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.