ED Treatment of “Complex” Atrial Fibrillation


    ED Treatment of “Complex” Atrial Fibrillation


    You receive RESUS signout on a 60F DMII, HTN here with urosepsis s/p abx, lactate downtrending, BPs holding in the 90s-low 100s systolic with IVF. Only thing left to do is talk to the MICU. You note the patient to be in persistent afib with HR 130-150, no h/o afib.

    When you call the MICU fellow he is confused as to why you haven’t given medication for rate control


    TLDR: One recent study showed ED patients with afib/aflutter and a “complex” underlying illness who received rate/rhythm control medications may be at an increased risk for adverse events compared to those who were not managed with rate/rhythm control



    Scheuermeyer et al: Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm

    -Retrospective descriptive cohort study using an EKG database in 2 urban EDs

    -Examined cases of “complex” atrial fibrillation/flutter defined as patient with an acute underlying illness

    -Acute underlying illness: Sepsis (including pneumonia), acute coronary syndrome, acute decompensated heart failure, pulmonary embolism, chronic obstructive pulmonary disease exacerbation, thyrotoxicosis, hypertensive emergency, drug overdose, acute valvular disease, hypothermia, acute renal failure, or gastrointestinal bleeding

    -Primary outcome:  Safety of rate or rhythm control, measured by whether patients had a predefined adverse event or not

    -Adverse event: New hypotension requiring pressors, intubation or NIV, new bradycardia requiring pharmacologic intervention or pacing, stroke/thromboembolic event, chest compressions, death.

    Conclusion: In ED patients with complex atrial fibrillation or flutter, attempts at rate and rhythm control are associated with a nearly 6-fold higher adverse  event rate than that for patients who are not managed with rate or rhythm control. Success rates of rate or rhythm control attempts appear low


    Walkey et al: Practice Patterns and Outcomes of Treatments for Atrial Fibrillation During Sepsis

    -Retrospective cohort study using billing data

    -Examined hospitalized septic patients with afib who received IV AF treatment

    -Propensity score matching and instrumental variable approaches were used to compare mortality between AF treatments

    Conclusion: BBs were associated with lower hospital mortality when compared with CCBs, digoxin, and amiodarone




    MICU fellow comes down to the bedside, you cite the first article, he cites the second. You both agree to disagree. Once the patient is admitted MICU orders BB IVP.

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