How to Manage Atrial Fibrillation in the Emergency Department: a Critical Appraisal

  • Rafael Thiesen Magliari Hospital Santa Paula – São Paulo (SP), Brazil/ Centro de Arritmias e Eletrofisiologia Cardíaca – São Paulo (SP), Brazil/ Sociedade Brasileira de Arritmias Cardíacas – São Paulo (SP), Brazil.
  • José Nunes de Alencar Neto Sociedade Brasileira de Arritmias Cardíacas – São Paulo (SP), Brazil/ Instituto Dante Pazzanese de Cardiologia – São Paulo (SP), Brazil.


Atrial fibrillation is the most common cardiac arrhythmia in emergency departments. There is growing evidence that certain patients with acute atrial fibrillation can be safely managed in the emergency room without the need for hospitalization, minimizing costs and reducing unnecessary exposures. This review addresses the emergency management of atrial fibrillation based on the latest updates on the subject with a focus on the assessment and prevention of thromboembolic phenomena, control of frequency x control of rhythm and strategies for cardioversion and restoration of sinus rhythm or for heart rate control.


Download data is not yet available.


Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, Gillum RF, Kim YH, McAnulty JH, Zheng ZJ, Forouzanfar MH, Naghavi M, Mensah GA, Ezzati M, Murray CJL. Worldwide epidemiology of atrial fibrillation: A global burden of disease 2010 study. Circulation. 2014;129(8):837–47.

McDonald AJ, Pelletier AJ, Ellinor PT, Camargo Jr. CA. Increasing US Emergency Department Visit Rates and Subsequent Hospital Admissions for Atrial Fibrillation from 1993 to 2004. Ann Emerg Med [Internet]. 2008 Jan 1;51(1):58–65. Available from:

Stiell I, Macle L. Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Management of Recent-Onset Atrial Fibrillation and Flutter in the Emergency Department. Can J Cardiol. 2011 Feb 28;27:38–46.

Conen D. Epidemiology of atrial fibrillation. Eur Heart J [Internet]. 2018 Apr 21;39(16):1323–4. Available from:

Staerk L, Sherer JA, Ko D, Benjamin EJ, Helm RH. Atrial Fibrillation: Epidemiology, Pathophysiology, and Clinical Outcomes. Circ Res [Internet]. 2017 Apr 28;120(9):1501–17. Available from:

Middeldorp ME, Pathak RK, Meredith M, Mehta AB, Elliott AD, Mahajan R, Twomey D, Gallagher C, Hendriks JML, Linz D, McEvoy RD, Abhayaratna WP, Kalman JM, Lau DH, Sanders P. PREVEntion and regReSsive Effect of weight-loss and risk factor modification on Atrial Fibrillation: the REVERSE-AF study. Eur Eur pacing, arrhythmias, Card Electrophysiol J Work groups Card pacing, arrhythmias, Card Cell Electrophysiol Eur Soc Cardiol. 2018 Dec;20(12):1929–35.

January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JCJ, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014 Dec;130(23):2071–104.

January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC, Ellinor PT, Ezekowitz MD, Field ME, Furie KL, Heidenreich PA, Murray KT, Shea JB, Tracy CM, Yancy CW. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Hear Rhythm. 2019 Aug;16(8):e66–93.

Calkins H, Hindricks G, Cappato R, Kim Y, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen P, Chen S, Chung MK, Nielsen JC, Curtis AB, Davies DW, Day JD, Avila A, Groot NMSN De, Biase L Di, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao H, Verma A, Wilber DJ, Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation. 2017;(May).

A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation. N Engl J Med [Internet]. 2002 Dec 5;347(23):1825–33. Available from:

Kelly JP, DeVore AD, Wu JJ, Hammill BG, Sharma A, Cooper LB, Felker GM, Piccini JP, Allen LA, Heidenreich PA, Peterson ED, Yancy CW, Fonarow GC, Hernandez AF. Rhythm Control Versus Rate Control in Patients With Atrial Fibrillation and Heart Failure With Preserved Ejection Fraction: Insights From Get With The Guidelines-Heart Failure. J Am Heart Assoc. 2019;8(24):e011560.

