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        CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist
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For a French translation of this position statement, please see the Supplementary Material at DOI: 10.107/cem.2018.26

The CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist was created to assist emergency physicians in Canada and elsewhere manage patients who present to the emergency department (ED) with acute/recent-onset atrial fibrillation or flutter. The checklist focuses on symptomatic patients with acute atrial fibrillation (AAF) or flutter (AAFL), i.e. those with recent-onset episodes (either first detected, recurrent paroxysmal or recurrent persistent episodes) where the onset is generally less than 48 hours but may be as much as seven days. These are the most common acute arrhythmia cases requiring care in the ED. 1 , 2 Canadian emergency physicians are known for publishing widely on this topic and for managing these patients quickly and efficiently in the ED. 3 - 5

This project was funded by a research grant from the Canadian Arrhythmia Network and the resultant guidelines have been formally recommended by the Canadian Association of Emergency Physicians (CAEP). We chose to adapt, for use by emergency physicians, existing high-quality clinical practice guidelines (CPG) previously developed by the Canadian Cardiovascular Society (CCS). 6 - 8 These CPGs were developed and revised using a rigorous process that is based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system of evaluation. 9 , 10 With the assistance of our PhD methodologist (IG), we used the recently developed Canadian CAN-IMPLEMENT© process adapted from the ADAPTE Collaboration. 11 - 13 We created an Advisory Committee consisting of ten academic emergency physicians (one also expert in thrombosis medicine), four community emergency physicians, three cardiologists, one PhD methodologist, and two patients. Our focus was four key elements of ED care: assessment and risk stratification, rhythm and rate control, short-term and long-term stroke prevention, and disposition and follow-up. The Advisory Committee communicated by a two-day face-to-face meeting in March 2017, teleconferences, and email. The checklist was prepared and revised through a process of feedback and discussions on all issues by all panel members. These revisions went through ten iterations until consensus was achieved. We then circulated the draft checklist for comment to approximately 300 emergency medicine and cardiology colleagues; their email written feedback was further incorporated and the final version created and approved by the panel.

During the consensus and feedback processes, we addressed a number of issues and concerns, some of which required extensive discussion. We spent considerable time defining what is meant by “unstable” and highlighting the issue that many unstable patients are actually suffering from underlying medical problems rather than a primary arrhythmia. Where possible we chose to simplify the checklist, for example listing only procainamide for pharmacological cardioversion. Other drugs were considered including vernakalant, ibutilide, propafenone, flecainide, and amiodarone. We also tried to give specific drug dosage recommendations, recognizing that physicians are free to consult any number of excellent pharmaceutical references. The panel believes that, overall, a strategy of ED cardioversion and discharge home from the ED is preferable from both the patient and the healthcare system perspective, for most patients. One controversial recommendation is to consider rate control or transesophageal echocardiography (TEE)-guided CV if the duration of symptoms is 24-48 hours and the patient has two or more CHADS-65 criteria. This is based on some recent data from Finland. 14 , 15 We emphasize the importance of evaluating long-term stroke risk by use of the CHADS-65 algorithm and encourage ED physicians to prescribe anticoagulants where indicated.

Our hope is that the CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist will standardize and improve care of AAF and AAFL in large and small EDs alike. We believe that these patients can be managed rapidly and safely, with early ED discharge and return to normal activities.

Acknowledgments

Funding for this guideline was supported by the Cardiac Arrhythmia Network of Canada (CANet) as part of the Networks of Centres of Excellence (NCE). IS has received funding from Boehringer Ingelheim Canada Ltd. and from JDP Therapeutics for participation in clinical studies. PA has received research funding and/or honoraria from BMS-Pfizer Alliance, Boehringer Ingelheim, and Servier, KD has received research funding from Bayer. MD has received honoraria and research funding from Biosense Webster, Bayer, Bristol-Myers-Squibb, Abbott, and Servier. AS has received honoraria from Boehringer Ingelheim, Bayer, Pfizer, and Servier. TT has received honoraria from Cardiome Pharma Corp. We thank the hundreds of Canadian emergency physicians and cardiologists who reviewed the draft guidelines and who provided very helpful feedback.

