Antiarrhythmic - Class III (K+ channel blockers)
| Level |
Direction |
Primary Outcome |
Patient/Process |
Setting |
Reference |
|
I
|
Supportive (Green)
|
Restoration of sinus rhythm
|
Patient
|
ED-MD
|
Vardas PE., Kochiadakis GE. Amiodarone for the restoration of sinus rhythm in patients with atrial fibrillation. Card Electrophysiol Rev 2003; 7(3):297-299. Medline
|
|
I
|
Neutral (Yellow)
|
Cardioversion
|
Patient
|
ED-MD
|
Stead LG., Decker WW. Evidence-based emergency medicine/systematic review abstract. Rhythm versus rate control for atrial fibrillation and flutter. Ann Emerg Med 2006; 47(5):496-498. Medline
|
|
I
|
Neutral (Yellow)
|
Conversion to sinus rhythm
|
Patient
|
ED-MD
|
Thomas SP., Guy D., Wallace E., Crampton R., Kijvanit P., Eipper V., et al. Rapid loading of sotalol or amiodarone for management of recent onset symptomatic atrial fibrillation: a randomized, digoxin-controlled trial. Am Heart J 2004; 147(1):E3. Medline
|
|
II
|
Supportive (Green)
|
Conversion to Normal Sinus Rhythm, Time to conversion
|
Process
|
PH-Paramedic
|
Bertini G., Conti A., Fradella G., et al. Propafenone versus amiodarone in field treatment of primary atrial tachydysrhythmias. J Emerg Med 1990; 8(1):15-20. Medline
|
|
II
|
Supportive (Green)
|
Conversion
|
Patient
|
ED-MD
|
Stiell IG., Dickinson G., Butterfield NN., et al. Vernakalant hydrochloride: A novel atrial-selective agent for the cardioversion of recent-onset atrial fibrillation in the emergency department. Acad Emerg Med 2010; 17(11):1175-1182. Medline
|
|
II
|
Supportive (Green)
|
Conversion to sinus rhythm
|
Patient
|
ED-MD
|
Viktorsdottir O., Henriksdottir A., Arnar DO. Ibutilide for treatment of atrial fibrillation in the emergency department. Emerg Med J 2006; 23(2):133-134. Medline
|
Antiarrhythmic - Class IV (Ca+ channel blockers)
| Level |
Direction |
Primary Outcome |
Patient/Process |
Setting |
Reference |
|
I
|
Supportive (Green)
|
Conversion to sinus rhythm
|
Patient
|
ED-MD
|
Alabed S, Sabouni A, Providencia R, Atallah E, Qintar M, Chico TJ. Adenosine versus intravenous calcium channel antagonists for supraventricular tachycardia. The Cochrane database of systematic reviews 2017; 10. Medline
|
|
I
|
Supportive (Green)
|
Conversion of SVT
|
Patient
|
ED-MD
|
Lim SH., Anantharaman V., Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation 2009; 80(5):523-8. Medline
|
|
I
|
Supportive (Green)
|
Ventricular heart rate
|
Patient
|
ED-MD
|
Schreck DM., Rivera AR., Tricarico VJ. Emergency management of atrial fibrillation and flutter: Intravenous diltiazem vs digoxin. Ann Emer Med 1997; 29:135-40. Medline
|
|
I
|
Neutral (Yellow)
|
Reduction in ventricular heart rate
|
Patient
|
ED-MD
|
Demircan C., Cikriklar HI., Engindeniz Z., Cebicci H., Atar N., Guler V., et al. Comparison of the effectiveness of intravenous diltiazem and metoprolol in the management of rapid ventricular rate in atrial fibrillation. Emerg Med J 2005; 22(6):411-4. Medline
|
|
I
|
Neutral (Yellow)
|
Ventricular rate control and conversion to sinus rhythm
|
Patient
|
ED-MD
|
Hassan S., Ahmad S., Kamalakannan D., et al. Conversion of Atrial Fibrillation to Sinus Rhythm During Treatment With Intravenous Esmolol or Diltiazem: A Prospective, Randomized Comparison, J of Cardio Pharm and Thera 2007; 12(3):227-31. Medline
|
|
II
|
Supportive (Green)
|
Conversion of SVT
|
Patient
|
PH-Paramedic
|
Brady WJ. Jr., DeBehnke DJ., Wickman LL., Lindbeck G. Treatment of out-of-hospital supraventricular tachycardia: Adenosine vs verapamil. Acad Emerg Med 1996; 3(6):574-85. Medline
|
|
II
|
Supportive (Green)
|
Rate control of AF
|
Patient
|
Other
|
McGrath P, Kersten B, Chilbert MR, Rusch C, Nadler M. Evaluation of metoprolol versus diltiazem for rate control of atrial fibrillation in the emergency department. Am J Emerg Med 2021; 46:585–90. Medline
|
|
II
|
Supportive (Green)
|
Percentage of treatment failure at 4+/1 hour.
