Abstract
The current emergency medicine literature on cardioversion for atrial fibrillation (AF) describes its performance on those who are hemodynamically unstable, present within 48hours of the onset of the arrhythmia, or are on long-term anticoagulants. For patients who are not anticoagulated and present with atrial fibrillation for more than 48hours, one option is to perform a transesophageal echocardiogram and then synchronized cardioversion in the absence of atrial clot. The objective of this study is to compare outcomes of patients presenting to the emergency department (ED) with atrial fibrillation (AF) of more than 48hours who underwent a transesophageal echocardiogram (TEE) and subsequent cardioversion in the ED versus the cardiology ward. This was a retrospective comparison study of patients who presented to the ED with AF for more than 48hours, underwent a transesophageal echocardiogram, and then were electrically cardioverted either in the emergency department or in the cardiology ward. Outcomes include: time to cardioversion, length of hospital stay, rate of successful cardioversion, and rate of complications. Electrical cardioversion was performed in the ED on 94 patients (62%) and the cardiology ward on 57 (38%). Over 90% of cardioversions were successful in both groups. Time to cardioversion was significantly less in the ED group versus the cardiology group (1.04±0.9days versus 3.81±1.9; P<.001). Similarly, the mean length of hospital stay was less for the ED group (1.6±1.6days versus 7.3±3.5; P<.001). Patients who present in atrial fibrillation for more than 48hours and then have a TEE undergo electrical cardioversion faster in the ED compared with the cardiology ward. This clinical pathway also results in a shorter length of hospital stay without having more side effects.
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