eMedicine Specialties > Emergency Medicine > Cardiovascular

Atrial Fibrillation: Follow-up

Author: Pierre Borczuk, MD, Assistant Professor of Medicine, Harvard Medical School, Associate in Emergency Medicine, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Jul 15, 2009

Follow-up

Further Inpatient Care

  • Preventing complications of atrial fibrillation (AF)
    • Cardioversion (either electrical or chemical) carries a significant risk of embolization. Anticoagulants usually are administered to patients with atrial fibrillation lasting more than 48 hours. They are administered 3 weeks before to 4 weeks after cardioversion. Stunning of the atria may occur for several weeks following cardioversion, and the atrial chambers are at increased risk of developing thrombi. For this reason, antiarrhythmic agents that restore sinus rhythm should be withheld until anticoagulation has been achieved.
    • Stroke recurrence rate is high for patients with atrial fibrillation; therefore, long-term warfarin therapy is recommended. Aspirin offers only modest protection against stroke for patients with atrial fibrillation. The effect is less consistent than that of oral anticoagulation. However, for patients who cannot tolerate warfarin, aspirin is a suitable alternative.

Further Outpatient Care

Long-term management of atrial fibrillation has most commonly centered around 1 of 2 strategies: rhythm control versus rate control.18 The discussion surrounding these strategies has been dominated by the following questions: Is AF best managed by rhythm control?, Is AF best managed by rate control?, How is sinus rhythm best maintained?, What is the best means of preventing thromboembolism? While these questions are arguably the purview of cardiologists, it behooves the emergency medicine physician to have a basic knowledge of recent developments in this area. The main studies can be summarized as follows:

  • AFFIRM - Atrial Fibrillation Follow-up Investigation of Rhythm Management19,20
    • 4000 patients with paroxysmal or persistent AF, randomized to rate versus rhythm control
    • No change in mortality at 5 years (24% vs 21%) in rhythm vs rate
    • Not all patients remained anticoagulated in the rhythm group, and this caused a higher risk/trend for ischemic stroke.
  • RACE – Rate Control Versus Electrical Cardioversion for Persistent Atrial Fibrillation21,22,23
    • 522 patients who had persistent AF despite electrical cardioversion randomized to rate versus rhythm control
    • In the rhythm group, option to stop warfarin (Coumadin) if sinus rhythm >1 months
    • 2.3 year follow-up, and no change in composite endpoint of death from cardiovascular causes, heart failure, or thromboembolic causes
    • There was a high incidence of a thromboembolic event in the rhythm controlled, subtherapeutic or non-warfarin patients

Transfer

  • Transfer to a referral center if the patient has complications, including the following:
    • Bradycardia caused by sick sinus syndrome that requires pacemaker therapy
    • Unresponsive rate control despite adequate medical therapy - After electrical cardioversion, referral for electrophysiologic ablation may be appropriate. These patients generally are transferred from one inpatient facility to another.
    • Embolic complications requiring surgical therapy (arterial embolization) or CVA requiring neurointensive care

Complications

  • Stroke (AF-associated stroke is particularly a problem for patients older than 75 years)
  • Arterial embolization
  • Congestive heart failure
  • Severe bradycardia
  • Rate-related myocardial ischemia

Prognosis

  • The rate of ischemic stroke among patients with nonrheumatic atrial fibrillation averages 5% year, which is somewhere between 2-7 times the rate of stroke in patients without atrial fibrillation.
  • The total mortality rate is approximately doubled in patients with atrial fibrillation compared with patients in normal sinus rhythm and is linked with the severity of underlying heart disease.

Patient Education

  • In cases of intermittent atrial fibrillation, educating the patient on rapid access to 911 services is beneficial.
  • Long-term education should be the responsibility of the primary care provider, but certainly knowledge about stroke risk and prevention should be initially imparted by the emergency to the patient with atrial fibrillation.
  • For excellent patient education resources, visit eMedicine's Heart Center. Also, see eMedicine's patient education article Atrial Fibrillation.

Miscellaneous

Medicolegal Pitfalls

  • Watch for development of severe bradycardia during treatment. This may cause severe hypotension and death if not carefully monitored.
  • Rarely, atrial fibrillation (AF) may be due to pulmonary embolism, pericardial disease/effusion, or carbon monoxide intoxication. Keep these rare events in mind when dealing with the unusual case that does not respond to standard therapy.
  • Managed care has recently pushed for discharging stable patients with lone atrial fibrillation for follow-up within 24-48 hours. In these patients, carefully document normal ventricular function (using echocardiography, if possible) and obtain baseline thyroid studies. Be certain that a qualified internist or cardiologist will follow-up with the patient within this time frame. Once established in the ED, oral medication for rate control may be appropriate in these cases.
  • Most patients with lone or paroxysmal atrial fibrillation will self-convert. Episodes of paroxysmal atrial fibrillation may last from a few seconds to several weeks. Spontaneous conversion of paroxysmal atrial fibrillation to sinus rhythm occurs in 68% of persons presenting with atrial fibrillation of fewer than 72 hours duration.
  • Beware of atrial fibrillation in Wolfe-Parkinson-White syndrome. In young patients with this disorder, which appears as rapid wide-complex AF with a rate of more than 200 beats per minute, the use of calcium channel blockers may induce ventricular fibrillation.

Special Concerns

 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Jeffrey Lazar, MD, and Alan D Clark, MD†, to the development and writing of this article.



More on Atrial Fibrillation

Overview: Atrial Fibrillation
Differential Diagnoses & Workup: Atrial Fibrillation
Treatment & Medication: Atrial Fibrillation
Follow-up: Atrial Fibrillation
Multimedia: Atrial Fibrillation
References
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Further Reading

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Keywords

atrial fibrillation, AF, atrial fib, atrial fibrillation treatment, bradyarrhythmia, tachyarrhythmia, arrhythmia, heart disease, acute myocardial infarction, AMI, congestive heart disease, CHD, coronary artery disease, CAD, cardiovascular disease, heart attack, rhythm disturbance, atrioventricular node, AV node, palpitations, dyspnea, chest pain, angina, syncope, hypotension, congestive heart failure, CHF, jugular venous distension, hypertension, valvular heart disease, rheumatic heart disease 

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Contributor Information and Disclosures

Author

Pierre Borczuk, MD, Assistant Professor of Medicine, Harvard Medical School, Associate in Emergency Medicine, Massachusetts General Hospital
Pierre Borczuk, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

William Lober, MD, Associate Professor, Department of Medical Education, Division of Biomedical and Health Informatics, University of Washington School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gary Setnik, MD, Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD, Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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