Open Access

Antiarrhythmic drug therapy among patients presenting to emergency department with symptomatic atrial fibrillation – a prospective nationwide cohort

  • Tero Penttilä1Email author,
  • Heikki Mäkynen1,
  • Juha Hartikainen2,
  • Harri Hyppölä3,
  • Timo Lauri4,
  • Mika Lehto5,
  • Juha Lund6,
  • MJ Pekka Raatikainen5 and
  • for the FinFib2 investigators
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine201725:81

https://doi.org/10.1186/s13049-017-0424-7

Received: 18 May 2017

Accepted: 2 August 2017

Published: 15 August 2017

Abstract

Background

Atrial fibrillation (AF) is a common arrhythmia that causes numerous visits to emergency departments (ED). The aim of the FinFib2 study was to evaluate whether treatment of patients with AF in ED is consistent with the contemporary European Society of Cardiology (ESC) management guidelines. Here we report the results of antiarrhythmic drug therapy (AAD) in ED.

Methods

All patients within the two-week study period whose primary reason for the ED visit was symptomatic AF were included into this prospective multicentre study. Comprehensive data on factors contributing to the treatment of AF were collected, including a data of previous use of ADDs, and changes made for them during a visit in ED.

Results

The study population consisted of 1013 consecutive patients (mean age 70 ± 13 years, 47.6% female). The mean European Heart Rhythm Association (EHRA) symptom score was 2.2 ± 0.8. Rhythm control strategy was opt for 498 (63.8%) and 140 (64.5%) patients with previously and newly diagnosed AF, respectively. In patients with previously diagnosed AF the most frequently used AAD was a beta blocker (80.9%). Prior use of class I (11.4%) and III (9.1%) AADs as well as start or adjustment of their dosage (7.4%) were uncommon. Most of the patients with newly diagnosed AF were prescribed a beta blocker (71.0%) or a calcium channel antagonist (24.0%), and only two of them received class I or class III AADs.

Conclusions

Our data demonstrated that in patients presenting to the ED with recurrent symptomatic AF and aimed for rhythm control strategy, the use of class I and class III AADs was rare despite ESC guideline recommendations. It is possible that early adaptation of a more aggressive rhythm control strategy might improve a quality of life for symptomatic patients and alleviate the ED burden associated with AF. Beta blockers were used by majority of patients as rate control therapy both in rate and rhythm control groups.

Trial registration

NCT01990105. Registered 15 November 2013.

Keywords

Atrial fibrillation Emergency department Antiarrhythmic medication Rhythm control Rate control EHRA score

Background

Atrial fibrillation (AF) is the most common sustained arrhythmia [1]. Given the predicted increase in the incidence of AF it has been estimated that in 2030 there will be 14–17 million patients with AF in Europe [24]. Consequently, the amount of AF related visits to the emergency departments (ED) is likely to rise extensively in near future [5].

Emergency departments play a key role in management of AF [6]. In patients with acute AF the decision between rhythm and rate control is done in the ED. The severity of symptoms related to AF is the main factor in selection of the treatment strategy [7]. Age, presence of structural heart disease and other co-morbidities, the type of AF and contraindications to antiarrhythmic drugs (AAD) should also be taken into account when evaluating the need and reasonability of cardioversion, and how to prevent recurrent AF episodes [8]. The efficacy and safety of beta blockers and calcium channel antagonists are well established in acute and long-term rate control [9]. Rate control therapy should consider for all patients with AF if needed, both in a rate and a rhythm control strategies [10, 11]. In a rhythm control strategy, additionally class I and III AADs are recommended to maintain sinus rhythm [1217]. Regardless of the chosen treatment strategy the need of oral anticoagulation (OAC) along with risk factors for thromboembolic complications and bleeding must be evaluated [10, 11].

The results of previous studies indicate that there is large variation in the management of AF in the ED [18, 19]. The FinFib2 study was designed to evaluate whether the treatment of patients with symptomatic AF in the ED is in line with the European Society of Cardiology (ESC) treatment guidelines valid at the study period 2013 [10, 11]. We report real life data on the selection of the treatment strategy, symptoms and risk factors of AF, and use of antiarrhythmic medication in these patients.

