databases and grey literature completed. Randomized controlled trials (RCTs) and prospective controlled cohort studies including adults with acute AFF comparing procainamide with other cardioversion strategies were eligible. Two independent reviewers performed study selection and data extraction. Relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random-effects model. The protocol was registered with PROSPERO (CRD42019142080).&#x0D; Results: From 3847 potential citations, 6 studies were included (four RCTs and two cohort studies). Procainamide was less effective in achieving conversion to normal sinus rhythm (NSR) at 1st attempt compared to other chemical (RR 0.76; 95% CI: 0.65 to 0.90) and electrical (RR 0.72; 95% CI: 0.56 to 0.92) options. Procainamide in a drug-shock approach was as effective as electrical cardioversion alone in restoring NSR (RR 1.04; 95% CI 1.00 to 1.08). The occurrence of hypotension was higher in patients receiving procainamide compared to electrical cardioversion (RR 1.87; 95% CI: 1.14 to 3.06). Deaths and strokes were not well-reported.&#x0D; Conclusion: Procainamide is less effective than other chemical options and electrical cardioversion strategies to restore NSR. The efficacy of procainamide in a drug-shock approach is similar to electrical alone at restoring NSR. The evidence shows that hypotension is a common procainamide adverse effect suggesting that electrical cardioversion as a first approach is preferable.

LO07: Procainamide for the acute management of atrial fibrillation and flutter in the emergency department: a systematic review

Introduction: Management of acute atrial fibrillation or flutter (AFF) in the emergency department (ED) can be performed with chemical or electrical cardioversion. Procainamide is the most common chemical agent used in Canada; however, there is substantial practice variation. The objective of this systematic review was to provide comparative evidence on return to normal sinus rhythm (NSR) and adverse events to better support clinical decisions. Methods: Systematic search of five electronic databases and grey literature. Randomized controlled trials (RCTs) and prospective controlled cohort studies including adults (≥17 years) with recent-onset of AFF comparing intravenous procainamide with other cardioversion strategies (e.g., electrical cardioversion, placebo or other antiarrhythmic drugs) were eligible. Two independent reviewers performed study selection and data extraction. Relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random-effects model. The protocol was registered with PROSPERO (CRD42019142080). Results: From 4060 potentially relevant citations, 7 studies were considered eligible and three RCTs and two cohort studies included in the analysis. Procainamide was less effective in promoting return to NSR at 1st attempt compared to other chemical (RR 0.76; 95% CI: 0.65 to 0.90) and electrical (RR 0.58; 95% CI: 0.53 to 0.64) options. Electrical cardioversion was more effective in restoring NSR compared to procainamide when used as 2nd attempt in one RCT (RR 0.46; 95% CI: 0.23 to 0.92). Pre-specified serious adverse events were assessed and reported by two studies showing that hypotension was more common in patients receiving procainamide in comparison with electrical cardioversion (RR 20.57; 95% CI: 1.59 to 265.63). Treatment discontinuation due to adverse events was infrequently reported with only two studies reporting that no patients withdrew from the study following treatment with procainamide. The remaining studies provided incomplete data reporting on adverse events. Conclusion: Shared decision-making for patients with acute AFF in the ED requires knowledge of the effectiveness and safety of comparative interventions. Overall, procainamide is less effective than other chemical options and electrical cardioversion strategies to restore NSR. Evidence shows that hypotension is a concern when procainamide is administered; however, the overall adverse events information provided from the studies is suboptimal.

Acute management of atrial fibrillation with rapid ventricular response

Acute management of atrial fibrillation with rapid ventricular response

Metoprolol vs. diltiazem in the acute management of atrial fibrillation in patients with heart failure with reduced ejection fraction

