A clinical pathway for safely and effectively cardioverting emergency
department patients with atrial fibrillation greater than 48 hours
Abstract
Background: The current emergency medicine literature on cardioversion
for atrial fibrillation (AF), describes its performance on those who are
hemodynamically unstable, present within 48 hours of the onset of the
arrhythmia, or are on long term anticoagulants. This article describes a
clinical pathway comparing patients presenting to the emergency
department (ED) with atrial fibrillation (AF) of more than 48 hours who
underwent a transesophageal echocardiogram (TEE) and subsequent
cardioversion in the ED. The objective of this study is to evaluate such
a pathway looking at the time to cardioversion, length of hospital stay,
rate of successful cardioversion, and the rate of complications compared
to the traditional pathway of admitting patients directly to the
cardiology department for evaluation and treatment. Methods: This was a
retrospective observational study of patients who presented to the ED
with AF for more than 48 hours, underwent a transesophageal
echocardiogram, and then were electrically cardioverted either in the
emergency department versus the cardiology ward. Results: Electrical
cardioversion was performed in the ED on 92 patients (61%) and the
cardiology department on 59 (39%). Over 90% of cardioversions were
successful in both groups. Time to cardioversion was significantly less
in the ED group versus the cardiology group (1.03 ± 0.8 days versus 4.17
± 1.9; p<0.001). Similarly, the mean length of hospital stay
was less for the ED group (1.5± 1.5 days versus 7.2 ± 3.5;
p<0.001). Conclusion: Patients who present in atrial
fibrillation for more than 48 hours and then have a TEE, undergo
electrical cardioversion faster in the ED compared to the cardiology
ward. This clinical pathway also results in a shorter length of hospital
stay without having more side effects.