Related Experiment Video
Updated: Mar 3, 2026
The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation
Published on: February 28, 2012
Anticoagulation Practices Surrounding Emergency Department Cardioversion for Atrial Fibrillation and Flutter
Thomas Maouris1, Peter Del Mar1, Nathan Brown1
1Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.
Insights
Most emergency department patients undergoing cardioversion for atrial fibrillation (AF) or flutter receive guideline-based anticoagulation. However, improved follow-up and care pathways are needed to reduce high revisit rates after AF cardioversion.
Area of Science:
- Cardiology
- Emergency Medicine
- Pharmacology
Background:
- Atrial fibrillation (AF) and flutter are common arrhythmias requiring cardioversion.
- International guidelines recommend specific anticoagulation protocols for patients undergoing direct current cardioversion (DCCV).
- Adherence to these guidelines in the emergency department (ED) setting is crucial for patient safety and outcomes.
Purpose of the Study:
- To evaluate adherence to anticoagulation guidelines during DCCV for AF/flutter in an ED.
- To identify patient characteristics and outcomes associated with guideline adherence.
- To assess the impact of anticoagulation management on ED revisit rates.
Main Methods:
- Retrospective study of 158 patients undergoing DCCV for AF/flutter in a metropolitan ED (2020-2023).
- Data collected on arrhythmia details, anticoagulation timing, and outcomes.
- Analysis based on 2024 European Society of Cardiology criteria for anticoagulation.
Main Results:
- High adherence to pre-cardioversion (94%) and post-cardioversion (90%) anticoagulation guidelines was observed.
- Direct oral anticoagulants (DOACs) were frequently used, with appropriate dosing in 88.2%.
- Higher adherence was noted in patients with CHA2DS2-VA score ≥2 (p<0.01); however, ED revisit rates were high (17.1% at 30 days, 46.2% at 12 months).
Conclusions:
- Guideline-concordant anticoagulation is common for ED cardioversion of AF/flutter.
- Variability in anticoagulation dosing and post-procedure management persists, especially in lower-risk patients.
- Enhanced follow-up and structured care pathways are essential to mitigate high revisit rates post-ED cardioversion.
Objective:
To assess adherence to international anticoagulation guidelines in emergency department (ED) patients undergoing direct current cardioversion (DCCV) for atrial fibrillation (AF) or flutter, and to describe associated outcomes.
Methods:
A retrospective study was conducted at a metropolitan ED (January 2020-December 2023). Of 410 AF/flutter presentations, 158 patients (mean age 57 years; 83.5% male) underwent DCCV. Data on arrhythmia characteristics, anticoagulation timing, and outcomes were reviewed using 2024 European Society of Cardiology criteria.
Results:
AF was present in 91.1% and flutter in 8.9% of cases. Most arrhythmias were recent onset (71.5% < 24 h; 10.1% < 48 h), with no precipitant identified in 87.3%. Rivaroxaban (48.7%) and apixaban (22.1%) were the most prescribed anticoagulants. After cardioversion, 76.6% of patients were discharged directly from ED, 12.7% transferred to short-stay, and 10.1% admitted. Adherence to anticoagulation guidelines was achieved in 94% of cases pre-cardioversion and 90% post-cardioversion, with appropriate DOAC dosing in 88.2%. Patients with CHA2DS2-VA ≥ 2 were significantly more likely to receive appropriate therapy (p < 0.01). ED revisit rates were 17.1% at 30 days and 46.2% at 12 months, often related to recurrent AF.
Conclusion:
Most patients undergoing ED cardioversion received guideline-concordant anticoagulation. However, variability in dosing and post-procedural therapy persists, particularly among low-risk patients. High revisit rates highlight the need for improved follow-up, continuity of anticoagulation, and structured care pathways following ED cardioversion.
Related Concept Videos
01:29Venous Thrombosis III: Interprofessional Care
01:25ECG Interpretation of Arrhythmias II: Atrial, Junctional and Ventricular Arrhythmias
01:30Anticoagulant Drugs: Low-Molecular-Weight Heparins
01:25Cardiopulmonary Resuscitation IV: Pharmacological Management
01:25Dysrhythmias VI: Management of Dysrhythmias
01:18Anticoagulant Drugs: Vitamin K Antagonists and Direct Oral Anticoagulants
Warfarin, a prominent vitamin K antagonist family member, exerts its effect by inhibiting the enzyme VKORC1 (vitamin K epoxide reductase complex 1). By hindering this enzyme, warfarin...