|
Process
|
|
Means KN., Gentry AE., Nguyen TT. Intravenous Continuous Infusion vs. Oral Immediate-release Diltiazem for Acute Heart Rate Control. The western journal of emergency medicine 2018;19(2):417-22. Medline
|
|
II
|
Supportive (Green)
|
Improvement in heart rate
|
Patient
|
PH-Paramedic
|
Pil E, Levy M, Chizmar T, Troncoso R, Garfinkel E, Margolis A. Efficacy and Safety of Prehospital Diltiazem. Prehosp Emerg Care. March 2024; 1-8. Medline
|
|
II
|
Supportive (Green)
|
Successful treatment
|
Patient
|
ED-MD
|
Ross AL., O'Sullivan DM., Drescher MJ., Krawczynski MA. Comparison of Weight-Based Dose vs. Standard Dose Diltiazem in Patients with Atrial Fibrillation Presenting to the Emergency Department. J Emerg Med 2016;51(4):440-6. Medline
|
|
II
|
Supportive (Green)
|
Conversion rate
|
Patient
|
PH-Paramedic
|
Smith G., McD Taylor D., Morgans A., Cameron P. Prehospital management of supraventricular tachycardia in Victoria, Australia: Epidemiology and effectiveness of therapies. Emerg Med Australas 2014; 26(4):350-355. Medline
|
|
II
|
Supportive (Green)
|
Cardioversion rate
|
Patient
|
ED-MD
|
Vinson DR., Hoehn T., Graber DJ., Williams TM. Managing emergency department patients with recent-onset atrial fibrillation. J Emerg Med 2012; 42(2):139-148. Medline
|
|
II
|
Supportive (Green)
|
Functional the out-of-hospital setting. Annal of Emer Med 37: 38-45
|
Patient
|
PH-Paramedic
|
Wang HE., et al. The use of diltiazem for treating rapid atrial fibrillation in the out-of-hospital setting. Annal of Emer Med 2001; 37:38-45. Medline
|
|
II
|
Neutral (Yellow)
|
HR control at arrival to ED
|
Patient
|
PH-Paramedic
|
Berkenbush M, Sherman N, Jain N, Cosmi P. Prehospital Treatment of Atrial Fibrillation: Infusion Pump for Bolus and Infusion? Prehosp Emerg Care April 2024; 1-6. Medline
|
|
II
|
Neutral (Yellow)
|
Conversion
|
Patient
|
PH-Paramedic
|
Madsen CD., Pointer JE., Lynch TG. A comparison of adenosine and verapamil for the treatment of supraventricular tachycardia in the prehospital setting. Ann Emerg Med 1995; 25:649-655. Medline
|
|
III
|
Supportive (Green)
|
Conversion
|
Patient
|
ED-MD
|
Innes GD., Vertesi L., Dillon EC., Metcalfe C. Effectiveness of verapamil-quinidine versus digoxin-quinidine in the emergency department treatment of paroxysmal atrial fibrillation. Ann Emerg Med 1997; 29(1):126-34. Medline
|
|
X
|
Not Yet Graded (White)
|
-
|
|
|
Fornage LB, O'Neil C, Dowker SR, Wanta ER, Lewis RS, Brown LH. Prehospital Intervention Improves Outcomes for Patients Presenting in Atrial Fibrillation with Rapid Ventricular Response. Prehosp Emerg Care Nov 2023; 1-10. Medline
|
Antiarrhythmic - Class V (other mechanism)
| Level |
Direction |
Primary Outcome |
Patient/Process |
Setting |
Reference |
|
I
|
Supportive (Green)
|
Converted to sinus rhythm
|
Patient
|
ED-MD
|
Alabed S, Sabouni A, Providencia R, Atallah E, Qintar M, Chico TJ. Adenosine versus intravenous calcium channel antagonists for supraventricular tachycardia. The Cochrane database of systematic reviews 2017; 10. Medline
|
|
I
|
Supportive (Green)
|
Cardioversion success, Length of Stay