ObjectiveThe objective of this study was to examine the effects of metoprolol versus diltiazem in the acute management of atrial fibrillation (AF) with rapid ventricular response (RVR) in patients with heart failure with reduced ejection fraction (HFrEF). MethodsThis retrospective cohort study of patients with HFrEF in AF with RVR receiving either intravenous push (IVP) doses of metoprolol or diltiazem was conducted between January 2012 and September 2016. The primary outcome was successful rate control within 30 min of medication administration, defined as a heart rate (HR) < 100 beats per minute or a HR reduction ≥ 20%. Secondary outcomes included rate control at 60 min, maximum median change in HR, and incidence of hypotension, bradycardia, or conversion to normal sinus rhythm within 30 min. Signs of worsening heart failure were also evaluated. ResultsOf the 48 patients included, 14 received metoprolol and 34 received diltiazem. The primary outcome, successful rate control within 30 min, occurred in 62% of the metoprolol group and 50% of the diltiazem group (p = 0.49). There was no difference in HR control at predefined time points or incidence of hypotension, bradycardia, or conversion. Although baseline HR varied between groups, maximum median change in HR did not differ. Signs of worsening heart failure were similar between groups. ConclusionsFor the acute management of AF with RVR in patients with HFrEF, IVP diltiazem achieved similar rate control with no increase in adverse events when compared to IVP metoprolol.

Intravenous Flecainide for Emergency Department Management of Acute Atrial Fibrillation

BackgroundAtrial fibrillation (AF) is the most commonly encountered dysrhythmia in the emergency department, and its prevalence is increasing. A substantial proportion of these patients have recent-onset AF (<48 h). The poor prognosis associated with AF is being increasingly recognized, and there is some evidence for better outcomes in younger patients with recent-onset AF when sinus rhythm is restored. Flecainide is recommended in the latest international guidelines for cardioversion of recent-onset AF, but its safety and efficacy relative to other recommended agents are unclear. ObjectiveOur aim was to clarify the Level 1 evidence for the use of i.v. flecainide in acute AF. MethodsWe performed a systematic review and meta-analysis of the literature. Medline, Ovid, Embase, and Cochrane Central databases were searched for relevant studies. Only randomized controlled trials (RCTs) of i.v. flecainide for acute conversion of recent-onset AF were selected for meta-analysis. ResultsFour hundred and three studies were screened, of which 11 RCTs were eligible for meta-analysis. Flecainide had high efficacy for cardioversion within 2 h (number needed to treat [NNT] = 1.8). Efficacy was superior to propafenone, amiodarone, procainamide, ibutilide, and sotalol (NNT = 4.3). There was no statistically significant difference in pro-dysrhythmia compared to these anti-dysrhythmics or placebo. ConclusionsIntravenous flecainide cardioversion could be a safe and effective option for emergency physicians to restore sinus rhythm in selected patients with acute AF.

Acute Management of Atrial Fibrillation: From Emergency Department to Cardiac Care Unit.

The prevalence of atrial fibrillation is increasing rapidly, resulting in more patients presenting for care in the emergency department and in-hospital settings. To reduce morbidity and mortality, and improve patient quality of life, clinicians working in these settings need to be both current and facile in their approach to management of these patients. Frequent updates to guideline recommendations (based on emerging research) make this challenging for practicing physicians. This article reviews the acute management of atrial fibrillation in the emergency and in-hospital settings, including practical approaches to rhythm and rate control, anticoagulation, and special situations, incorporating the most up-to-date guidelines.

The safety and efficacy of sotalol in the management of acute atrial fibrillation: a retrospective case control study

Objective: The European Society of Cardiology, American Heart Association and the American College of Cardiology guidelines on atrial fibrillation (AF) 2006 state that Sotalol should not be used in acute AF. We assessed the safety and efficacy of sotalol in acute AF when compared to other anti-arrhythmic drugs (ADD). Methods: A single centre retrospective observational study on 300 patients admitted with acute AF over a 12 months period. Study drugs used were sotalol, amiodarone, flecainide, propafenone or disopyramide for rhythm control. Digoxin, beta blockers, verapamil, diltiazem were prescribed for rate control. Rates of cardioversion to sinus rhythm, readmission rates due to AF, all cause readmissions, mortality rates due to sudden cardiac death and all-cause mortality was recorded over a 2 year follow up period. For paired data, the Wilcoxon matched-pairs signed- ranks or paired t-test were used. For unpaired data, Fisher’s exact test was used. Results: 120 patients were discharged on sotalol. The mean total dose used was 169.2 mg daily. Cardioversion to sinus rhythm on discharge occurred in 68% in the rhythm control group versus 42% for rate control group (p<0.001). Sotalol had a significantly higher cardioversion rate regardless of the dose when compared to amiodarone (p=0.036) however, there were similar readmission rates for AF. Four patients died acutely in hospital, none were on sotalol. Compared to all drugs sotalol had the lowest mortality rates (p=0.001). Mortality rates were lower in patients who received the higher dose of sotalol; 7.4% for patients who received a total of 320 mg daily versus 11.8% in those who received 160 mg daily. Conclusion: Sotalol is as safe and effective as other anti-arrhythmic drugs; in fact it was significantly more effective than amiodarone in this cohort. All AAD\\\\\\\\\\\\\\\'s demonstrated a significant improvement in cardioversion rates and a significantly lower mortality rate than rate controlling drugs.

