Atrial Fibrillation

Atrial fibrillation is one of the most common arrhythmias we encounter.  However, there is no universally accepted approach for ED management of recent onset atrial fibrillation.  There is a protocol called the “Ottawa Aggressive Protocol” for rapid discharge of ED patients with rapid onset atrial flutter or atrial fibrillation.  (

In short the protocol states it is safe to cardiovert patients with recent onset A-fib or a-flutter (<48 hours) with either a 1 gram infusion of procainamide over an hour, and / or synchronized cardioversion.  In the initial study, the protocol was an infusion of procainamide.  For the individuals that failed chemical conversion, a dose of 150-200 J of synchronized cardioversion under procedural sedation was utilized.  The success rate of procainamide alone was 58.3%, and overall with subsequent cardioversion was 91.7%.  

There was an adverse even reported in 7.6% of patients, with the most common event being hypotension.  No strokes or deaths were reported.

Rob Orman, of the ERCast Podcast, has a nice post about the safety of cardioversion in the ED, along with an excerpt from his podcast, with the relevant material starting at about 1:45 in to the audio.  Here is the link

If you want more links advocating this policy:

Dr. David Vinson, from “Physician’s Weekly,” replicated similar results in a smaller study.

And here is something from ACEP, although it is a bit older, from 2009:—Practice-Management/Aggressive-Ottawa-Protocol-for-A-Fib-Succeeded-in-ED/

What do you all think?  Have you utilized this approach before?  What is your approach to the recent onset atrial fibrillation patient?  Please discuss.