Marrouche NF, Brachmann J, Andresen D, Siebels J, Boersma L, Jordaens L, Merkely B, Pokushalov E, Sanders P, Proff J, Schunkert H, Christ H, Vogt J, Bänsch D. Catheter Ablation for Atrial Fibrillation with Heart Failure. N Engl J Med. 2018 Jan;378(5):417–27.

Russo V, Navarin S, Zampini G, Magrini L, Mann C, Muiesan M, Caterina R, Yılmaz M, Beton O, Monzani V, Kubica J, Müller C, Salvatore di somma, Network N. Management of atrial fibrillation in the Emergency Department: Current approach and future expectations. Eur Rev Med Pharmacol Sci. 2013 Dec 1;17:3132–47.

Scheuermeyer FX, Pourvali R, Rowe BH, Grafstein E, Heslop C, MacPhee J, McGrath L, Ward J, Heilbron B, Christenson J. Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm. Ann Emerg Med. 2015 May;65(5):511-522.e2.

Dietrich C, Cirenza C, Costa GDF, de Paola ÂAV. Abordagem da fibrilaçao atrial na emergência: controle do ritmo ou da frequência? J Card Arrhythm. 2013;26(2).

Coll-Vinent B, Sala-Blanch X, Fernández C, Bragulat E, Espinosa G, Miró O, Millá J, Sanchez M. Sedation for Cardioversion in the Emergency Department: Analysis of Effectiveness in Four Protocols. Ann Emerg Med. 2004 Jan;42:767–72.

Soeiro ADEM, Leal TDECAT, Soeiro MCFDEA, Serrano Junior CV, Oliveira Junior MT. Atrial fibrillation with high ventricular rate in emergency room: What_s the best strategy for treatment? Vol. 62, Revista da Associação Médica Brasileira. scielo; 2016. p. 879–85.

Khan IA. Atrial stunning: determinants and cellular mechanisms. Am Heart J. 2003 May;145(5):787–94.

Crijns HJGM, Weijs B, Fairley A-M, Lewalter T, Maggioni AP, Martín A, Ponikowski P, Rosenqvist M, Sanders P, Scanavacca M, Bash LD, Chazelle F, Bernhardt A, Gitt AK, Lip GYH, Le Heuzey J-Y. Contemporary real life cardioversion of atrial fibrillation: Results from the multinational RHYTHM-AF study. Int J Cardiol. 2014 Apr;172(3):588–94.

Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener H-C, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016 Oct;37(38):2893–962.

Danias PG, Caulfield TA, Weigner MJ, Silverman DI, Manning WJ. Likelihood of Spontaneous Conversion of Atrial Fibrillation to Sinus Rhythm. J Am Coll Cardiol [Internet]. 1998;31(3):588–92. Available from:

Garg A, Khunger M, Seicean S, Chung MK, Tchou PJ. Incidence of Thromboembolic Complications Within 30 Days of Electrical Cardioversion Performed Within 48 Hours of Atrial Fibrillation Onset. JACC Clin Electrophysiol. 2016 Aug;2(4):487–94.

Pluymaekers NAHA, Dudink EAMP, Luermans JGLM, Meeder JG, Lenderink T, Widdershoven J, Bucx JJJ, Rienstra M, Kamp O, Van Opstal JM, Alings M, Oomen A, Kirchhof CJ, Van Dijk VF, Ramanna H, Liem A, Dekker LR, Essers BAB, Tijssen JGP, Van Gelder IC, Crijns HJGM. Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation. N Engl J Med. 2019 Apr;380(16):1499–508.

Long B, Robertson J, Koyfman A, Maliel K, Warix JR. Emergency medicine considerations in atrial fibrillation. Am J Emerg Med. 2018 Jun;36(6):1070–8.

Piccini JP, Fauchier L. Rhythm control in atrial fibrillation. Lancet. 2016 Aug;388(10046):829–40.

