title: An international view of how recent-onset atrial fibrillation is treated in the emergency department.
abstract: OBJECTIVE
  This study was conducted to determine if there is practice variation for emergency physicians' (EPs) management of recent-onset atrial fibrillation (RAF) in various world regions (Canada, United States, United Kingdom, and Australasia).
  
  
  METHODS
  The authors completed a mail and e-mail survey of members from four national emergency medicine (EM) associations. One prenotification letter and three survey letters were sent to members of the Canadian Association of Emergency Physicians (CAEP; Canada-1,177 members surveyed), American College of Emergency Physicians (ACEP; United States-500), College of Emergency Medicine UK (CEM; United Kingdom-1,864), and Australasian College for Emergency Medicine (ACEM; Australasia-1,188) as per the modified Dillman technique. The survey contained 23 questions related to the management of adult patients with symptomatic RAF (either a first episode or paroxysmal-recurrent) where onset is less than 48 hours and cardioversion is considered a treatment option. Data were analyzed using descriptive and chi-square statistics.
  
  
  RESULTS
  Response rates were as follows: overall, 40.5%; Canada, 43.0%; United States, 50.1%; United Kingdom, 38.1%; and Australasia, 38.0%. Physician demographics were as follows: 72% male and mean (±SD) age 41.7 (±8.39) years. The proportions of physicians attempting rate control as their initial strategy are United States, 94.0%; Canada, 70.7%; Australasia, 61.1%; and United Kingdom, 43.1% (p < 0.0001). Diltiazem is the predominant agent for rate control in Canada (65.36%) and the United States (95.22%), while metoprolol is used in Australasia (65.94%) and the United Kingdom (67.64%). Cardioversion is attempted at varying rates in Canada (65.9%), Australasia (49.9%), United Kingdom (49.5%), and the United States (25.9%) (p < 0.0001). Pharmacologic cardioversion is attempted first in all regions, with the preferred drug being procainamide in Canada (61.93%) and amiodarone in Australasia (63.39%), the United Kingdom (47.97%), and the United States (22.41%; p < 0.0001). If drugs fail, electrical cardioversion is then attempted in Canada (70.64%), Australasia (46.19%), the United States (29.69%), and the United Kingdom (27.78%; p < 0.0001).
  
  
  CONCLUSIONS
  There is much variation in emergency department (ED) management of RAF among world regions, most markedly for use of rate versus rhythm control, choice of drugs, and use of electrical cardioversion. Canadians are more likely to use an aggressive approach for management of RAF, whereas Americans are more likely to employ conservative management. U.K. and Australasian EPs fall somewhere in the middle. These differences demonstrate the need for better evidence, or better synthesis of existing knowledge, to create guidelines to guide ED management of this common dysrhythmia.
authors.affiliation: Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Carly
authors.initials: C
authors.lastname: Rogenstein
authors.forename: Anne-Maree
authors.initials: AM
authors.lastname: Kelly
authors.forename: Suzanne
authors.initials: S
authors.lastname: Mason
authors.forename: Sandra
authors.initials: S
authors.lastname: Schneider
authors.forename: Eddy
authors.initials: E
authors.lastname: Lang
authors.forename: Catherine M
authors.initials: CM
authors.lastname: Clement
authors.forename: Ian G
authors.initials: IG
authors.lastname: Stiell
mesh_terms: D000328:Adult; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D000925:Anticoagulants / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000628:therapy*; D044362:Australasia; D002170:Canada; D016009:Chi-Square Distribution; D016292:Procedural Sedation / Q000379:methods; D004554:Electric Countershock / Q000706:statistics & numerical data; D004635:Emergency Medicine / Q000592:standards* / Q000639:trends; D004636:Emergency Service, Hospital; D005260:Female; D019538:Health Care Surveys; D006339:Heart Rate; D006801:Humans; D007391:International Cooperation; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000639:trends*; D011795:Surveys and Questionnaires; D015996:Survival Rate; D016896:Treatment Outcome; D006113:United Kingdom; D014481:United States
chemical_list: D000889:Anti-Arrhythmia Agents; D000925:Anticoagulants