|
Patient
|
ED-MD
|
Bellone A., Etteri M., Vettorello M., Bonetti C., Clerici D., Gini G., et al. Cardioversion of acute atrial fibrillation in the emergency department: a prospective randomised trial. Emerg Med J 2012; 29(3):188-91. Medline
|
|
I
|
Supportive (Green)
|
Time to discharge
|
Process
|
PH-Paramedic
|
Honarbakhsh S., Baker V., Kirkby C., Patel K., Robinson G., Antoniou S., et al. Safety and efficacy of paramedic treatment of regular supraventricular tachycardia: a randomised controlled trial. Heart 2017;103(18):1413-8. Medline
|
|
I
|
Supportive (Green)
|
Conversion of SVT
|
Patient
|
ED-MD
|
Lim SH., Anantharaman V., Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation 2009; 80(5):523-8. Medline
|
|
I
|
Neutral (Yellow)
|
Termination rate
|
Patient
|
ED-MD
|
Miyawaki IA, Gomes C, Caporal S Moreira V, et al. The Single-Syringe Versus the Double-Syringe Techniques of Adenosine Administration for Supraventricular Tachycardia: A Systematic Review and Meta-Analysis. Am J Cardiovasc Drugs July 2023; 23(4):341-53. Medline
|
|
II
|
Supportive (Green)
|
Conversion of SVT
|
Patient
|
PH-Paramedic
|
Brady WJ. Jr., DeBehnke DJ., Wickman LL., Lindbeck G. Treatment of out-of-hospital supraventricular tachycardia: Adenosine vs verapamil. Acad Emerg Med 1996; 3(6):574-85. Medline
|
|
II
|
Supportive (Green)
|
Detection stable narrow complex tachycardia
|
Process
|
PH-Paramedic
|
Lozano M., McIntosh BA., Giodano LM. Effect of Adenosine on the management of SVT by urban paramedics. Ann Emerg Med 1995; 26:691-6. Medline
|
|
II
|
Supportive (Green)
|
Conversion
|
Patient
|
PH-Paramedic
|
Morrison LJ., Allan R., Vermeulen M., Dong SL., McCallum AL. Conversion rates for prehospital paroxysmal supraventricular tachycardia (PSVT) with the addition of adenosine: a before-and-after trial. Prehosp Emerg Care 2001; 5(4):353-9. Medline
|
|
II
|
Supportive (Green)
|
Successful cardioversion of SVT
|
Patient
|
PH-Paramedic
|
Nelson AR, Cone DC, Aydin A, Burns K, Cicero MX, et al. An Evaluation of Prehospital Adenosine Use. Prehosp Emerg Care 2022; 1–12. Medline
|
|
II
|
Neutral (Yellow)
|
Conversion
|
Patient
|
PH-Paramedic
|
Madsen CD., Pointer JE., Lynch TG. A comparison of adenosine and verapamil for the treatment of supraventricular tachycardia in the prehospital setting. Ann Emerg Med 1995; 25:649-655. Medline
|
|
II
|
Neutral (Yellow)
|
Rate control at 40 minutes
|
Patient
|
Other
|
Milojevic K, Beltramini A, Nagash M, Muret A, Richard O, Lambert Y. Esmolol Compared with Amiodarone in the Treatment of Recent-Onset Atrial Fibrillation (RAF) An Emergency Medicine External Validity Study. J Emerg Med 2019; 56(3) 308-18. Medline
|
|
III
|
Supportive (Green)
|
Adenosine induced arrhythmia
|
Process
|
ED-MD
|
Camaiti A., Pieralli F., Olivotto I., et al. Prospective evaluation of adenosine-induced proarrhythmia in the emergency room. Eur J Emerg Med 2001; 8(2):99-105. Medline
|
|
III
|
Supportive (Green)
|
Converted to sinus rhythm
|
Patient
|
PH-Paramedic
|