Methods

Study design and patient population

This prospective snapshot study was conducted in 35 EDs around Finland. There were a large variation of size and facilities of EDs; units from small heath care centers to big university hospitals were participating. Finland is divided into five university hospital districts, and patients from all of them were enrolled in order to avoid any bias due to geographical differences. All patients whose primary reason for the ED visit was symptomatic AF during a two-week study period (November 11–23, 2013) were included.

Data on concomitant diseases, risk factors for AF, and a history of thromboembolic complications, treatment strategy, and use of antiarrhythmic medication was collected using predefined internet based case report form. A rhythm control strategy means a physician’s aim to maintain a sinus rhythm. A rate control strategy means a physician’s decision to accept a permanent AF. Symptoms associated to AF were ranked using European Heart Rhythm Association (EHRA) score [10] (Fig. 1). Antiarrhythmic drugs were classified according to the Vaughan Williams classification (Table 1).
Fig. 1

Classification of AF related symptoms according to the European Heart Rhythm Association (EHRA) score in patients with prior (n = 780) and newly diagnosed AF (n = 217) (a) and in patients with rhythm control (n = 659) and rate control strategy (n = 336) (b). EHRA 1 = no symptoms, EHRA 2 = mild symptoms (normal daily activity not affected), EHRA 3 = severe symptoms (normal daily activity affected), EHRA IV = disabling symptoms (normal daily activity discontinued)

Table 1

Antiarrhythmic drugs according to the Vaughan Williams classification. None of the patients received drugs which are presented in parenthesis

Classification

Agents

Mechanism of action

Notes

IA

(Disopyramide)

Quinidine

(Procainamide)

Sodium channel blockade with intermediate association/dissociation and potassium channel blockade

Contraindicated in patients with structural heart diseases

IB

(Lidocaine)

(Mexiletine)

Sodium channel blockade with rapid association/dissociation

Not indicated for AF

IC

Flecainide

(Propafenone)

Sodium channel blockade with slow association/dissociation

Contraindicated in patients with structural heart diseases

II

(Atenolol)

(Asebutolol)

(Betaxolol)

Bisoprolol

Carvedilol

Metoprolol

(Nebivolol)

(Pindolol)

Propranolol

(Seliprolol)

Beta adrenergic receptor blockade

Can be used also in patients with structural heart disease

More effective in rate than rhythm control

III

Amiodarone

Dronedarone

Sotalol

Vernakalant

Potassium channel blockade

Amiodarone and dronedarone have also class I, II and IV activity

Sotalol has also class II activity

Vernakalant blocks sodium and potassium channels in atria but not in ventricles

Dronedarone is contraindicated in severe heart failure and permanent AF

Extra cardiac adverse events (e.g., liver and pulmonary toxicity and thyroid dysfunction) are common with amiodarone

Vernakalant is available only for acute intravenous use

IV

Verapamil

Diltiazem

Calcium channel blockade

Should be avoided in patients with congestive heart failure

Others

Digoxin

Variable mechanisms

May have adverse effect on the prognosis of patients with AF

A data of prior use and changes made for AADs in ED were collected. A physician in ED made an independent decision to choose a rate control strategy or a rhythm control strategy for each patient. We evaluated the use of AAD therapy during an ED visit to support that decision; if the rhythm control was chosen, were a class I or III AAD started or a dosage of these drugs changed. We also evaluated a use of rate control drugs (beta and calcium channel blockers) for all patients, both in a rate and a rhythm control groups.

Statistical analysis

The data were analysed using IBM SPSS Statistics software package version 22 (IBM SPSS Inc., Armonk, NY, USA). Missing data values were excluded from the statistical analysis. Continuous variables are expressed as mean ± standard deviation and compared with independent variables t-test or Mann-Whitney U-test when appropriate. Categorical variables are expressed as numbers and percentages and compared by Fisher’s exact test. All tests were two-sided and a P value of <0.05 was considered statistically significant.

