Atrial Fibrillation

There are many ways in which to treat atrial fibrillation, observation offers an excellent, evidence-based option

Inclusion Criteria

  • Stable BP, HR under 110 consistently for one hour (with treatment)
  • No chest pain with rate controlled
  • Normal chest X ray
  • No evidence of acute comorbidities - MI, CHF, PE, CVA, etc.
  • Onset clearly less than 48 hours
  • Rhythm conversion drugs given prior to CDU (i.e. propafenone 450mg PO if no CHF)
  • Cardiologist agrees with plan to observe (if notified)

Exclusion Criteria

  • HR not controlled under 110 with ED meds
  • IV vasoactive drips required (ie diltiazem)
  • Hemodynamically unstable – i.e. BP
  • Ongoing ischemic chest pain after rate control
  • Acute comorbidities - Evidence of Acute MI, CHF, PE, Sepsis, CVA / embolic event,
  • Recent comorbidities - Stroke/TIA within 3 months, Acute MI within 4 weeks.
  • Chronic Atrial Fibrillation. Onset over 48 hours or unknown
  • Cardiologist or Primary Care physician chooses inpatient admission

Potential Interventions

  • Cardiac monitoring, pulse oximetry
  • Vitals Q 2 hours for 6 hours, then Q4 hours
  • Anticoagulate if not contraindicated - PO ASA (325 mg ) or subQ heparin (LMWH or UFH)
  • Rate control Options - Oral Cardizem, Verapamil, or beta blockers
  • Testing - Serial tropoins, and ECGs at 2 and 6 hour from 1st ED blood draw
  • TSH, 2D Echocardiogram if indicated
  • Educate patient on cardioversion (medical or electrical) if initial obs treatment fails within 12 hours. Electrical cardioversion to occur outside of the CDU
  • NPO at 12 hours from arrival in Observation Unit if not spontaneously converted

Discharge Criteria


    • Patient converts and remains in NSR for over one hour
    • Negative diagnostic testing
    • Stable condition
    • Discuss home medication therapy with cardiologist


    • Failure to maintain control of rate under 100
    • Positive diagnostic testing ( as indicated for MI, PE, CHF, etc.)
    • Unstable condition


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