View source for EBQ:Ottawa Aggressive ED Cardioversion Protocol

{{JC info
| title= Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter
| abbreviation=  Ottawa Rapid Afib Protocol
| expansion=Ottawa Aggressive ED Cardioversion Protocol
| published= 2010
| author= Stiell I. et al. 
| journal= CJEM
| year= May 2010
| volume= =12
| issue= 3
| pages= 181-91
| pmid=     20522282
| fulltexturl= http://www.cjem-online.ca/v12/n3/p181
| pdfurl=http://www.cjem-online.ca/sites/default/files/pg181.pdf
| status = Complete
}}
==Clinical Question==
What is the effectiveness and safety of the Ottawa Aggressive Protocol to perform rapid cardioversion and discharge of patients with new onset atrial fibrillation?

==Conclusion==
In patients with new onset atrial fibrillation or flutter with symptoms onset <48 hours, rapid conversion with procainamide or electrical cardioversion is safe and will also decrease treatment time and hospital admissions.

==Major Points== 
Reviews of the literature have shown that stable patients with close followup who have recent-onset atrial fibrillation after cardioversion in the ED can be safely discharged after cardioversion in the ED.<ref name="von Besser">von Besser K. et al. Is discharge to home after emergency department cardioversion safe for the treatment of recent-onset atrial fibrillation? Ann Emerg Med. 2011 Dec;58(6):517-20</ref>  Also Among patients with[[EBQ:48hr_Cardioversion_for_Afib| Atrial Fibrillation clinically estimated to be <48 hours]], the likelihood of cardioversion-related clinical thromboembolism is very low.<ref name="Weigner">Weigner MJ et al. "Risk for clinical thromboembolism associated with conversion to sinus rhythm in patients with atrial fibrillation lasting less than 48 hours". Ann Intern Med. 1997. 126(8):615-620.</ref>

*The relapse rate for atrial fibrillation is 3% -17% and close followup and ability to return to the ED if there is return of symptoms is essential.<ref name="von Besser"></ref> 

The following is a reproduction of the ED Cardioversion Protocol
{| class="wikitable"
|style="background:#f0f0f0;"|'''1. Assessment for Cardioversion'''
|-
| Stable without ischemia, hypotension or acute CHF? 
|-
| Onset clear and less than 48 hours? 
|-
| Severity of symptoms? 
|-
| Previous episodes and treatments? 
|-
| Anticoagulated with warfarin and INR therapeutic? 
|-
|style="background:#f0f0f0;"|'''2.Rate Control If highly symptomatic or not planning to convert'''
|-
| Diltiazem IV (0.25 mg/kg over 10 min; repeat at 0.35 mg/kg) 
|-
| Metoprolol IV (5 mg doses every 15 min) 
|-
|style="background:#f0f0f0;"|'''3. Pharmacologic Cardioversion'''
|-
| Procainamide IV (1 g IV over 60 min; hold if blood pressure < 100 mm Hg) 
|-
|style="background:#f0f0f0;"|'''4. Electrical cardioversion'''
|-
| Consider keeping patient NPO × 6 h 
|-
| Procedural sedation and analgesia given by emergency physician (propofol IV and fentanyl IV) 
|-
| Start at 150–200 J biphasic synchronized* 
|-
| Use anterior–posterior pads, especially if not responding
|-
|style="background:#f0f0f0;"|'''5. Anticoagulation'''
|-
| Usually no heparin or warfarin for most patients if onset clearly < 48 h or if therapeutic INR for > 3 wk
|-
|style="background:#f0f0f0;"|'''6. Disposition'''
|-
| Home within 1 h after cardioversion 
|-
| Usually no antiarrhythmic prophylaxis or anticoagulation given
|-
| Arrange outpatient echocardiography if first episode 
|-
| Cardiology follow-up if first episode or frequent episodes 
|-
|style="background:#f0f0f0;"|'''7. Patients not treated with cardioversion'''
|-
| Achieve rate control with diltiazem IV (target heart rate < 100 beats/min) 
|-
| Discharge home on diltiazem (or metoprolol) 
|-
| Discharge home on warfarin and arrange INR monitoring
|-
| Arrange outpatient echocardiography 
|-
| Follow-up with cardiology at 4 wk for elective cardioversion 
|-
|style="background:#f0f0f0;"|'''8. Recommended additions to protocol'''
|-
| Consider transesophageal echocardiography if onset unclear 
|-
| Alternate rhythm-control drugs: propafenone, vernakalant, amiodarone 
|-
| If TEE-guided cardioversion > 48 h, start warfarin 
|-
| If CHADS2 score ≥ 1, consider warfarin and arrange early follow-up 
|}