Khan IA. Oral loading single dose flecainide for pharmacological cardioversion of recent-onset atrial fibrillation. Int J Cardiol. 2003 Feb;87(2–3):121–8.

Martínez-Marcos FJ, García-Garmendia JL, Ortega-Carpio A, Fernández-Gómez JM, Santos JM, Camacho C. Comparison of intravenous flecainide, propafenone, and amiodarone for conversion of acute atrial fibrillation to sinus rhythm. Am J Cardiol. 2000 Nov;86(9):950–3.

Alboni P, Botto GL, Baldi N, Luzi M, Russo V, Gianfranchi L, Marchi P, Calzolari M, Solano A, Baroffio R, Gaggioli G. Outpatient Treatment of Recent-Onset Atrial Fibrillation with the “Pill-in-the-Pocket” Approach. N Engl J Med. 2004 Dec;351(23):2384–91.

Boriani G, Biffi M, Capucci A, Botto GL, Broffoni T, Rubino I, Della Casa S, Sanguinetti M, Magnani B. Oral propafenone to convert recent-onset atrial fibrillation in patients with and without underlying heart disease. A randomized, controlled trial. Ann Intern Med. 1997 Apr;126(8):621–5.

Andrade JG, MacGillivray J, Macle L, Yao RJR, Bennett M, Fordyce CB, Hawkins N, Krahn A, Jue J, Ramanathan K, Tsang T, Gin K, Deyell MW. Clinical effectiveness of a systematic “pill-in-the-pocket” approach for the management of paroxysmal atrial fibrillation. Hear Rhythm. 2018 Jan;15(1):9–16.

Reisinger J, Gatterer E, Lang W, Vanicek T, Eisserer G, Bachleitner T, Niemeth C, Aicher F, Grander W, Heinze G, Kühn P, Siostrzonek P. Flecainide versus ibutilide for immediate cardioversion of atrial fibrillation of recent onset. Eur Heart J. 2004 Aug;25(15):1318–24.

Stambler BS, Wood MA, Ellenbogen KA, Perry KT, Wakefield LK, VanderLugt JT. Efficacy and safety of repeated intravenous doses of ibutilide for rapid conversion of atrial flutter or fibrillation. Ibutilide Repeat Dose Study Investigators. Circulation. 1996 Oct;94(7):1613–21.

Roy D, Pratt CM, Torp-Pedersen C, Wyse DG, Toft E, Juul-Moller S, Nielsen T, Rasmussen SL, Stiell IG, Coutu B, Ip JH, Pritchett ELC, Camm AJ. Vernakalant hydrochloride for rapid conversion of atrial fibrillation: a phase 3, randomized, placebo-controlled trial. Circulation. 2008 Mar;117(12):1518–25.

Bash LD, Buono JL, Davies GM, Martin A, Fahrbach K, Phatak H, Avetisyan R, Mwamburi M. Systematic review and meta-analysis of the efficacy of cardioversion by vernakalant and comparators in patients with atrial fibrillation. Cardiovasc drugs Ther. 2012 Apr;26(2):167–79.

Singh SN, Tang XC, Reda D, Singh BN. Systematic electrocardioversion for atrial fibrillation and role of antiarrhythmic drugs: a substudy of the SAFE-T trial. Hear Rhythm. 2009 Feb;6(2):152–5.

Bianconi L, Mennuni M, Lukic V, Castro A, Chieffi M, Santini M. Effects of oral propafenone administration before electrical cardioversion of chronic atrial fibrillation: a placebo-controlled study. J Am Coll Cardiol. 1996 Sep;28(3):700–6.

Singh BN, Singh SN, Reda DJ, Tang XC, Lopez B, Harris CL, Fletcher RD, Sharma SC, Atwood JE, Jacobson AK, Lewis HDJ, Raisch DW, Ezekowitz MD. Amiodarone versus sotalol for atrial fibrillation. N Engl J Med. 2005 May;352(18):1861–72.

