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Cardioversion of paroxysmal atrial fibrillation in the emergency department
J A Michael1, I G Stiell, S Agarwal
1Division of Emergency Medicine, University of Ottawa, University of Ottawa Emergency Medicine Residency Programme, Ottawa, Ontario, Canada. jmichael@javanet.com
Insights
Emergency department cardioversion and discharge for acute atrial fibrillation is safe and effective. This approach allows most patients with acute atrial fibrillation to be discharged directly from the emergency department.
Area of Science:
- Emergency Medicine
- Cardiology
Background:
- Traditionally, patients with acute atrial fibrillation are admitted to the hospital.
- This practice may lead to unnecessary hospitalizations and resource utilization.
Purpose of the Study:
- To review the success and safety of emergency department (ED) cardioversion and discharge for patients with acute atrial fibrillation.
Main Methods:
- Retrospective analysis of health records for patients presenting with acute atrial fibrillation to an ED.
- Exclusion of unstable patients or those with complicating diagnoses.
- Categorization of patient visits by intervention: no intervention, spontaneous resolution, heart rate control, chemical cardioversion, or electrical cardioversion.
Main Results:
- 62% underwent chemical cardioversion (50% success); 28% underwent electrical cardioversion (89% success).
- Electrical cardioversions were primarily performed by emergency physicians.
- Overall complication rate was 6%, with 95% minor complications. 97% of patients were discharged directly from the ED.
Conclusions:
- Cardioversion and immediate discharge for acute atrial fibrillation in the ED is safe and effective.
- This management strategy warrants prospective evaluation in diverse clinical settings.
Study Objective:
Patients presenting to the emergency department with acute atrial fibrillation are traditionally admitted to hospital. The objective of this study was to review the success and safety of ED cardioversion and discharge of patients with acute atrial fibrillation.
Methods:
This health records survey included a cohort sample of consecutive patients presenting with acute atrial fibrillation to the ED of a university-affiliated tertiary hospital. Patients who were in unstable condition on presentation, who had a complicating cardiac diagnosis, or those with other medical or surgical conditions requiring admission were excluded from the study analysis. Patient visit information was entered into a database that included demographics and clinical presentation, investigations, ED therapy, complications, consultations, disposition, and follow up. Patient visits were then categorized into the following groups: no ED intervention, spontaneous resolution, heart rate control, attempted chemical cardioversion, or electrical cardioversion. The data were analyzed using descriptive methods.
Results:
Of the 289 eligible patients seen during an 18-month period, 62% (180) underwent attempted chemical cardioversion with a 50% success rate and 28% (80) had attempted electrical cardioversion with a 89% success rate. Ninety-three percent of electrical cardioversions were performed by emergency physicians. There was an overall 6% (19) complication rate, 95% of which were regarded as minor. One patient had a complication caused by a rate control medication, which necessitated hospital admission. Ninety-seven percent (280) of the patients were discharged home directly from the ED.
Conclusion:
Cardioversion and immediate discharge of patients who present to the ED with acute atrial fibrillation appears to be both safe and effective. This management approach should be prospectively evaluated in multiple settings.