An aggressive electrophysiologist-guided rhythm control strategy significantly reduces hospital admissions in patients presenting with atrial fibrillation in the emergency department

Abstract Introduction Atrial fibrillation (AF) is the most common arrhythmia encountered in the emergency department (ED). Registry data have shown that about 60% of AF patients who visit the ED are being admitted to hospital leading to increased numbers of AF-related hospital admissions. Towards this direction we created the "HEROMEDICUS" study for the management of these patients in the acute phase. The protocol includes an aggressive electrophysiologist-guided rhythm control strategy for patients presenting with AF in the ED. Purpose We examined retrospectively the incidence and management of AF our ED during the period of September of 2021 to September 2023 and we compared admission rates applying the HEROMEDICUS protocol. Methods In the retrospective phase we reviewed the charts of patients diagnosed with a primary diagnosis of Atrial Fibrillation/Afflutter/ Atrial tachycardia who visited our hospital's ED from September 2021 to September 2023 and examined the management of the arrythmia in the emergency department. We applied the HEROMEDICUS protocol from September 2023 to October 2025. With the use of tablet and an application designed specifically for this protocol, there was continuous counseling by a specialist electrophysiologist. Patients with poor anticoagulation were offered rate control and programmed for an outpatient cardioversion. Otherwise, intravenous flecainide was administered and upon failure or in case of contraindications to intravenous flecainide (prior home loading with 300mg propafenone or 200mg flecainide), electrical cardioversion was performed. The primary endpoint was safety of protocol and efficacy based on hospital admission. Results From September 2021 to September 2023, 14360 patients visited the cardiology emergency department out of which 715 had AF. Among AF patients 300 were admitted to cardiology clinic (41.9%) and the remaining 415 patients were managed in the ED. From the period 08/09/2023 to 10/10/2025, 277 cases visited our ED, of which 15 had atrial tachycardia, 28 had atrial flutter and 234 had atrial fibrillation. Rate control was performed in 17% with beta-blockers and verapamil. Spontaneous cardioversion happened in 12%. Successful cardioversion to sinus rhythm with intravenous flecainide was performed in 61 of 85 patients (71.7%) while in 112 of 116 patients electrical cardioversion was successful. A total of 71% of patients had sinus rhythm after evaluation and admission took place in 4.6% of cases compared to 41.9% before the HEROMEDICUS protocol. Conclusion An aggressive electrophysiologist-guided rhythm control strategy for patients presenting with AF in the ED resulted in a significant reduction in hospital admissions