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Atrial fibrillation (AF) usually presents to the emergency room (ED) with a rapid ventricular rate, which commonly, but not always, is symptomatic. Rate control is usually easily managed with diltiazem (DTZ) and beta blockers (BBs), typically metoprolol (MTP). Sinus rhythm is frequently restored within 48 hours by means of spontaneous conversion, electrical cardioversion, or medications. However, AF recurs within one year in 60-80% of these subjects. There are little data describing doses of DTZ and MTP used for AF rate control at discharge. A retrospective study of 576 patients presenting with acute AF were evaluated for admission and discharge rate control medications (RCMs). For the 319 (68%) patients with a ventricular rate ≥110bpm the admission and discharge dose of MTP was 61mg and 63mg and DTZ was 195mg and 204mg, respectively. Those who remained in AF had a modest increase in the two medications compared to the patients who converted to sinus rhythm. Current guidelines recommend DTZ up to 300 to 400mg and MTP up to 300mg for rate control for select patients.  Concerns about high doses of MTP are mitigated by the MERIT-HF Trial demonstrating improved mortality and symptoms with doses of MTP up to 200mg demonstrating the safety and efficacy of MTP in high risk patients. Lack of follow-up of future AF recurrences is a limitation of the study. For those patients with acute AF and a heart rate (HR) &gt;110bpm, a minimal increase in RCMs for those in AF at discharge was noted.

FAILURE TO CONSIDER FUTURE ATRIAL FIBRILLATION RATE CONTROL NEEDS AFTER PRESENTATION TO THE EMERGENCY DEPARTMENT WITH RAPID RATE