Results

Baseline characteristic of the study population

A total of 1013 consecutive patients with symptomatic AF were enrolled into the study. In 217 (21.4%) patients AF was diagnosed for the first time in the ED, whereas 780 (77.0%) patients had recurrent AF. The mean age of the patients was 70.0 ± 13.1 years (19–103 years) - 67.7% of them were 65 years or older, and 39.5% were 75 years or older. Slightly less than half of them (47.6%) were female. The most common underlying diseases were hypertension (65.0%), dyslipidaemia (43.5%), coronary artery disease (23.2%), and diabetes (21.1%) (Table 2).
Table 2

Clinical characteristics of the patients with symptomatic atrial fibrillation (AF) on admission to the emergency department in the rhythm versus rate control groups

 

Total

n (%)

Rhythm control

n (%)

Rate control

n (%)

P-value

Patients

1013

659 (65.1)

336 (33.2)

 

 Previously diagnosed AF

780

498 (63.8)

261 (33.5)

 

 Newly diagnosed AF

217

140 (64.5)

71 (32.7)

 

Age

70.0 ± 13.1 (19–103)

65.7 ± 12.4

78.6 ± 10.1

< 0.001

Female

482 (47.6)

267 (40.5)

205 (61.0)

< 0.001

Congestive heart failure

176 (17.4)

57 (8.6)

115 (34.2)

< 0.001

Hypertension

658 (65.0)

395 (59.9)

251 (74.7)

< 0.001

Diabetes

214 (21.1)

116 (17.6)

95 (28.3)

< 0.001

Stroke

81 (8.0)

37 (5.6)

41 (12.2)

< 0.001

Transient ischemic attack

53 (5.2)

21 (3.2)

32 (9.5)

< 0.001

Other thromboembolic events

24 (2.4)

8 (1.2)

15 (4.5)

0.003

Coronary artery disease

235 (23.2)

106 (16.1)

122 (36.3)

< 0.001

Previous myocardial infarction

126 (12.4)

55 (8.3)

66 (19.6)

< 0.001

Atherosclerosis

39 (3.8))

15 (2.3)

24 (7.1)

< 0.001

Dyslipidaemia

441 (43.5)

273 (41.4)

161 (47.9)

0.042

Ongoing or ex-smoking

254 (25.1)

174 (26.4)

75 (22.3)

0.809

Valvular disease

128 (12.6)

63 (9.6)

65 (19.3)

< 0.001

Thyroid dysfunction

112 (11.1)

66 (10.0)

45 (13.4)

0.136

Lung disease

135 (13.3)

72 (10.9)

61 (18.2)

0.002

Renal insufficiency

100 (9.9)

27 (4.1)

70 (20.8)

< 0.001

Liver insufficiency

18 (1.8)

7 (1.1)

11 (3.3)

0.021

Anaemia

103 (10.2)

39 (5.9)

62 (18.5)

< 0.001

History of major bleeding

34 (3.4)

16 (2.4)

18 (5.4)

0.026

Echocardiography

508 (50.1)

353 (53.6)

152 (45.2)

0.015

EHRA score

2.2 ± 0.8

2.3 ± 0.7

2.0 ± 0.9

< 0.001

CHA2DS2-VASc score

3.1 ± 2.1

2.4 ± 1.9

4.4 ± 1.8

< 0.001

HAS-BLED score

1.9 ± 1.2

1.5 ± 1.1

2.6 ± 1.2

< 0.001

The mean EHRA score was 2.2 ± 0.8. The most frequent symptom was palpitation (620 patients, 61.2%). Other AF related symptoms included dyspnoea (270 patients, 26.7%), dizziness (197 patients, 19.4%), and chest pain (125 patients, 12.3%). Eighteen patients (1.8%) had had syncope. Almost half of the patients with previously diagnosed AF (354 patients, 45.4%) had had at least one visit to the ED because of AF within the preceding 12 months. For these patients, the mean number of prior ED admissions per patient was 2.7 ± 3.6 (range 1–30).