Link MS, Atkins DL, Passman RS, Halperin HR, Samson RA, White RD, Cudnik MT, Berg MD, Kudenchuk PJ, Kerber RE. Part 6: electrical therapies: automated external defibrillators, defibrillation, cardioversion, and pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov;122(18 Suppl 3):S706-19.

Suneet M, Shervin A, M. SK, David S, Doris C, J. TP, M. MS, J. SD, A. SM, B. LB. Transthoracic Cardioversion of Atrial Fibrillation . Circulation. 2000 Mar;101(11):1282–7.

DeSilva RA, Graboys TB, Podrid PJ, Lown B. Cardioversion and defibrillation. Am Heart J. 1980;100(6, Part 1):881–95.

Gurevitz OT, Ammash NM, Malouf JF, Chandrasekaran K, Rosales AG, Ballman K V, Hammill SC, White RD, Gersh BJ, Friedman PA. Comparative efficacy of monophasic and biphasic waveforms for transthoracic cardioversion of atrial fibrillation and atrial flutter. Am Heart J. 2005 Feb;149(2):316–21.

Falk RH. Is rate control or rhythm control preferable in patients with atrial fibrillation? Rate control is preferable to rhythm control in the majority of patients with atrial fibrillation. Circulation. 2005 Jun;111(23):3141–50; discussion 3157.

Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, Said SA, Darmanata JI, Timmermans AJM, Tijssen JGP, Crijns HJGM. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med. 2002 Dec;347(23):1834–40.

Packer DL, Mark DB, Robb RA, Monahan KH, Bahnson TD, Poole JE, Noseworthy PA, Rosenberg YD, Jeffries N, Mitchell LB, Flaker GC, Pokushalov E, Romanov A, Bunch TJ, Noelker G, Ardashev A, Revishvili A, Wilber DJ, Cappato R, Kuck K-H, Hindricks G, Davies DW, Kowey PR, Naccarelli G V, Reiffel JA, Piccini JP, Silverstein AP, Al-Khalidi HR, Lee KL. Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA. 2019 Apr;321(13):1261–74.

Medeiros de Vasconcelos JT. Reflexões sobre o estudo CABANA (Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation Trial). J Card Arrhythm. 2019 Oct;32(2):73–5.

Berger M, Schweitzer P. Timing of thromboembolic events after electical cardioversion of atrial fibrillation or flutter: a retrospective analysis. Am J Cardiol [Internet]. 1998 Dec 15;82(12):1545–7. Available from:

Wakai A, O’Neill JO. Emergency management of atrial fibrillation. Postgrad Med J [Internet]. 2003 Jun 1;79(932):313 LP – 319. Available from:

Olesen JB, Lip GYH, Hansen ML, Hansen PR, Tolstrup JS, Lindhardsen J, Selmer C, Ahlehoff O, Olsen A-MS, Gislason GH, Torp-Pedersen C. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. BMJ. 2011 Jan;342:d124.

Lip GYH, Nielsen PB. Should Patients With Atrial Fibrillation and 1 Stroke Risk Factor (CHA2DS2-VASc Score 1 in Men, 2 in Women) Be Anticoagulated? Yes: Even 1 Stroke Risk Factor Confers a Real Risk of Stroke. Circulation. 2016 Apr;133(15):1498–503; discussion 1503.

Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, Pogue J, Reilly PA, Themeles E, Varrone J, Wang S, Alings M, Xavier D, Zhu J, Diaz R, Lewis BS, Darius H, Diener H-C, Joyner CD, Wallentin L. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009 Sep;361(12):1139–51.

Nagarakanti R, Ezekowitz MD, Oldgren J, Yang S, Chernick M, Aikens TH, Flaker G, Brugada J, Kamensky G, Parekh A, Reilly PA, Yusuf S, Connolly SJ. Dabigatran versus warfarin in patients with atrial fibrillation: an analysis of patients undergoing cardioversion. Circulation. 2011 Jan;123(2):131–6.

Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, Breithardt G, Halperin JL, Hankey GJ, Piccini JP, Becker RC, Nessel CC, Paolini JF, Berkowitz SD, Fox KAA, Califf RM. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011 Sep;365(10):883–91.

Piccini JP, Stevens SR, Lokhnygina Y, Patel MR, Halperin JL, Singer DE, Hankey GJ, Hacke W, Becker RC, Nessel CC, Mahaffey KW, Fox KAA, Califf RM, Breithardt G. Outcomes after cardioversion and atrial fibrillation ablation in patients treated with rivaroxaban and warfarin in the ROCKET AF trial. J Am Coll Cardiol. 2013 May;61(19):1998–2006.

Cappato R, Ezekowitz MD, Klein AL, Camm AJ, Ma C-S, Le Heuzey J-Y, Talajic M, Scanavacca M, Vardas PE, Kirchhof P, Hemmrich M, Lanius V, Meng IL, Wildgoose P, van Eickels M, Hohnloser SH. Rivaroxaban vs. vitamin K antagonists for cardioversion in atrial fibrillation. Eur Heart J. 2014 Dec;35(47):3346–55.

Warden BA, MacKay J, Jafari M, Willman A, Stecker EC. Use of Direct Oral Anticoagulants Among Patients Undergoing Cardioversion: The Importance of Timing Before Cardioversion. J Am Heart Assoc. 2018 Nov;7(22):e010854–e010854.

Granger CB, Alexander JH, McMurray JJ V, Lopes RD, Hylek EM, Hanna M, Al-Khalidi HR, Ansell J, Atar D, Avezum A, Bahit MC, Diaz R, Easton JD, Ezekowitz JA, Flaker G, Garcia D, Geraldes M, Gersh BJ, Golitsyn S, Goto S, Hermosillo AG, Hohnloser SH, Horowitz J, Mohan P, Jansky P, Lewis BS, Lopez-Sendon JL, Pais P, Parkhomenko A, Verheugt FWA, Zhu J, Wallentin L. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011 Sep;365(11):981–92.

Ezekowitz MD, Pollack CVJ, Halperin JL, England RD, VanPelt Nguyen S, Spahr J, Sudworth M, Cater NB, Breazna A, Oldgren J, Kirchhof P. Apixaban compared to heparin/vitamin K antagonist in patients with atrial fibrillation scheduled for cardioversion: the EMANATE trial. Eur Heart J. 2018 Aug;39(32):2959–71.

Giugliano RP, Ruff CT, Braunwald E, Murphy SA, Wiviott SD, Halperin JL, Waldo AL, Ezekowitz MD, Weitz JI, Špinar J, Ruzyllo W, Ruda M, Koretsune Y, Betcher J, Shi M, Grip LT, Patel SP, Patel I, Hanyok JJ, Mercuri M, Antman EM. Edoxaban versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med. 2013 Nov;369(22):2093–104.

Plitt A, Ezekowitz MD, De Caterina R, Nordio F, Peterson N, Giugliano RP. Cardioversion of Atrial Fibrillation in ENGAGE AF-TIMI 48. Clin Cardiol. 2016 Jun;39(6):345–6.

Goette A, Merino JL, Ezekowitz MD, Zamoryakhin D, Melino M, Jin J, Mercuri MF, Grosso MA, Fernandez V, Al-Saady N, Pelekh N, Merkely B, Zenin S, Kushnir M, Spinar J, Batushkin V, de Groot JR, Lip GYH. Edoxaban versus enoxaparin-warfarin in patients undergoing cardioversion of atrial fibrillation (ENSURE-AF): a randomised, open-label, phase 3b trial. Lancet (London, England). 2016 Oct;388(10055):1995–2003.

How to Cite
Magliari, R. T., & Alencar Neto, J. N. de. (2020). How to Manage Atrial Fibrillation in the Emergency Department: a Critical Appraisal. JOURNAL OF CARDIAC ARRHYTHMIAS, 33(1), 55-66. Retrieved from
Point of View