==Study Design==
*Single study retrospective cohort of ED patients presenting with recent onset atrial fibrillation (<48hrs)
*660 patients
*June 2000-June 2005
*Consecutive review of the retrospective record

==Population==
===Patient Demographics===
*Mean age: 64
*Male: 55%
*Mean duration of arrhythmia 8.9hr
*Previous atrial fibrillation: 83%
*Hypertension: 42.1%
*CAD: 21%
*Thyroid disease: 15%
*Valvular heart disease: 4%
*CHF: 7.7%
*Thromboembolic disease: 6.5%
*Chronic lung disease 6%

===Inclusion Criteria===
*Recent onset (<48 hrs) of atrial flutter
*Use of ED cardioversion
*No recent cardioversion within 7 days

===Exclusion Criteria===
*Atrial fibrillation >48hrs
*Presence of other diagnosis requiring admission
==Interventions==
*Patients were cardioverted with procainamide or electrically

==Outcomes== 
===Primary Outcome===
*Proportion of patients converted to sinus rhythm before discharge from ED
**58% of all cases responded to procainamide
**92% responded to electrical cardioversion
*Length of stay in ED
**Mean length of stay <5 hours
*Final disposition and adverse events (hypotension or arrhythmia)
**97% discharged home 
**90 discharged with normal sinus rhythm

===Secondary Outcomes=== 
*Death, stroke or relapse to atrial fibrillation within 7 days
**Stroke: 0%
**Death: 0%
**Relapse within 7 days: 8.7%

==Criticisms & Further Discussion==
*In general, practice guidelines recommended anticoagulation for the conversion of atrialfibillatin or flutter if duration of dysrhythmia is > 48 hours.   More recent literature suggests that the 12-48 hour window in this study still only represented a 1.1% risk for 30-day thromboembolism, compared to the ~2% risk after 48 hours.

*Although this study demonstrates the safety and efficacy of a cardioversion first strategy in the ED in new onset (<48hr) [[Atrial Fibrillation]] it was performed in a system with very good outpatient followup.  Results of this study should be individualized the healthcare system of practice.
===Anticoagulation prior to cardioversion===
{{Anticoagulation prior to cardioversion}}

===Anticoagulation after cardioversion===
{{Anticoagulation in atrial fibrillation}}

==Funding==
*Dr Dickinson, a author on the paper is a paid consultant for Cardiome Pharma Corp but none of the other members were paid or had disclosures

==External Links==
*[http://thesgem.com/2014/09/sgem88-shock-through-the-heart-ottawa-aggressive-atrial-fibrillation-protocol/ SGEM - Ottawa Gressive Protocol]
*[http://emottawa.blogspot.ca/2014/10/2014-canadian-guidelines-for-af.html EM Ottawa Blog post on Rapid Ottawa Protocol]
*[http://emergencymedicinecases.com/episode-57-stiell-sessions-2-update-atrial-fibrillation-2014/ Dr. Ian Stiell - Audio - EmergencyMedicineCases.com]
*[http://emottawa.blogspot.ca/2014/10/2014-canadian-guidelines-for-af_14.html Canadian Guidelines for AF - EM Ottawa]

==Sources==
<references/>

[[Category:EBQ]]
[[Category:Cardiology]]