Supplementary material

To view supplementary material for this article, please visit https://doi.org/10.1017/cem.2018.26

REFERENCES

1. Connors, S, Dorian, P. Management of supraventricular tachycardia in the emergency department. Can J Cardiol 1997;13(Suppl A):19A-24A.
2. Michael, JA, Stiell, IG, Agarwal, S, Mandavia, DP. Cardioversion of paroxysmal atrial fibrillation in the emergency department. Ann Emerg Med 1999;33:379-387.
3. Scheuermeyer, FX, Innes, G, Pourvali, R, et al. Missed opportunities for appropriate anticoagulation among emergency department patients with uncomplicated atrial fibrillation or flutter. Ann Emerg Med 2013;62(6):557-565.
4. Atzema, CL, Yu, B, Ivers, N, et al. Incident atrial fibrillation in the emergency department in Ontario: a population-based retrospective cohort study of follow-up care. CMAJ Open 2015;3(2):E182-E191.
5. Stiell, IG, Clement, CM, Rowe, BH, et al. Outcomes for ED Patients with Recent-onset Atrial Fibrillation and Flutter (RAFF) Treated in Canadian Hospitals. Ann Emerg Med 2017;69(5):562-571.
6. Stiell, IG, 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;27(1):38-46.
7. Verma, A, Cairns, JA, Mitchell, LB, et al. Focused update of the canadian cardiovascular society guidelines for the management of atrial fibrillation. Can J Cardiol 2014;30(10):1114-1130.
8. Macle, L, Cairns, J, Leblanc, K, et al. Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2016;32(10):1170-1185.
9. Gillis, AM, Skanes, AC. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: implementing GRADE and achieving consensus. Can J Cardiol 2011;27(1):27-30.
10. Guyatt, GH, Oxman, AD, Vist, GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924-926.
11. The ADAPTE Collaboration. Guideline Adaptation: A Resource Toolkit. Version 2.0; 2009. Available at: http://www.g-i-n.net/document-store/working-groups-documents/adaptation/adapte-resource-toolkit-guideline-adaptation-2-0.pdf.
12. Harrison, MB, Graham, ID, van den Hoek, J, et al. Guideline adaptation and implementation planning: a prospective observational study. Implement Sci 2013;8:49.
13. Harrison, MB, van den Hoek, J, Graham, ID. CAN-IMPLEMENT: Planning for best-practice implementation. Philadelphia: Lippincott Williams & Wilkins; 2014.
14. Nuotio, I, Hartikainen, JE, Gronberg, T, et al. Time to cardioversion for acute atrial fibrillation and thromboembolic complications. JAMA 2014;312(6):647-649.
15. Stiell, IG, Healey, JS, Cairns, JA. Safety of urgent cardioversion for patients with recent-onset atrial fibrillation and flutter. Can J Cardiol 2015;31(3):239-241.

APPENDICES

Figure 1 Overall management algorithm for patients presenting to the ED with acute atrial fibrillation or flutter. Adapted from CCS 2014 Figure 2.7 Notes. * Consider medical cause (e.g. sepsis, bleeding, PE, heart failure, ACS, etc) if not sudden onset, HR<150, fever, known permanent AF; cardioversion may be harmful, rate control discouraged; investigate and treat underlying condition aggressively Consider rate control or transesophageal echocardiography (TEE)-guided CV if duration 24-48 hrs and two or more CHADS-65 criteria If CHADS-65 positive, start OAC; if stable CAD, discontinue ASA; if CAD with other anti-platelets or recent PCI, consult cardiology (see Figure 2) ASA=acetylsalicylic acid; CAD=coronary artery disease; CHADS-65=age 65, congestive heart failure, hypertension, age, diabetes, stroke / transient ischemic attack; CV=cardioversion; NOAC=novel direct oral anticoagulant; OAC=oral anticoagulant; TIA=transient ischemic attack.

Figure 2 Rapid Ventricular Pre-Excitation

Figure 3 “CCS algorithm” (“CHADS65”) for long-term stroke prevention in AF