A prospective, randomized trial of an emergency department observation unit for acute onset atrial fibrillation

Wyatt W Decker, Peter A Smars, Lekshmi Vaidyanathan, Deepi G Goyal, Eric T Boie, Latha G Stead, Douglas L Packer, Thomas D Meloy, Andy J Boggust, Luis H Haro, Dennis A Laudon, Joseph K Lobl, Annie T Sadosty, Raquel M Schears, Nicola E Schiebel, David O Hodge, Win-Kuang Shen
Annals of Emergency Medicine 2008, 52 (4): 322-8

STUDY OBJECTIVE: An emergency department (ED) observation unit protocol for the management of acute onset atrial fibrillation is compared with routine hospital admission and management.

METHODS: Adult patients presenting to the ED with atrial fibrillation of less than 48 hours' duration without hemodynamic instability or other comorbid conditions requiring hospitalization were enrolled. Participants were randomized to either ED observation unit care or routine inpatient care. The ED observation unit protocol included pulse rate control, cardiac monitoring, reassessment, and electrical cardioversion if atrial fibrillation persisted. Patients who reverted to sinus rhythm were discharged with a cardiology follow-up within 3 days, whereas those still in atrial fibrillation were admitted. All cases were followed up for 6 months and adverse events recorded.

RESULTS: Of the 153 patients, 75 were randomized to the ED observation unit and 78 to routine inhospital care. Eighty-five percent of ED observation unit patients converted to sinus rhythm versus 73% in the routine care group (difference 12%; 95% confidence interval [CI] -1% to 25%]; P=.06). The median length of stay was 10.1 versus 25.2 hours (difference 15.1 hours; 95% CI 11.2 to 19.6; P<.001) for ED observation unit and inhospital care respectively. Nine ED observation unit patients required inpatient admission. Eleven percent of the ED observation unit group had recurrence of atrial fibrillation during follow-up versus 10% of the routine inpatient care group (difference 1%; 95% CI -9% to 11%; P=.93). There was no significant difference between the groups in the frequency of hospitalization or the number of tests, and the number of adverse events during follow-up was similar in the 2 groups.

CONCLUSION: An ED observation unit protocol that includes electrical cardioversion is a feasible alternative to routine hospital admission for acute onset of atrial fibrillation and results in a shorter initial length of stay.

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