Prior antiarrhythmic therapy

Most of the patients (85.3%) with previously diagnosed AF were using antiarrhythmic medication for rhythm or rate control when admitted to the ED. Beta blockers were used by 631 (80.9%), digoxin by 72 (9.2%), and verapamil or diltiazem by 23 (2.9%) of these patients. Class I AADs were used by 89 (11.4%) patients. The majority of them were using flecainide (87 patients, 11.2%), and two patients were on quinidine (0.3%). The other AADs included amiodarone (26 patients, 3.3%), dronedarone (30 patients, 3.8%) and sotalol (15 patients, 1.9%).

Treatment strategy and initial management in the ED

In patients with previously diagnosed AF the rhythm disorder was paroxysmal in 282 (36.5%), persistent in 298 (38.7%) and permanent in 191 (24.8%) patients. Rhythm control strategy was chosen by ED physicians in 498 of the 580 (85.9%) patients with paroxysmal or persistent AF. Among them 287 and 62 patients underwent successful acute electrical or pharmacological cardioversion, respectively. Sinus rhythm restored spontaneously or an elective cardioversion were planned in 149 patients. The AADs used for pharmacological cardioversion included flecainide (17 patients), amiodarone (7 patients), vernakalant (6 patients), and a beta blocker or digoxin (32 patients).

There were 217 patients with newly diagnosed AF in the study population. The rhythm control strategy was chosen for 140 (64.5%) of them. Normal sinus rhythm resumed spontaneously in 51 patients. Electrical or pharmacological cardioversion was performed in 43 and 21 (beta blocker 17, digoxin 1, flecainide 3, amiodarone 1) patients, respectively. An elective cardioversion was planned for 25 patients.

The patients in whom rate control strategy was chosen were significantly older than those with rhythm control strategy (78.6 ± 10.1 vs. 65.7 ± 12.4 years, P < 0.001). The EHRA score was significantly higher among patients with rhythm control strategy (2.3 ± 0.7 vs. 2.0 ± 0.9, P < 0.001), whereas the CHA2DS2VASc (4.4 ± 1.8 vs. 2.4 ± 1.9, P < 0.001) and HAS-BLED (2.6 ± 1.2 vs. 1.5 ± 1.1, P < 0.001) scores were higher among those with rate control strategy (Table 2).

Antiarrhythmic drug therapy at discharge

At discharge from the ED 625 (80.1%) patients with prior AF diagnosis were prescribed beta blocker medication. Despite recurrent AF symptoms a change in antiarrhythmic medication was done only in 97 of these patients (12.4%). Class I or III antiarrhythmic medication was started or the dosage of the drug used was adjusted in 37 (7.4%) of the patients with previous AF diagnosis and rhythm control strategy. The reasons for the changes in AAD therapy included inadequate antiarrhythmic efficacy (68 patients), adverse effects (11 patients), change into rate control strategy (19 patients) and lack of compliance (1 patient).

In patients with newly diagnosed AF a beta blocker was prescribed for 154 (71.0%), a calcium channel antagonist for 52 patients (24.0%), and digoxin for 8 patients (3.7%). Amiodarone was started for 2 patients, but no class I drugs were prescribed for the patients with newly diagnosed AF.

Discussion

The results of the FinFib2 study demonstrated that despite recurrent symptoms and ESC guideline recommendations prior use and initiation of class I and class III antiarrhythmic medication are rare in patients presenting to the ED with symptomatic AF (Fig. 2).
Fig. 2

The use of antiarrhythmic drugs among patients with previously diagnosed AF (n = 780) at admission to the ED (black column) and at discharge (light grey column)

At admission to the ED class I or III antiarrhythmic drugs were used only by 20.5% of the patients with prior AF diagnosis, and at discharge 36.5% of the patients in the rhythm control group were prescribed class I or III antiarrhythmic medication. With regard to the current guidelines recommending execution of “upstream” therapy and use of class I and III antiarrhythmic drugs in the early stage of the disease, these numbers appear low [20, 21]. In patients with highly symptomatic AF active rhythm control strategy is expected not only to improve the quality of life, but also to reduce ED burden associated with AF.