The safety and efficacy of sotalol in the management of acute atrial fibrillation: a retrospective case control study

Objective: The European Society of Cardiology, American Heart Association and the American College of Cardiology guidelines on atrial fibrillation (AF) 2006 state that Sotalol should not be used in acute AF. We assessed the safety and efficacy of sotalol in acute AF when compared to other anti-arrhythmic drugs (ADD). Methods: A single centre retrospective observational study on 300 patients admitted with acute AF over a 12 months period. Study drugs used were sotalol, amiodarone, flecainide, propafenone or disopyramide for rhythm control. Digoxin, beta blockers, verapamil, diltiazem were prescribed for rate control. Rates of cardioversion to sinus rhythm, readmission rates due to AF, all cause readmissions, mortality rates due to sudden cardiac death and all-cause mortality was recorded over a 2 year follow up period. For paired data, the Wilcoxon matched-pairs signed- ranks or paired t-test were used. For unpaired data, Fisher’s exact test was used. Results: 120 patients were discharged on sotalol. The mean total dose used was 169.2 mg daily. Cardioversion to sinus rhythm on discharge occurred in 68% in the rhythm control group versus 42% for rate control group (p<0.001). Sotalol had a significantly higher cardioversion rate regardless of the dose when compared to amiodarone (p=0.036) however, there were similar readmission rates for AF. Four patients died acutely in hospital, none were on sotalol. Compared to all drugs sotalol had the lowest mortality rates (p=0.001). Mortality rates were lower in patients who received the higher dose of sotalol; 7.4% for patients who received a total of 320 mg daily versus 11.8% in those who received 160 mg daily. Conclusion: Sotalol is as safe and effective as other anti-arrhythmic drugs; in fact it was significantly more effective than amiodarone in this cohort. All AAD\\\\\\\\\\\\\\\'s demonstrated a significant improvement in cardioversion rates and a significantly lower mortality rate than rate controlling drugs.

Reduced Hospitalisation and Improved Documentation of Risk Stratification – Impact of a New Acute Atrial Fibrillation (AF) Pathway

Background: Atrial fibrillation is a common cause of acute hospitalisation. We evaluated the impact of a new clinical AF pathway on hospitalisation rates for AF and documentation of risk assessment for stroke and bleeding. Methods: To evaluate a new clinical pathway for management of AF, we performed a prospective single centre audit of the first hundred consecutive patients presenting with AF to the cardiology service at Christchurch Hospital between 01/10/2015 and 31/12/2015. Patient data was collected from clinical notes and the electronic record. Results: Among the first 100 patients presenting with AF [Males 67%, 69±12 years, HASBLED and CHADS2VA2Sc scores 2±1 and 2.5±1.7 respectively], 52 had prior history of AF/AFL and 75 presented with “acute persistent AF” as the primary diagnosis. Thirty-three patients were managed via the AF pathway, 22 of whom were discharged safely avoiding overnight hospital admission, with next day clinic review. There was one re-admission within thirty days and no stroke or bleeding complications. Patients managed with AF pathway tended to be younger (63±13 vs 71±11 years) with lower CHA2DS2VASc score (2±1.4 vs 3±1.8). 39/100 patents had CHADS2VA2Sc and HASBLED scores documented. Documentation of CHADS2VA2Sc and HASBLED scores was 100% in AF pathway group compared to only 10% in the cohort managed without AF pathway. Conclusion: Introduction of a new acute AF pathway was associated with reduced hospitalisation in low risk patients and with improved documentation of stroke and bleeding risk.