title: The epidemiology and management of recent-onset atrial fibrillation and flutter presenting to the Emergency Department.
abstract: OBJECTIVE
  Atrial fibrillation (AF) and flutter are common tachyarrhythmias seen in the Emergency Department (ED). The management of recent-onset AF remains poorly defined. Two management strategies have been proposed: rhythm control versus rate control. The aims of this study were to investigate the epidemiology and management of recent-onset AF presenting to one large tertiary ED.
  
  
  METHODS
  Retrospective analysis of ED records was carried out using the ED PAS database to identify eligible patients presenting between 1 July 2009 and 30 June 2011 with onset of AF in the previous 7 days. Patients were included for analysis if it was their first presentation, first diagnosis or a paroxysm of atrial fibrillation.
  
  
  RESULTS
  A total of 494 patients (625 presentations) were analysed. AF (n=564; 90.2%) and flutter (n=61; 9.8%) were the presenting rhythms. In all, 374 (53.8%) presentations were paroxysmal atrial fibrillation. For patients with AF, rhythm control was attempted in 171 (55.0%) patients presenting less than 48 h after symptom onset. Pharmacotherapy was the approach in 105 (31.4%) patients, compared with direct current cardioversion (n=45; 26.3%). Twenty-one patients received both. Flecainide (n=85) and amiodarone (n=33) were the main first-line pharmacotherapies, restoring sinus rhythm in 81.3 and 81.4% of patients, respectively. The overall efficacy of direct current cardioversion in restoring sinus rhythm was similar (78.8%). Eighty-one patients presented more than 48 h after symptom onset. Of those patients managed in the ED (n=38; 71.7%) were managed with rate control. The majority of patients with atrial flutter presented less than 48 h after symptom onset (n=48; 78.7%). Sixteen of these patients were managed with rhythm control strategies in the ED.
  
  
  CONCLUSIONS
  The epidemiology of recent-onset AF in this series is comparable with previous publications. Rhythm control was only attempted in approximately half of all eligible patients. There was no single-favoured management strategy. Our results mirror the literature in emphasizing the variation in management and the lack of robust evidence guiding the management of recent-onset AF and flutter.
authors.affiliation: aFoundation Year 1 Doctor, NHS Lothian bDepartment of Emergency Medicine, Southeast Scotland Training Scheme Departments of cEmergency Medicine dCardiology, Royal Infirmary of Edinburgh, Edinburgh, UK.
authors.forename: Ailsa
authors.initials: A
authors.lastname: Hamilton
authors.forename: Donna
authors.initials: D
authors.lastname: Clark
authors.forename: Alasdair
authors.initials: A
authors.lastname: Gray
authors.forename: Aidan
authors.initials: A
authors.lastname: Cragg
authors.forename: Neill
authors.initials: N
authors.lastname: Grubb
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000638:Amiodarone / Q000627:therapeutic use; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000188:drug therapy / Q000453:epidemiology* / Q000628:therapy; D001282:Atrial Flutter / Q000188:drug therapy / Q000453:epidemiology* / Q000628:therapy; D003131:Combined Modality Therapy; D004554:Electric Countershock / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D005424:Flecainide / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D062606:Tertiary Care Centers / Q000706:statistics & numerical data; D006113:United Kingdom / Q000453:epidemiology; D055815:Young Adult
chemical_list: D000889:Anti-Arrhythmia Agents; D005424:Flecainide; D000638:Amiodarone