After cardioversion, the likelihood of AF recurrences is highest during the following weeks [22]. It has been shown that 56% of the patients presenting to the ED with symptomatic AF will have a repeat ED visit due to AF recurrence within a year [18]. This was reflected in our study population by the high number of previous visits to ED. In patients with acute AF normal sinus rhythm can be effectively restored by electrical or pharmacological cardioversion [20]. However, in rhythm control strategy cardioversion alone is hardly ever enough but a physician should always try to find a way to prevent AF recurrences. In our survey, a class I or III antiarrhythmic medication was started or the dosage was optimized as a part of a rhythm control strategy only in about 7% of the patients with a previously diagnosed AF. It is well established that early intervention is crucial for the long-term efficacy of antiarrhythmic drugs and catheter ablation. Therefore, decision to start a class I or III antiarrhythmic medication should be done in the ED if structural heart disease has been excluded by recent examinations and clinical history. Echocardiography plays a key role in diagnosis of many cardiac diseases and selection of AF treatment strategy. In our study, it had been done earlier for half of the patients.

However, as the rhythm control strategy has not demonstrated a mortality benefit compared to the rate control strategy in large studies, it should be not used for all patients with AF [2325]. In our study, patients in the rate control group were older, had more concomitant diseases, and a lower symptom score.

A rate control therapy should be considered for all patients with AF despite of a treatment strategy, if a heart rate during AF is rapid. In this study population, a rate control therapy was used by most of the patients. In line with the results of previous studies, about 80% of the patients in our study were using beta blockers [26]. The efficacy of beta blockers to reduce ventricular rate in patients with AF is well established, but their efficacy in preventing AF recurrences is only modest [22, 27].

According to the contemporary AF management guidelines class I agents should be the drug of choice for rhythm control in patients with lone AF. Despite this, significantly less effective beta blocker medication was used as a first line therapy in most of these patients, and none of them received class I antiarrhythmic medication after a first documented AF episode.

The facilities to treat patients with AF vary between different EDs in Finland. In small heath care centers it’s not possible to make an electrical cardioversion, and a patient has to be sent to a bigger unit. In smaller EDs physicians experience to use AADs might not be as good as in bigger units. In Finland, we are going towards bigger ED units in near future, which is expected to improve the quality of rhythm control therapy of patients with AF, and also improve acute collaboration between ED physicians and cardiologists.

Limitations

This study provided a snapshot of the management of patient with AF in an emergency care setting. Therefore, no follow-up data are available. For example, many patients were referred to a cardiologist but the results of the further examinations and therapies were not available. Likewise, it was not possible to assess a rationality of all individual treatment decisions; therefore we assessed a treatment decisions the physicians made after choosing a treatment strategy. Finally, the results of this study may not be directly extrapolated to different health care systems. In Finland all inhabitants are covered by national health insurance and patients need to pay only a nominal fee for ED visits and hospitalization.

Clinical implications

ED physicians play a key role in treatment of acute AF. We have previously shown that patients with high risk of thromboembolic complications were recognized well by the ED physicians, and oral anticoagulation therapy (OAC) was prescribed for the majority of these patients [28]. The results of the current analysis indicate that rhythm control therapy is not understood and executed as well as OAC therapy. According to contemporary ESC clinical practice guidelines rhythm control strategy should be considered for patients with recurrent episodes of symptomatic AF [10, 11]. On the other hand, rate control strategy is a feasible choice in patients with mild symptoms. In many cases the treatment strategy can be selected and implemented in the ED. In our study the factors favouring a rate control strategy included older age, concomitant diseases and mild/moderate symptoms.

Early adaptation of an aggressive rhythm control strategy is likely to alleviate the ED burden associated with symptomatic AF. In order to be able to select the most appropriate antiarrhythmic therapy for a given patient the ED physician should evaluate the symptoms of the patient and take thorough clinical history. He/she should have enough information on the results of prior cardiac examinations (e.g., electronic nationwide patient records) and knowledge of the key features of the antiarrhythmic drugs (Table 1). Class I AADs have been shown to be safe and effective in patients with lone AF but contraindicate in patients with structural heart disease [29]. Hence, if no data on echocardiographic and other cardiac examination are available the patient should be referred to cardiologist for elective evaluation or rather a cardiologic consultation should be readily available in ED. Structured local instructions for treatment of AF patients and close collaboration with cardiologists play a key role in this process.

