A clinical pathway for safely and effectively cardioverting
emergency department patients with atrial fibrillation greater than 48
hours
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.