What to D.O.

atrial fibrillation, rapid ventricular response: Schematic of micro and macroreentrant circuits in atrial fibrillation.FigureSince the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial was published in 2002, emergency department management of atrial fibrillation patients with rapid ventricular response has been defined by a rate reduction strategy, nearly always followed by hospital admission, and facilitated by an increasingly haphazard smorgasbord of chronotropic control. The trial, a randomized, multicenter, unblinded trial of clinician-choice medications in strategies of rate versus rhythm control, included more than 4000 patients with nonvalvular atrial fibrillation. Strikingly, no significant difference was seen between the two groups in mortality: 25.9 percent v. 26.7 percent (HR 1.15; 95% CI 0.99-1.34; P=0.08). Furthermore, no significant difference was found between the groups in the rates of the secondary endpoints of death, disabling stroke, disabling anoxic encephalopathy, major bleeding, and cardiac arrest—32.7 percent v. 32.0 percent (P=0.33). A litany of other secondary endpoints—rate of stroke, intracranial hemorrhage, other hemorrhage—were all negative as well, but patients in the rate control group were less likely to be hospitalized, 73.0 percent v. 80.1 percent (P<0.001), or to develop torsades de pointes, 0.2 percent v. 0.8 percent (P=0.007). Nonetheless, the authors and nearly two decades of clinicians following them made reasonable conclusions from the data. With no identifiable benefit to rhythm control seen in the study, hints of rate control superiority hidden throughout the forest plots, and a diverging survival curve also suggesting an advantage in the corner of rate control, the implication was that rate control should be considered a primary approach to therapy and that rhythm control, if used, may be abandoned early if not fully satisfactory. But in the almost 20 years since AFFIRM, practice shifts, evolving medication strategies, and maturing clinical perspectives have created a landscape irreflective of the setting informed by the landmark trial. Where patients in the emergency department are generally most likely to receive diltiazem or metoprolol, the therapies in AFFIRM showed some stark differences from the modern-day approach, with 70.6 percent of patients in the rate control group receiving digoxin at some point, and only a small minority of the rhythm control group receiving any of the sodium-channel-blocking agents that are a bit more common today. (By the way, diltiazem and metoprolol both have pretty good success rates, though diltiazem will often lead to success a bit more quickly and reliably. [Eur J Emerg Med. 2015;22[3]:150.]) Perhaps most importantly, a slew of observational and interventional trials published in the intervening years have painted a more comprehensive picture of the unique challenges and considerations that must be addressed when handling atrial fibrillation in the ED. An Evolution Managing rapid a-fib was one of the first pathways I recall learning in residency. Despite the patient having spent hours or even days in a rapid ventricular state, I would rush to the bedside armed with a slug of Cardizem or bolus of Lopressor, marveling at my heroic management and daring the AV node to cross me ever again. More often than not, the patient would end up on a continuous infusion of the antiarrhythmic du jour and be swept up to the cardiac care unit while I dutifully documented 31 minutes of critical care time. But my practice has evolved. After a bevy of observational studies suggesting benefit and the LOMAGHI trial marking it safe and likely helpful, it's typical for me to add low-dose magnesium sulfate as a therapeutic adjunct. (Acad Emerg Med. 2019;26[2]:183.) I eventually learned that not only do they make diltiazem in oral form, but its use translates to a higher rate of treatment success than the drip-and-admit approach I'd learned. (West J Emerg Med. 2018;19[2]:417.) In fact, with even a minimal stretch of the imagination, these patients once properly controlled and adequately observed can be safely discharged. (J Atr Fibrillation. 2018;11[1]:1810; http://bit.ly/34oC0Pf.) When the nihilistic RACE 7 trial was published, showing high rates of spontaneous cardioversion even among rate-controlled and discharged patients, the concepts of bedside heroics and infusion admission took an even further step back. In 2010, however, noted ED researcher Ian Stiell, MD, published his group's experience with the Ottawa Aggressive Protocol, in which 660 patients with recent-onset atrial fibrillation or atrial flutter were included, and nearly all were discharged home after a dose of procainamide and (if needed) electrical cardioversion back to sinus rhythm. (CJEM. 2010;12[3]:181; http://bit.ly/3r8NWy2.) No one died or had a stroke, and the torsades de pointes that was seen in AFFIRM never materialized. In the years that followed, a flurry of studies and perspectives from emergency medicine and cardiology reinforced this aggressive rhythm control approach, pointing toward operational, logistical, and patient-oriented benefits that tip the scale away from the rate control paradigm we have long followed. The RAFF2 trial, for example (Stiell again), reinforced that patients do just fine with cardioversion, whether electrical, chemical, or both, and expedited discharge. (Lancet. 2020;395[10221]:339.) Combined with growing comfort with outpatient “pill-in-the-pocket” management, such an approach represents an attractive option for both patients and clinicians. Ultimately, we stand now at a bit of a therapeutic precipice in managing atrial fibrillation with rapid ventricular response in the ED. Certainly, some things are clear: The traditionally-taught bedside battles and inpatient infusions need not be our typical approach any longer, and for those pursuing a rate control approach, patients should be given oral medications (after IV boluses) and strong consideration toward discharge. Whether rate control should be our primary approach any further is less clear. The lessons learned from AFFIRM are important, but deeper perspective over the years has taught us the value and reasonability of a rhythm control approach. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website, www.EM-News.com. Comments? Write to us at [email protected]. Dr. Pescatoreis the chief physician for the Delaware Division of Public Health and an emergency physician at Albert Einstein Health Network in Philadelphia. He is also the host with Ali Raja, MD, of the podcast EMN Live, which focuses on hot topics in emergency medicine:http://bit.ly/EMNLive. Follow him on Twitter@Rick_Pescatore, and read his past columns athttp://bit.ly/EMN-Pescatore.

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