Conclusions

Current survey is one of the largest studies evaluating AF treatment strategy and antiarrhythmic therapy in an emergency care setting. Our data indicate that rhythm control therapy is not understood and executed adequately in the ED. That is, in contrast to contemporary AF management guidelines a beta blocker was by far the most commonly used AAD and use of more effective drugs was rare also in symptomatic patients in rhythm control group.

Abbreviations

AAD: 

antiarrhythmic drug

AF: 

atrial fibrillation

ED: 

emergency department

EHRA: 

European Heart Rhythm Association

ESC: 

European Society of Cardiology

FCS: 

Finnish Cardiac Society

OAC: 

oral anticoagulation therapy

Declarations

Acknowledgements

The FinFib2 investigators:

Pekka Raatikainen (Heart and Lung Center, Helsinki University Hospital, Finland); Mika Lehto, Aleksi Almenoksa, Juha Koskinen, Sergei Kesonen, Jyri Veräjänkorva (Carea, Kotka, Finland); Kimmo Salmio (North Kymi Hospital, Kouvola, Finland); Juhani Metsäniitty (Peijas Hospital, Vantaa, Finland); Laura Mikkonen (Porvoo Hospital, Porvoo, Finland); Jouni Nurmi, Risto Viitanen, Jukka Vaahersalo (Lohja Hospital, Lohja, Finland); Jukka Rinne (Länsi-Uusimaa Hospital, Tammisaari, Finland); Risto Pajari, Jani Mononen, Anna-Mari Hekkala (Haartman Hospital, Helsinki, Finland); Laura Moring, Bernd Günther (Maria Hospital, Helsinki, Finland); Juha Lund (Heart Center Turku University Hospital, Turku, Finland); Jarkko Karihuhta (Satakunta Cental Hospital, Pori, Finland); Jon Holmström (Vaasa Central Hospital, Vaasa, Finland); Juho Lindberg (Tyks Loimaa Hospital, Loimaa, Finland); Anja Toljamo, Jonna Juhola (Tyks Salo Hospital, Salo, Finland); Marjatta Strandberg (Tyks Vakka-Suomi Hospital, Uusi-Kaupunki); Tuula Meinander, Heikki Mäkynen, Tero Penttilä (Heart Center Tampere University Hospital, Tampere, Finland); Ville Hällberg, Tapio Innamaa (Kanta-Häme Central Hospital, Hämeenlinna, Finland); Hanna Suurmunne (Päijät-Häme Central Hospital, Lahti, Finland); Jari Nyrhilä (Seinäjoki Central Hospital, Seinäjoki, Finland); Katja Jokela (Vammala Regional Hospital, Vammala, Finland); Peeter Kasemets (Valkeakoski Regional Hospital, Valkeakoski, Finland); Juha Hartikainen, Matti Onnela, Harri Hyppölä (Kuopio University Hospital, Kuopio, Finland); Kai Nyman, Pirjo Mustonen (Central Finland Central Hospital, Jyväskylä, Finland); Tuomas Rissanen (North Carelia Central Hospital, Joensuu, Finland); Jaana Luukkonen (Savonlinna Central Hospital, Savonlinna, Finland); Pertti Salmi, Pekka Salminen, Teemu Lasanen, Matti Kettunen (Health Center of Varkaus); Timo Lauri (Oulu University Hospital, Oulu, Finland); Ari Toppinen (Kainuu Central Hospital, Kajaani, Finland); Jussi Sia (Keski-Pohjanmaa Central Hospital, Kokkola, Finland); Hanna Tormilainen, Magnus Hagnäs (Lapland Central Hospital, Rovaniemi, Finland); Tapio Åman (Länsi-Pohja Central Hospital, Kemi, Finland); Liisa Miettinen (Oulaskangas Hospital, Oulainen, Finland); Niilo Keränen (Health Center of Kuusamo, Kuusamo, Finland).

Funding

This study was sponsored by the FCS. The FCS have received unrestricted research grants from Bayer, Biosense Webster, BMS/Pfizer Alliance, Boehringer-Ingelheim, Meda, Sanofi and St Jude Medical.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Authors’ contributions

PR, HM, JH, TL, ML and JL designed the study. TP made an analysis of data and drafted the manuscript. All authors took part for a writing process, and approved the final manuscript.

