Management of atrial fibrillation in the emergency department

Given the lack of standardization in the treatment and disposition of patients presenting to the emergency department with complaints referable to atrial fibrillation, it is necessary to adopt a framework that is evidence-based. Greater than half of the patients presenting with acute atrial fibrillation will convert spontaneously to sinus rhythm within a 24-hour period. In patients who are hemodynamically stable, identifying the time of onset of atrial fibrillation is critical with regard to the initiation of anticoagulation and the decision as to whether cardioversion, either electrical or chemical, should be attempted. For chronic atrial fibrillation, a conservative approach with rate control and anticoagulation remains a safe, effective and often preferable mode of management. Those patients who are hemodynamically unstable must undergo immediate cardioversion. The patient's disposition depends ultimately on the chronicity of atrial fibrillation, symptoms, and presence of underlying structural abnormalities. It is expected that, as our approach to patients presenting with atrial fibrillation becomes more clearly delineated, a greater subset of these patients may be managed safely and discharged from the emergency department setting with appropriate longitudinal follow-up.