Managing Atrial Fibrillation in the Emergency Department.

This month one of our residents presented a perfect scenario for a JC topic namely, disparate advice provided by different attendings regarding selection of the most appropriate agent of choice when managing a patient presenting with atrial fibrillation and RVR. Unfortunately, I was the attending posed with addressing his question which prompted me to review current evidence only to find a paucity of highly powered, well designed clinical studies that address this common ED complaint. Review of 2019 update to the  2014 AHA A-Fib guidelines  did not provide much additional guidance to the use of our stalwarts metoprolol and diltiazem.  The agent of “best” choice of course, needs to be contextualized along the spectrum from the otherwise healthy intern presenting to the ED with new onset AF after trying to keep up with his senior resident as she kicks back shots of tequila (true story), to the patient with acute decompensated CHF and poor rate control already on a B-blocker. In February of 2018 we had an incredibly informative JC that was co-moderated by two of our most highly-esteemed and coolest cardiology colleagues Drs. Bhasin & Iyer both of whom have graciously accepted an invite for a return engagement and field your questions on the topic. Looking forward to seeing your smiling faces on Zoom and I expect an incredibly helpful discussion. Charlie

Fromm et al., Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department J Emerg Med Aug;49(2):175-82. 2015 Appraisal

 Nicholson et al., Hemodynamic comparison of intravenous push diltiazem versus metoprolol for atrial fibrillation rate control Am J Emerg Med . 2020 Jun 21;38(9):1879-1883.  Appraisal

Alowais et al., Heart rate outcomes with concomitant parenteral calcium channel blockers and beta blockers in rapid atrial fibrillation or flutter Am J Emerg Med 2020 May 8;735-757(20) Appraisal