Ethics approval and consent to participate

The study protocol was approved by the Pirkanmaa Hospital District Ethical Committee (R13044). According to Ethical Committee, individual approval from patients participating was not needed.

Consent for publication

Not applicable.

Competing interests

TP and PR have received research grants from the Finnish Cardiac Society (FCS). All other authors declare that there is no conflict of interest.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Heart Center Co. Tampere University Hospital
(2)
Heart Center, Kuopio University Hospital
(3)
Emergency Department, Kuopio University Hospital
(4)
Oulu University Hospital
(5)
Heart and Lung Center, Helsinki University Hospital
(6)
Turku University Hospital

References

  1. Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med. 1982;306:1018–22.View ArticlePubMedGoogle Scholar
  2. Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, et al. Worldwide epidemiology of atrial fibrillation: a global burden of disease 2010 study. Circulation. 2014;129(8):837–47.View ArticlePubMedGoogle Scholar
  3. Zoni-Berisso M, Lercari F, Carazza T, Dominicucci S. Epidemiology of atrial fibrillation: European perspective. Clin Epidemiol. 2014;6:213–20.View ArticlePubMedPubMed CentralGoogle Scholar
  4. Miyasaka Y, Barnes ME, Gersh BJ, Cha SS, Bailey KR, Abhayaratna WP, et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota 1980 to 2000, and implications on the projections for future prevalence. Circulation. 2006;114:119–25.View ArticlePubMedGoogle Scholar
  5. Magnani JW, Rienstra M, Lin H, Siiner MF, Lubitz SA, McManus DD, et al. Atrial fibrillation: current knowledge and future directions in epidemiology and genomics. Circulation. 2011;124:1982–93.View ArticlePubMedPubMed CentralGoogle Scholar
  6. Kyhälä-Valtonen H, Lehto M, Rossinen J, Pajari R, Mustonen H, Koponen L, et al. Quality of emergency room care for atrial fibrillation. Scand Cardiovasc J. 2006;40:267–73.View ArticlePubMedGoogle Scholar
  7. Rolf S, Kornej J, Dagres N, Hindricks G. What can rhythm control therapy contribute to prognosis in atrial fibrillation? Heart. 2015;101:842–6.View ArticlePubMedGoogle Scholar
  8. Piccini JP, Fauchier L. Rhythm control in atrial fibrillation. Lancet. 2016;388:829–40.View ArticlePubMedGoogle Scholar
  9. Segal JB, McNamara RL, Miller MR, Kim N, Goodman SN, Powe NR, et al. The evidence regarding the drugs used for ventricular rate control. J Fam Pract. 2000;49:47–59.PubMedGoogle Scholar
  10. Camm AJ, Kirchhof P, Lip GY, et al. Guidelines for the management of atrial fibrillation. Eur Heart J. 2010;31:2369–429.View ArticlePubMedGoogle Scholar
  11. Camm AJ, Lip GY, De Caterina R, et al. 2012 focuser update of the ESC guidelines for the management of atrial fibrillation: an update of the 2010 ESC guidelines for the management of atrial fibrillation. Developed with the special contribution of the European heart rhythm association. Eur Heart J. 2012;33:2719–47.View ArticlePubMedGoogle Scholar
  12. Lafuente-Lafuente C, Mouly S, Longas-Tejero MA, Bergman JF. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Cochrane Database Syst Rev. 2007;4:CD005049.Google Scholar
  13. Van Gelder IC, Crijns HJ, Van Gilst WH, Van Wijk LM, Hamer HP, Lie KI. Efficacy and safety of flecainide acetate in the maintenance of sinus rhythm after electrical cardioversion of chronic atrial fibrillation or atrial flutter. Am J Cardiol. 1989;64:1317–21.View ArticlePubMedGoogle Scholar
  14. Hohnloser SH, Crijns HJ, van Eickels M, Gaudin C, Page RL, Torp-Pedersen C, et al. Effect of dronedarone on cardiovascular events in atrial fibrillation. N Engl J Med. 2009;360:668–78.View ArticlePubMedGoogle Scholar
