Article Data

  • Views 922
  • Dowloads 174

Original Research

Open Access

Heterogeneity in the role of emergency physicians and treatment of acute atrial fibrillation in emergency departments—results of the International Atrial Fibrillation Background (AFiB) Study

  • Markus Holmberg1
  • Ville Hällberg1,*,
  • Hjalti M Björnsson2
  • Timothy H Rainer3
  • Colin A Graham4
  • Marc B Sabbe5
  • Wilhelm Behringer6
  • Gayle Galletta7
  • Hans Domanovits8
  • Harri Pikkarainen9
  • Bruce M Lo10
  • Christophe Laurent11
  • Pascal Vanelderen12,13
  • Ari Palomäki1,14

1Department of Emergency Medicine, Kanta-Häme Central Hospital, 13530 Hämeenlinna, Finland

2Department of Emergency Medicine, Landspitali—The National University Hospital of Iceland, 101 Reykjavik, Iceland

3Emergency Medicine, University of Hong Kong, Hong Kong, China

4Emergency Medicine, Chinese University of Hong Kong, Hong Kong, China

5University Hospitals of Leuven, 3000 Leuven, Belgium

6Department of Emergency Medicine, Jena University Hospital, 07747 Jena, Germany

7University of Massachusetts Medical Center, Worcester, MA 01605, USA

8Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria

9Department of Emergency Medicine, Päijät-Häme Central Hospital, 15850 Lahti, Finland

10Department of Emergency Medicine, Sentara Norfolk General Hospital/Eastern Virginia Medical School, Norfolk, MA 23510, USA

11Emergency Department, Heilig Hartziekenhuis Mol, 2400 Mol, Belgium

12Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium

13Department of Life Sciences, University of Hasselt, 3500 Diepenbeek, Belgium

14Faculty of Medicine and Health Technology, Tampere University, 33520 Tampere, Finland

DOI: 10.22514/sv.2024.038 Vol.20,Issue 4,April 2024 pp.25-32

Submitted: 12 October 2023 Accepted: 28 November 2023

Published: 08 April 2024

*Corresponding Author(s): Ville Hällberg E-mail:


The consept of emergency departments (EDs) with specialized teams of emergency physicians originated in the United Kingdom and the United States during the 1970s and was expanded across most European countries in the twenty-first century. Among the various cardiac arrhythmias encountered in EDs, atrial fibrillation (AF) is the most prevalent, contributing to ED congestion. Existing guidelines offer multiple treatment options for acute-onset AF occurring within 48 hours. The aim of The Atrial Fibrillation Background Study is to evaluate treatment strategies, practices and the role of emergency physicians in managing acute-onset AF in Western medical tradition across Europe, the United States and China (Hong Kong). The data for this nonexperimental survey were collected through a questionnaire administered to the medical director or a senior physician at each of the 12 participating EDs. We obtained information regarding the total number of physicians employed in these EDs, their respective specialties, and the patient caseloads they managed. Additionally, we gathered data on the diagnostic and treatment protocols employed for atrial fibrillation (AF). In the investigated EDs in Hong Kong, the United Kingdom and the United States, patients were treated by emergency physicians. Comparatively, many European EDs primarily relied on physicians with traditional medical specialties. Diagnostic methods employed for acute AF ranged from point-of-care testing to comprehensive laboratory panels and echocardiography. In terms of AF treatment, rate control was the preferred approach in Hong Kong and the USA EDs, while rhythm control was preferred in European settings. Regarding rhythm control, there were considerable variations in preferences between pharmacological and electrical cardioversion methods. Findings from the AFiB Study highlight the growing significance of emergency physicians in the management of acute AF, as well as the divergent treatment approaches for acute AF observed in EDs between Europe and the United States.