Furlong R., Gerhardt R., Farber P., et al. Intravenous adenosine as first-line prehospital management of narrow-complex tachycardias by EMS personnel without direct physician control. Am J Emerg Med 1995; 13:383-8. Medline
|
|
III
|
Supportive (Green)
|
Converted to sinus rhythm
|
Patient
|
PH-Paramedic
|
Gausche M., Persse D., Sugarman T., et al. Adenosine for the prehospital treatment of paroxysmal supraventricular tachycardia. Ann Emerg Med 1994; 24:183-9. Medline
|
|
III
|
Supportive (Green)
|
Relapse
|
Patient
|
PH-Paramedic
|
Minhas R., Vogelaar G., Wang D., et al. A prehospital treat-and-release protocol for supraventricular tachycardia. CJEM 2015; 17(4):395-402. Medline
|
|
III
|
Supportive (Green)
|
Conversion to a sinus rhythm
|
Patient
|
ED-MD
|
Podolsky SM., Varon J. Adenosine use during pregnancy. Ann Emerg Med 1991; 20(9):1027-8. Medline
|
|
III
|
Supportive (Green)
|
Conversion to normal sinus rhythm.
|
Patient
|
PH-Paramedic
|
Wittwer LK., Muhr MD. Adenosine for the treatment of PSVT in the prehospital arena: Efficacy of an initial 6 mg dosing regimen. Prehosp Disaster Med 1997; 12(3):237-239. Medline
|
|
III
|
Neutral (Yellow)
|
Safety
|
Process
|
PH-Paramedic
|
Torres-Ness CR, Desai SA. Cardiac Arrest After Adenosine Administration in Compensatory Tachycardia: A Case Report. Cureus February 2024; 16(2):e54780. Medline
|
|
III
|
Opposes (Red)
|
Death
|
Patient
|
PH-Paramedic
|
Haynes BE. Two deaths after prehospital use of adenosine. J Emerg Med 2001; 21(2):151-4. Medline
|
Beta Blockers
| Level |
Direction |
Primary Outcome |
Patient/Process |
Setting |
Reference |
|
I
|
Neutral (Yellow)
|
Reduction in ventricular heart rate
|
Patient
|
ED-MD
|
Demircan C., Cikriklar HI., Engindeniz Z., Cebicci H., Atar N., Guler V., et al. Comparison of the effectiveness of intravenous diltiazem and metoprolol in the management of rapid ventricular rate in atrial fibrillation. Emerg Med J 2005; 22(6):411-4. Medline
|
|
I
|
Neutral (Yellow)
|
Cardioversion
|
Patient
|
ED-MD
|
Stead LG., Decker WW. Evidence-based emergency medicine/systematic review abstract. Rhythm versus rate control for atrial fibrillation and flutter. Ann Emerg Med 2006; 47(5):496-498. Medline
|
|
II
|
Supportive (Green)
|
Rate control
|
Patient
|
PH-Paramedic
|
Fornage LB, O'Neil C, Dowker SR, Wanta ER, Lewis RS, Brown LH. Prehospital Intervention Improves Outcomes for Patients Presenting in Atrial Fibrillation with Rapid Ventricular Response. Prehosp Emerg Care Nov 2023; 1-10. Medline
|
|
II
|
Supportive (Green)
|
Sustained rate control
|
Patient
|
ED-MD
|
Hargrove KL, Robinson EE, Lusk KA, Hughes DW, Neff LA, Fowler AL. Comparison of sustained rate control in atrial fibrillation with rapid ventricular rate: Metoprolol vs. Diltiazem. Am J Emerg Med 2021; 40:15-9. Medline
|
|
II
|
Supportive (Green)
|
Rate control at 40 minutes
|
Patient
|
Other
|
Milojevic K, Beltramini A, Nagash M, Muret A, Richard O, Lambert Y. Esmolol Compared with Amiodarone in the Treatment of Recent-Onset Atrial Fibrillation (RAF) An Emergency Medicine External Validity Study. J Emerg Med 2019; 56(3) 308-18. Medline
|
|
II
|
Neutral (Yellow)
|
Predictors of choice of rate control therapy