  15. Singh BN, Connolly SJ, Crijns HJ, Roy D, Kowey PR, Capucci A, et al. Dronedarone for maintenance of sinus rhythm in atrial fibrillation or flutter. N Engl J Med. 2007;357:987–99.View ArticlePubMedGoogle Scholar
  16. Singh BN, Singh SN, Reda DJ, Tang XC, Lopez P, Harris CL, et al. Amiodarone versus sotalol for atrial fibrillation. N Engl J Med. 2005;352:1861–72.View ArticlePubMedGoogle Scholar
  17. Roy D, Talajic M, Dorian P, Connolly S, Eisenberg MJ, Green M, et al. Amiodarone to prevent recurrence of atrial fibrillation. Canadian trial of atrial fibrillation investigators. N Engl J Med. 2000;342:913–20.View ArticlePubMedGoogle Scholar
  18. Tran C, Bennell MC, Qiu F, Ko DT, Singh SM, Dorian P, et al. Predictors and clinical outcomes of inpatient versus ambulatory management after an emergency department visit for atrial fibrillation: a population-based study. Am Heart J. 2016;173:161–9.View ArticlePubMedGoogle Scholar
  19. Rogenstein C, Kelly A-M, Mason S, Schneider S, Lang E, Clement CM, et al. An international view of how recent-onset atrial fibrillation is treated in the emergency department. Acad Emerg Med. 2012;19:1255–60.View ArticlePubMedGoogle Scholar
  20. Kirchhof P, Bax J, Blomstrom-Lundquist C, Calcins H, Camm AJ, Cappato R, et al. Early and comprehensive management of atrial fibrillation: executive summary of the proceedings from the 2nd AFNET-EHRA consensus conference ‘research perspectives in AF’. Eur Heart J. 2009;30:2969–77.View ArticlePubMedGoogle Scholar
  21. Cosio FG, Aliot E, Botto GL, Heidbuchel H, Geller CJ, Kirchhof P, et al. Delayed rhythm control of atrial fibrillation may be a cause of failure to prevent recurrences: reasons for change to active antiarrhythmic treatment at the time of the first detected episode. Europace. 2008;10:21–7.View ArticlePubMedGoogle Scholar
  22. Lafuente-Lafuente C, Valembois L, Bergmann JF, Belmin J. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Cochrane Database SystRev. 2015; doi:10.1002/14651858.CD005049.pub4.
  23. Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347:1825–33.View ArticlePubMedGoogle Scholar
  24. Van Gelder IC, Hagens VE, Bosker HA, Kingma H, Kamp O, Kingma T, et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med. 2002;347:1834–40.View ArticlePubMedGoogle Scholar
  25. Roy D, Talajic M, Nattel S, Wyse DG, Dorian P, Lee KL, et al. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008;358:2667–77.View ArticlePubMedGoogle Scholar
  26. Kuang P, Mah ND, Barton CA, Miura AJ, Tanas LR, Ran R. Achieving ventricular rate control using metoprolol in β-blocker-naive patients vs patients on chronic β-blocker therapy. Am J Emerg Med. 2016; doi:10.1016/j.ajem.2015.12.084. Epub 2016 Jan 7
  27. Kühlkamp V, Schirdewan A, Strangl K, Homberg M, Ploch M, Beck OA. Use of metoprolol CR/XL to maintain sinus rhythm after cardioversion from persistent atrial fibrillation: a randomized, double-blind, placebo-controlled study. J Am Coll Cardiol. 2000;36:139–46.View ArticlePubMedGoogle Scholar
  28. Penttilä T, Mäkynen H, Hartikainen J, Lauri T, Lehto M, Lund J, et al. Anticoagulation therapy among patients presenting to the emergency department with symptomatic atrial fibrillation – the FinFib2 study. Eur J Emerg Med. 2016; (Epub ahead of print)Google Scholar
  29. Cosedis Nielsen J, Johannessen A, Raatikainen P, Hindricks G, Walfridsson H, Kongstad O, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med. 2012;367:1587–95.View ArticlePubMedGoogle Scholar

Copyright

© The Author(s). 2017