Emergency department; Role of emergency physicians; Acute-onset atrial fibrillation; Treatment strategy; Treatment practices; Atrial fibrillation diagnostics; Rhythm control; Rate control

Cite and Share

Markus Holmberg,Ville Hällberg,Hjalti M Björnsson,Timothy H Rainer,Colin A Graham,Marc B Sabbe,Wilhelm Behringer,Gayle Galletta,Hans Domanovits,Harri Pikkarainen,Bruce M Lo,Christophe Laurent,Pascal Vanelderen,Ari Palomäki. Heterogeneity in the role of emergency physicians and treatment of acute atrial fibrillation in emergency departments—results of the International Atrial Fibrillation Background (AFiB) Study. Signa Vitae. 2024. 20(4);25-32.


[1] Rainer TH. Emergency medicine—the specialty. Hong Kong Medical Journal. 2000; 6: 269–275.

[2] Zink BJ. Victory at last. In: Zink BJ (ed.) Anyone, anything, anytime: a history of emergency medicine (pp. 173–184). 2nd edn. American College for Emergency Physicians: Dallas, TX. 2018.

[3] Baldursson J, Björnsson HM, Palomäki A. Emergency medicine for 25 years in Iceland—history of the specialty in a nutshell. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2018; 26: 1.

[4] Möckel M, Nickel CH, Behringer W, Backus B. Status of physician education in emergency medicine in four European countries: no primary specialty yet. European Journal of Emergency Medicine. 2021; 28: 257–259.

[5] Do DH, Bernardes-Souza B, Merjanian M, Lombardo B, Donaldson DM, McCullough LB, et al. Development of a care pathway for atrial fibrillation patients in the emergency department. Critical Pathways in Cardiology. 2022; 21: 105–113.

[6] Martín A, Calvo D, Llamas P, Roldán V, Cózar R, Fernández de Simón A, et al. Emergency department management of atrial fibrillation: 2023 consensus from the Spanish society of emergency medicine (SEMES), the Spanish society of cardiology (SEC), and the Spanish society of thrombosis and hemostasis (SETH). Emergencias. 2023; 35: 359–377.

[7] Lee SR, Choi EK, Lee SY, Lee E, Han KD, Cha MJ, et al. Temporal trends of emergency department visits of patients with atrial fibrillation: a nationwide population-based study. Journal of Clinical Medicine. 2020; 9: 1485.

[8] Cheung CC, Nattel S, Macle L, Andrade JG. Management of atrial fibrillation in 2021: an updated comparison of the current CCS/CHRS, ESC, and AHA/ACC/HRS guidelines. Canadian Journal of Cardiology. 2021; 37: 1607–1618.

[9] Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European association for cardio-thoracic surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European society of cardiology (ESC) developed with the special contribution of the European heart rhythm association (EHRA) of the ESC. European Heart Journal. 2021; 42: 373–498.

[10] Donal E, Lip GY, Galderisi M, Goette A, Shah D, Marwan M, et al. EACVI/EHRA expert consensus document on the role of multi-modality imaging for the evaluation of patients with atrial fibrillation. European Heart Journal. Cardiovascular Imaging. 2016; 17: 355–383.

[11] White JL, Heller MB, Kahoud RJ, Slade D, Harding JD. Performance of an expedited rhythm control method for recent onset atrial fibrillation in a community hospital. The American Journal of Emergency Medicine. 2015; 33: 957–962.

[12] Gardarsdottir M, Sigurdsson S, Aspelund T, Gardarsdottir VA, Forsberg L, Gudnason V, et al. Improved brain perfusion after electrical cardioversion of atrial fibrillation. EP Europace. 2020; 22: 530–537.

[13] Konttila KK, Punkka O, Koivula K, Eskola MJ, Martiskainen M, Huhtala H, et al. The effect of atrial fibrillation on the long-term mortality of patients with acute coronary syndrome: the TACOS study. Cardiology. 2021; 146: 508–516.

[14] Stiell IG, Eagles D, Nemnom M, Brown E, Taljaard M, Archambault PM, et al. Adverse events associated with electrical cardioversion in patients with acute atrial fibrillation and atrial flutter. Canadian Journal of Cardiology. 2021; 37: 1775–1782.

