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Thursday, May 17, 2007

The Ottawa Aggressive Protocol for ED Management of Acute Atrial Fibrillation

Acad Emerg Med Volume 14, 5 Supplement 1 9,

The Ottawa Aggressive Protocol for ED Management of Acute Atrial Fibrillation

Ian Stiell, Catherine Clement, Garth Dickinson, Cheryl Symington, Jeffrey Perry and Christian Vaillancourt

University of Ottawa

Objectives
There is no consensus as to the optimal emergency department (ED) management of acute atrial fibrillation (AAF) or atrial flutter (AAFL). Our objective was to examine the efficacy and safety of the Ottawa Aggressive Protocol to convert and discharge ED patients with AAF/AAFL.

Methods
This 5-year cohort study included consecutive visits to a university hospital ED for adults presenting with acute-onset AAF/AAFL and who were managed with the Ottawa Aggressive Protocol. Patients were identified from the National Ambulatory Care Reporting System (NACRS) database. The Aggressive Protocol was overseen by the attending emergency physicians and included: (1) IV procainamide as infusion of 1 gram over 1 hour; (2) electrical cardioversion if necessary, by ED staff; (3) discharge from the ED with outpatient cardiology follow-up. Outcomes included conversion, adverse events, and relapse. The authors conducted descriptive data analyses with 95% CIs.

Results
Characteristics of the 660 eligible patient visits were mean age 64.5 years, mean heart rate 113.4, and mean duration symptoms 8.9 hours, AAF 95.2%, AAFL 4.9%. Overall, 96.8% of patients were discharged home from the ED and 90.3% were discharged in normal sinus rhythm. The respective discharge rates were 97.0% and 93.5% for those in AAF and 93.8% and 87.5% for those in AAFL. All patients received procainamide with a conversion rate of 58.3% (AAF 59.9%, AAFL 28.1%). Electrical cardioversion was attempted in 36.8% of visits with a success rate of 91.7% (AAF 91.0%, AAFL 100%). Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3%, AAF relapse within 7 days 8.6%, Torsades de Pointes 0%, cerebrovascular accident 0%, mortality 0%.


COMMENTARIES:


Acute atrial fibrillation managed in emergency department

17 May 2007
MedWire News: Over 90% of patients with acute atrial fibrillation (AAF) or atrial flutter (AAFL) can be discharged from the emergency department (ED) with a normal heart rhythm using the Ottawa Aggressive Protocol, a study from Canada shows.

The protocol involves an IV procainamide infusion of 1 g over 1 hour, electrical cardioversion if necessary, by ED staff, and discharge from the ED with outpatient cardiology follow-up. This contrasts with current practice in the USA, for example, where patients with AAF and AAFL are admitted to hospital and treated by cardiologists. Ian Stiell and colleagues from the University of Ottawa in Ontario studied the efficacy and safety of the Ottawa protocol in 660 consecutive patients, whose mean age was 64.5 years, mean heart rate 113.4 beats per minute, and mean duration of symptoms 8.9 hours. AAF was present in 95.2% and AAFL in 4.9%.

Overall, 96.8% of patients were discharged home from the ED and 90.3% were discharged with normal sinus rhythm. The corresponding discharge rates for patients in AAF and AAFL were 97.0% and 93.5%, and 93.8% and 87.5%.

All patients received procainamide with a conversion rate of 58.3% (AAF 59.9%, AAFL 28.1%) and electrical cardioversion was attempted in 36.8% patients, which was successful in 91.7% (AAF 91.0%, AAFL 100%).

Adverse events occurred in 7.6% of cases: hypotension in 6.7%, bradycardia in 0.3%, and AAF relapse within 7 days in 0.6%.

“This is the largest reported study of AAF/AAFL in the ED and demonstrates that the Ottawa Aggressive Protocol is extremely effective for the rapid cardioversion and discharge of patients by ED physicians,” said Stiell.

“This protocol is safe and could lead to a significant decrease in hospital admissions.”
The researchers presented their results at the annual meeting of the Society for Academic Emergency Medicine, held in Chicago, Illinois, USA.

Society for Academic Emergency Medicine Annual Meeting; Chicago, Illinois, USA: 16-19 May, 2007

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