Table 1 Management recommendations to improve care of ED patients with atrial fibrillation and flutter
Major recommendations in electronic clinical decision support applicationa | Rationale for recommendation |
|---|---|
1. Sustained rate reduction | |
Administer long-acting rate-reducing medications early in the ED encounter, either in addition to or in lieu of standard intravenous bolus medications | Medications with sustained effect on rapid ventricular response have been central to multifaceted ED interventions associated with reduced hospitalization of patients with isolated AF or atrial flutter [26, 27]. |
2. Effective cardioversion | |
2A. Electrical | |
Start with maximal joules and consider manual pressure augmentation, especially for obese patients | These measures improve first-shock success and may reduce sedation duration and risk [13, 39,40,41]. |
2B. Pharmacologic | |
Consider efficiency in addition to effectiveness, safety, and ease of administration when selecting medications | For example, medications with a shorter time to effect, e.g., intravenous procainamide [42] (median 30–40 min), facilitate ED operational efficiencies, unlike intravenous amiodarone, which does not distinguish itself from placebo for 6–8 h [43]. |
3. Stroke prevention | |
A. Identify patients at risk using auto-populating validated scoring system | Stroke risk stratification is the essential preparatory step for any subsequent stroke prevention action [13, 14, 29, 33]. |
B. Print risk-specific handout for eligible patients and review with patient and family at bedside | The handout helps initiate a shared decision-making conversation on stroke prevention [44] that can continue with outpatient physicians following discharge to home |
C1. Initiate outpatient anticoagulation at the time of ED discharge to home | Oral anticoagulation with DOACs or warfarin significantly reduces ischemic stroke and death in patients with AF or atrial flutter. Prescription on ED discharge can be associated with higher long-term use than when prescribing is left to post-discharge outpatient care [45, 46]. |
C2. Or electronically consult the Anticoagulation Management Service to request they contact patients who want to learn more about stroke prevention before initiating anticoagulation | Following discharge to home, anticoagulation pharmacists can call eligible patients to provide in-depth education on benefits and risks of anticoagulation for stroke prevention [47, 48]. |
4. Timely follow-up | |
a. Encourage or request close follow-up (< 7d) with outpatient physicians | Transferring care to outpatient physicians who can oversee longitudinal care of AF and atrial flutter and related conditions is key to long-term management success [14]. Moreover, follow-up of these patients within a week of discharge has been associated with a reduction in the rate of death and hospitalization within 1 year [49]. |