[15] P Prasai P, Shrestha DB, Saad E, Trongtorsak A, Adhikari A, Gaire S, et al. Electric cardioversion vs. pharmacological with or without electric cardioversion for stable new-onset atrial fibrillation: a systematic review and meta-analysis. Journal of Clinical Medicine. 2023; 12: 1165.

[16] Rooney MR, Lutsey PL, Alonso A, Selvin E, Pankow JS, Rudser KD, et al. Serum magnesium and burden of atrial and ventricular arrhythmias: the atherosclerosis risk in communities (ARIC) study. Journal of Electrocardiology. 2020; 62: 20–25.

[17] Bouillon-Minois JB, Khaled L, Vitte F, Miraillet L, Eschalier R, Jabaudon M, et al. Ionized magnesium: interpretation and interest in atrial fibrillation. Nutrients. 2023; 15: 236.

[18] Budolfsen C, Schmidt AS, Lauridsen KG, Hoeks CB, Waziri F, Poulsen CB, et al. NT-proBNP cut-off value for ruling out heart failure in atrial fibrillation patients—a prospective clinical study. The American Journal of Emergency Medicine. 2023; 71: 18–24.

[19] Li L, Selvin E, Hoogeveen RC, Soliman EZ, Chen LY, Norby FL, et al. 6-year change in high sensitivity cardiac troponin T and the risk of atrial fibrillation in the atherosclerosis risk in Communities cohort. Clinical Cardiology. 2021; 44: 1594–1601.

[20] De Michieli L, Lobo R, Babuin L, Melduni RM, Iliceto S, Prasad A, et al. Structural cardiac abnormalities in patients with atrial fibrillation/flutter and myocardial injury. The American Journal of Medicine. 2022; 135: 1488–1496.e5.

[21] Hannula O, Hällberg V, Meuronen A, Suominen O, Rautiainen S, Palomäki A, et al. Self-reported skills and self-confidence in point-of-care ultrasound: a cross-sectional nationwide survey amongst Finnish emergency physicians. BMC Emergency Medicine. 2023; 23: 23.

[22] Rogenstein C, Kelly A, Mason S, Schneider S, Lang E, Clement CM, et al. An international view of how recent-onset atrial fibrillation is treated in the emergency department. Academic Emergency Medicine. 2012; 19: 1255–1260.

[23] Funk AM, Kocher KE, Rohde JM, West BT, Crawford TC, Froehlich JB, et al. Variation in practice patterns among specialties in the acute management of atrial fibrillation. BMC Cardiovascular Disorders. 2015; 15: 21.

[24] Stiell IG, Clement CM, Brison RJ, Rowe BH, Borgundvaag B, Langhan T, et al. Variation in management of recent-onset atrial fibrillation and flutter among academic hospital emergency departments. Annals of Emergency Medicine. 2011; 57: 13–21.

[25] Addy K, Joyce LR, Al-Busaidi IS, Pickering JW, Troughton R, Than M. Implementation of an integrated emergency department acute atrial fibrillation pathway safely reduces cardioversions and hospitalisations: a comparative pre-post study. Emergency Medicine Australasia. 2023; 35: 828–833.

[26] Mohamed MS, Hashem A, Khalouf A, Osama M, Pendela VS, Rai D, et al. Delayed vs early cardioversion in patients with paroxysmal atrial fibrillation: a population-based study (2015–2020). Future Cardiology. 2023; 19: 441–452.

[27] Cabello I, Jacob J, Yuguero O, Arranz M, Guzmán JA, Morena A, et al. Factors related to the success or failure of cardioversion in atrial fibrillation and emergency department revisit according to restoration of sinus rhythm: analysis of the URGFAICS cohort. Signa Vitae. 2023; 19: 39–47.

Abstracted / indexed in

Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.

Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.

Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.

Index Copernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.

Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.

Scopus: CiteScore 1.0 (2022) Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.

Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.

Submission Turnaround Time