Managing atrial fibrillation: the need for an individualized approach even in the emergency department

Abstract

How to manage patients with recent-onset atrial fibrillation (AF) in the emergency department (ED)? What strategies and what practical options should be taken into account after the initial clinical evaluation and risk stratification for stroke/thromboembolism? In the present issue of the Journal, two interesting contributions [1, 2] consider, through opposite views, the clinical perspective of a wait-and-see approach for patients with recent-onset AF without hemodynamic impairment. Both articles, prompted by the publication by Pluymaekers et al. of a non-inferiority randomized clinical trial on the waitand-see strategy performed in the Netherlands [3], present a series of reasons in support of the respective views, but the complexity and heterogeneity of factors involved in decision-making in this setting [4] support the need for further considerations to facilitate a balanced view of this notsimple clinical topic. The burden of ED visits actually increased the last decade in the United States [5] and this was associated with a wide range of variability in the application of rateor rhythmcontrol treatment or no treatment. [6] Very recent data from Italy [7] highlighted that while the number of patients with a visit to the ED slightly decreased as compared to more than 15 years ago, an increasing number of patients is currently managed in the ED with avoidance of hospital admission. The time course of recent-onset AF, i.e. an AF whose onset can be precisely defined, on the basis of patient symptoms as being within 48 h, has been appropriately investigated in randomized studies that evaluated spontaneous conversion (in a control or placebo arm) and in observational studies with no active intervention within the first hours [8–14]. In these studies, it was shown that conversion to sinus rhythm may occur in patients with recent-onset AF admitted to an ED, under placebo or control in 34–45% of patients within 12 h, in 55–87% of patients within 24 h and in up to 76–94% of patients within 48 h [8–14]. This wide range of variability in achievement of sinus rhythm in recent-onset AF implies that a series of variables may influence the chance of spontaneous conversion to sinus rhythm and may be characteristic of specific patient subgroups. This bulk of knowledge had two principal consequences: