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Atrial Fibrillation -- Easier Decisions

Self-treatment with single-dose antiarrhythmic therapy appears safe and effective for treating atrial fibrillation.

The prevalence of atrial fibrillation (AF) increases with age, and given the future demographics in developed countries, AF will become an ever more common problem for emergency physicians. Two recent articles address its treatment.

In a review of the current literature on newly diagnosed AF, the author of the first article includes information from three sets of guidelines that provides some direction for emergency department management. The first step in treating patients should be rate control, and ß-blockers are the most effective agent for that purpose. Next is the question, "Who, if anyone, should be converted in the ED?" This question is difficult to answer because new evidence shows that rhythm control is no better than rate control in the long-term.

However, some aspects of AF treatment are clear. The risk for stroke, although small overall, rises steadily after age 60. Anticoagulation therapy reduces this risk; thus, patients older than 60 probably will need chronic anticoagulation therapy, which can be started with low-molecular-weight heparins and warfarin. Although AF is an uncommon manifestation of acute coronary syndromes, the prevalence of coronary heart disease in this age group sometimes prompts admission even in the absence of specific symptoms. Patients younger than 60 with recent-onset, as opposed to newly diagnosed, AF should be considered for conversion in an ED observation unit using a single dose of either flecainide or propafenone after echocardiography.

In another study, researchers in Italy sought to determine whether self-administration of flecainide or propafenone single-dose therapy is safe and effective for terminating episodes of AF outside the hospital ("pill-in-the-pocket" treatment). During 17 months, 268 patients who presented to several EDs with recent-onset AF met the study's many entry criteria (the number of patients screened was not noted). Patients were evaluated and treated with flecainide or propafenone in the hospital; 58 patients who fulfilled exclusion criteria or did not respond to treatment were excluded. The remaining 210 patients received instructions at discharge to take the study drug at the onset of subsequent symptoms. During a mean follow-up of 15.5 months, 165 patients reported 619 episodes, of which 569 were treated with "pill-in-the-pocket." Therapy was effective within 6 hours in 94% of episodes and effective in all episodes for 84% of patients. One case of atrial flutter with a 1:1 atrioventricular conduction ratio occurred. The number of ED visits per month was significantly reduced compared with the prior year.

Comment: Availability of new high-quality information should allow emergency physicians to work with cardiologists to develop pathways for disposition of patients with new-onset atrial fibrillation. Such pathways should address rate control, anticoagulation, duration of observation (in an observation unit if available), and chemical rhythm conversion. For now, outpatient rhythm control of any kind should remain the exclusive province of cardiologists.

— J. Stephen Bohan, MD, MS, FACP, FACEP

Published in Journal Watch Emergency Medicine January 19, 2005

Citation(s):

Page RL. Newly diagnosed atrial fibrillation. N Engl J Med 2004 Dec 2; 351:2408-16.

• Original article (Subscription may be required)
• Medline abstract (Free)

Alboni P et al. Outpatient treatment of recent-onset atrial fibrillation with the "pill-in-the-pocket" approach. N Engl J Med 2004 Dec 2; 351:2384-91.

• Original article (Subscription may be required)
• Medline abstract (Free)