Clinical pathways for patients with atrial fibrillation in the ED

Abstract Background Atrial fibrillation (AF) is already a common arrythmia in the emergency department (ED) with high morbidity. Given the aging population rising numbers of AF patients are expected, thus putting increasing strain on health care services. Recent evidence is supporting an early rhythm control strategy, particularly in patients with a recent onset of AF. However treatment pathways for patients with AF, especially patients a first diagnosis of AF, are complex and require further assessment. Purpose In this project we aim to identify different pathways of AF patients in a busy ED, exploring a range of questions from length of stay in the ED, through rhythm control strategies and anticoagulation strategies. Methods This project is part of the is a substudy of the HERA-FIB project, a single center, retrospective observational study of 10.222 AF patients presenting to the ED of the department of cardiology of a university hospital from June 2009 to March 2020. The methodology has previously been described. The project was performed according to the declaration of Helsinki and was approved by the local ethics committee and registered at ClinicalTrials.gov. Results The most common reasons for presentation to the ED were AF related symptoms, cardiac decompensation and infectious diseases. Overall 27% of patients were presenting with atrial fibrillation for the first time. The median length of stay in the ED was 4.65 hours (IQR 3.0-7.4 hours), with small differences throughout the day. Admissionrate was 61,6%. Urgent cardioversion was sparsely used (15% of patients) with a clear preference for electrical cardioversion. Early rhythm control was associated with improved survival in patients with first diagnosed AF (HR 1.61 95% CI 1.30-1.99, p0.0001). Oral anticoagulation was prescribed to the majority of patients. The uptake of the newly available new oral anticoagulants (NOACS) was swift, leading to an overall decrease of patients without oral anticoagulation. Conculsion The work up for AF in the ED is time consuming, regardless of the time of presentation. Early cardioversion was associated with improved longterm survival for patients with first diagnosed AF. Treatment pathways of patients with AF in the ED have changed dramatically with the implementation of NOACs, leading to a higher rate of oral anticoagulation use. Prospective studies are required to evaluate the optimal and pragmatic management strategy of patients with AF in the ED.