|
Process
|
|
Hines MC., Reed BN., Ivaturi V., Bontempo LJ., Bond MC., Hayes BD. Diltiazem versus metoprolol for rate control in atrial fibrillation with rapid ventricular response in the emergency department. Am J Health Syst Pharm 2016;73(24):2068-76. Medline
|
Electrical Cardioversion
| Level |
Direction |
Primary Outcome |
Patient/Process |
Setting |
Reference |
|
I
|
Supportive (Green)
|
Cardioversion success, Length of Stay
|
Patient
|
ED-MD
|
Bellone A., Etteri M., Vettorello M., Bonetti C., Clerici D., Gini G., et al. Cardioversion of acute atrial fibrillation in the emergency department: a prospective randomised trial. Emerg Med J 2012; 29(3):188-91. Medline
|
|
I
|
Supportive (Green)
|
Discharge from ED within 4 hours.
|
Patient
|
ED-MD
|
Scheuermeyer FX1, Andolfatto G, Christenson J, Villa-Roel C, Rowe B., A Multicenter Randomized Trial to Evaluate a Chemical-first or Electrical-first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation. Acad Emerg Med. 2019; Sep;26(9):969-981 Medline
|
|
II
|
Supportive (Green)
|
Conversion
|
Patient
|
ED-MD
|
Cohn BG., Keim SM., Yealy DM. Is emergency department cardioversion of recent-onset atrial fibrillation safe and effective? J Emerg Med 2013; 45(1):117-27. Medline
|
|
II
|
Supportive (Green)
|
Cardioversion success
|
Patient
|
ED-MD
|
Dankner R., Shahar A., Novikov I., Agmon U., Ziv A., Hod H. Treatment of stable atrial fibrillation in the emergency department: A population-based comparison of electrical direct-current versus pharmacological cardioversion or conservative management. Cardiology 2009; 112(4):270-8. Medline
|
|
II
|
Supportive (Green)
|
Prehospital rate control
|
Patient
|
PH-Paramedic
|
Fornage LB, O'Neil C, Dowker SR, Wanta ER, Lewis RS, Brown LH. Prehospital Intervention Improves Outcomes for Patients Presenting in Atrial Fibrillation with Rapid Ventricular Response. Prehosp Emerg Care Nov 2023; 1-10. Medline
|
|
II
|
Supportive (Green)
|
Conversion
|
Patient
|
ED-MD
|
Fried AM, Strout TD, Perron AD. Electrical cardioversion for atrial fibrillation in the emergency department: A large single-center experience. Am J Emerg Med 2021; 42:115-20. Medline
|
|
II
|
Supportive (Green)
|
Cardioversion rate
|
Patient
|
ED-MD
|
Vinson DR., Hoehn T., Graber DJ., Williams TM. Managing emergency department patients with recent-onset atrial fibrillation. J Emerg Med 2012; 42(2):139-148. Medline
|
|
II
|
Neutral (Yellow)
|
Cardiac rhythm conversion
|
Patient
|
ED-MD
|
Gallagher MM., Yap YG., Padula M., Ward DE., Rowland E., Camm AJ. Arrhythmic complications of electrical cardioversion: relationship to shock energy. Int J Cardiol 2008; 123(3):307-12. Medline
|
|
III
|
Supportive (Green)
|
Rhythm conversion, complications
|
Patient
|
ED-MD
|
Burton JH., Vinson DR., Drummond K., Strout TD., Thode HC., McInturff JJ. Electrical cardioversion of emergency department patients with atrial fibrillation. Ann Emerg Med 2004; 44(1):20-30. Medline
|
Modified Valsalva
| Level |
Direction |
Primary Outcome |
Patient/Process |
Setting |
Reference |
|
I
|
Supportive (Green)
|
Conversion
|
Patient
|
|
