DeMeester et al reported an algorithm for managing a patient with atrial fibrillation in the Emergency Department. This can reduce unnecessary hospital admissions. The authors are from St. Joseph Mercy Hospital in Ann Arbor and Methods Consultants in Ypsilanti.

Patient selection: atrial fibrillation with rapid heart rate (> 100 beats per minute) in community emergency department



(1) acute illness requiring hospitalization

(2) clinical conditions (acute coronary syndrome, acute heart failure, syncope or hemodynamic instability)

(3) CHADS2VASC score (? CHA2DS2-VASc, with range 0 to 9)

(4) INR

(5) heart rate in beats per minute


Admit to the hospital if either present:

(1) acute illness requiring hospitalization

(2) >= 1 clinical condition(s)


Perform synchronized cardioversion - at least one of the following:

(1) CHADS2VASC <= 1

(2) INR > 2


Discharge home:

(1) CHADS2VASC > 1 AND INR <= 2

(2) heart rate <= 110 beats per minute


Treat (avoid IV infusions) with metoprolol tartrate or diltiazem

(1) CHADS2VASC > 1 AND INR <= 2

(2) heart rate > 110 beats per minute



Dose for metoprolol: 50 mg bid po

Dose of diltiazem: extended release 120 mg or 180 mg qd po

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