Should the initiation of antiarrhythmic therapy for atrial fibrillation occur in the hospital or out of the hospital?: a review of the literature

Abstract

Background: Initiation of antiarrhythmic therapy for atrial fibrillation is a key step in the treatment of this disorder. Much controversy remains as to the risks and benefits of initiating therapy as an inpatient versus an outpatient.

Objective: To explore the various issues of debate and to determine the importance and validity of these various issues when it comes to the evaluation of patients for in- versus out-of-hospital initiation of antiarrhythmic therapy for atrial fibrillation.

Methods: A MEDLINE search of English language journal articles since 1966 and a hand search of bibliographies included in pertinent retrieved articles was undertaken. Articles used included review articles, retrospective studies, and meta-analyses.

Results: The literature is full of articles for and against outpatient initiation of antiarrhythmic therapy. One side feels that the risks of antiarrhythmic therapy initiation are serious enough in all patients and easy enough to reverse or ameliorate if the patient is in the safety of the monitored hospital setting. The other side argues that these complications are infrequent enough except in certain commonly identifiable patients, that not all need hospitalization during antiarrhythmic initiation. The issues at the heart of the dispute include: the presence or absence of underlying heart disease; the period of monitoring after initiation of therapy; the choice of antiarrhythmic agent used; and even the seriousness and prevalence of the arrhythmia which can be induced.

Conclusions: The issue of in versus out-of-hospital initiation of antiarrhythmic therapy for atrial fibrillation remains a widely disputed topic. Many factors come under consideration when this topic is studied. At present, we recommend that patients with significant structural heart disease, conduction disease, and/or QT prolongation be strongly considered for in-hospital initiation of antiarrhythmic medications. Further prospective studies are necessary to assess the magnitude of the difference of initiating antiarrhythmic therapy as an inpatient versus as an outpatient.