Appelboam A., Reuben A., Mann C., et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. The Lancet 2015; 386(10005):1747–53. Medline
|
|
I
|
Supportive (Green)
|
Success rate of achieving sinus rhythm and discharge from ED
|
Process
|
|
Çorbacıoğlu ŞK., Akıncı E., Çevik Y., Aytar H., Öncül MV., Akkan S., et al. Comparing the success rates of standard and modified Valsalva maneuvers to terminate PSVT: A randomized controlled trial. Am J Emerg Med 2017;35(11):1662-5. Medline
|
|
I
|
Supportive (Green)
|
Conversion to Sinus Rhythm
|
Patient
|
ED-MD
|
Lodewyckx E, Bergs J. Effectiveness of the modified Valsalva manoeuvre in adults with supraventricular tachycardia: a systematic review and meta-analysis. Eur J Emerg Med 2021; 28(6):432–9. Medline
|
|
III
|
Neutral (Yellow)
|
Valsalva maneuver success
|
Patient
|
ED-MD
|
Walker S, Cutting P. Impact of a modified Valsalva in termination PSVT. EMJ 2010; 27:291-7. Medline
|
Valsalva maneuver
| Level |
Direction |
Primary Outcome |
Patient/Process |
Setting |
Reference |
|
I
|
Supportive (Green)
|
Conversion
|
Patient
|
|
Appelboam A., Reuben A., Mann C., et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. The Lancet 2015; 386(10005):1747–53. Medline
|
|
I
|
Neutral (Yellow)
|
Success rate of achieving sinus rhythm and discharge from ED
|
Process
|
|
Çorbacıoğlu ŞK., Akıncı E., Çevik Y., Aytar H., Öncül MV., Akkan S., et al. Comparing the success rates of standard and modified Valsalva maneuvers to terminate PSVT: A randomized controlled trial. Am J Emerg Med 2017;35(11):1662-5. Medline
|
|
I
|
Neutral (Yellow)
|
Termination of SVT
|
Patient
|
ED-MD
|
Lim S., Anantharaman V., Teo W., et al. Comparison of treatment of supraventricular tachycardia by valsalva maneuver and carotid sinus massage. Annals of Emerg Med 1998; 31:30-35. Medline
|
|
I
|
Neutral (Yellow)
|
Termination of SVT
|
Patient
|
ED-MD
|
Smith GD., Fry MM., Taylor D., et al. Effectiveness of the Valsalva Manoeuvre for reversion of supraventricular tachycardia. Cochrane Database Syst Rev 2015; 2:CD009502. (Review) PMID: 25692498. Medline
|
|
II
|
Neutral (Yellow)
|
Conversion rate
|
Patient
|
PH-Paramedic
|
Smith G., McD Taylor D., Morgans A., Cameron P. Prehospital management of supraventricular tachycardia in Victoria, Australia: Epidemiology and effectiveness of therapies. Emerg Med Australas 2014; 26(4):350-355. Medline
|
|
III
|
Supportive (Green)
|
Predictive value
|
Process
|
ED-MD
|
Smith G., Taylor DM., Morgans A., Cameron P. Prehospital synchronized electrical cardioversion of a poorly perfused SVT patient by paramedics. Prehosp Disaster Med 2013; 28(3):301-304. Medline
|
|
III
|
Neutral (Yellow)
|
Conversion
|
Patient
|
ED-MD
|
Ornato J., Hallagan L., Reese W., et al. Treatment of paroxysmal supraventricular tachycardia in the emergency department by clinical decision analysis. Am J Emerg Med 1988; 6:555-60. Medline
|
|
III
|
Neutral (Yellow)
|
Conversion
|
Patient
|
PH-Paramedic
|
Smith G., Morgans A., Boyle M. Use of the Valsalva manoeuvre in the prehospital setting: a review of the literature. EMJ 2009; 26:8-10. Medline
|