Journal Club
August Journal Club

August 19 (Thursday)
6:30 PM
5510 Cramblet Hall Conference Room

Journal Club Vignette

A 66 year old man arrives in the emergency department complaining of palpitations. The patient states it started sometime yesterday morning and is intermittent in nature. He denies chest pain, shortness of breath, diaphoresis, nausea, vomiting, leg pain, or swelling. He thinks he may have felt something similar a couple of weeks ago but states it resolved in a couple of minutes. The current event has been fairly constant since it started. On PE, he is afebrile with a blood pressure of 135/80, heart rate of 120 and irregular, respirations 12, 98% on room air. His cardiac exam is significant for a tachycardic, irregular rhythm. His lungs are clear to auscultation. He has no leg edema or tenderness and a normal neurological exam. His ECG shows atrial fibrillation without any ST elevation or depressions. His lab work is normal. On discussion with your attending, they pose the question whether you should control the patient's heart rate and anti- coagulate and admit him to the hospital or would it be more prudent to control his rhythm, i.e. convert him to a normal sinus rhythm.

To investigate this, the following approach is explored:

PICO Question

Population: Adults with atrial fibrillation
Intervention: Rhythm control
Comparison: Rate control
Outcome: Hospital admission, quality of life, stroke, death


Search Strategy: Pubmed; Keywords: atrial fibrillation AND emergency department. Limits: English, adult, last 10 years
First years: Thirty-day Outcomes of Emergency Department Patients Undergoing Electrical Cardioversion for Atrial Fibrillation or Flutter: Scheuermeyer et al. (Pub Med Link) Academic Emerg Medicine April 2010

Article Critique
Second years: Emergency Department Use of Intravenous Procainamide for Patients with Acute Atrial Fibrillation or Flutter: Stiell et al. (Pub Med Link) Academic Emerg Medicine December 2007

Article Critique
Third years: A Prospective, Randomized Trial of an Emergency Department Observation Unit for Acute Onset Atrial Fibrillation: Decker et al. (Pub Med Link) Annals Emerg Medicine October 2008

Article Critique
1st years use the "Harm Critical Review Form" (Download)
2nd years use the "Observational Study Critical Review Form" (Download)
3rd years use the "RCT Critical Review Form" (Download)


Extra Articles: Management of Atrial Fibrillation in the Emergency Department: Raghavan et al. Emerg Med Clin N Am 23 (2005) 1127–1139.

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