Emergency Department Cardioversion Research Articles

Factors related to the success or failure of cardioversion in atrial fibrillation and emergency department revisit according to restoration of sinus rhythm: analysis of the URGFAICS cohort

Rhythm control in atrial fibrillation (AF) improves haemodynamic status and symptoms. However, there are few data related to revisit of patients who have undergone cardioversion in the Emergency Department (ED). The aim of the study was to compare ED revisit within 30 days according to the effectiveness of cardioversion and analyse the variables related to effective cardioversion. We undertook a multicentre, observational, cohort study with a 30-day follow-up. Older adults with AF presenting to 5 EDs in Spain and undergoing cardioversion were included. The primary endpoint was revisit to the ED within 30 days, and univariate and multivariate analyses were carried out according to the effectiveness of cardioversion. We enrolled 336 patients who underwent cardioversion in the ED. Following the index visit, 7.4% revisited the ED within 30 days, with no differences with respect to the effectiveness of cardioversion (hazard ratio: 0.87; 95%confidence interval (CI) 0.31–2.43). In the multivariate study, AF lasting <48 hours was related to more effective cardioversion (adjusted odds ratio (aOR): 2.14; 95% CI 1.16–3.59) while the use of amiodarone (aOR: 0.52; 95% CI 0.27–0.99) and digoxin in ED (aOR: 0.28; 95% CI 0.13–0.66) was related to less effective cardioversion. In patients with AF undergoing a rhythm control strategy in the ED, the absence of restoration of sinus rhythm was not associated with a greater frequency of 30-day ED revisit.

LIKELIHOOD OF SPONTANEOUS CARDIOVERSION AMONG PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT FOR ATRIAL FIBRILLATION AT SHORT-TERM FOLLOW-UP

Patients (pts) presenting to the emergency department (ED) with a primary diagnosis of atrial fibrillation (AF) are often admitted. To reduce hospitalizations, ED cardioversion (CV) protocols are often used. We propose an alternative protocol to discharge stable pts to a specialized AF clinic within

104 Cardioversion of Recent-Onset Atrial Fibrillation and Flutter in the Emergency Department: Relationship of Energy Level and Success

Emergency department cardioversion (EDC) of recent onset atrial fibrillation and flutter (AF) is an accepted management approach to patients with these arrhythmias. The ideal energy level for direct current (DC) cardioversion of AF patients has not been reported for the ED. This study examines the associations between energy levels and EDC success. Patients undergoing EDC were identified though a query of hospital and ED electronic health data bases. Patient records were abstracted for cardiac rhythm, number of cardioversion attempts, joules per attempt, and post conversion rhythms. All cardioversions were performed with the same model Biphasic Defibrillator. A total of 348 patients underwent emergency department cardioversion for AF over a 64-month period, 306 with atrial fibrillation and 42 with atrial flutter. Of the fibrillation patients 271 (88.6%) were successfully converted to normal sinus Rhythm compared to 40 (95.2%) of the Flutter patients. (p=0.149) Four patients had incomplete documentation of number of cardioversion attempts or joules used and were excluded from further analysis. Overall 262 (86.8%) of fibrillation patients received a single DC shock compared to 40 (95%) of flutter patients (p=0.26). Additional EDC attempts for fibrillation patients included: 2 attempts in 29 (9.6%) and 3 attempts in 11 (3.6%). For the flutter patients 1 (2.4%) received 2 attempts and 1 (2.4%) received 3 attempts. The most common initial energy level for fibrillation patients was 200 joules used in 278 (92.0%) cases, with the same initial energy level used in 37 (88.1%) Flutter patients (p=0.50). For fibrillation patients receiving a second EDC attempt the most common energy selected was again 200 joules used in 21 (52%) of patients while in those receiving 3 EDC’s, 4 (36%) received 300 joules, 4 (36%) received 300 joules, 2 (18%) received 200 joules and 1 (9%) received 285 joules. For the 2 multiple EDC flutter patients, 1 second attempt was at 250 joules and the other at 300 joules. The single flutter patient undergoing a third shock received it at 360 joules. The conversion to normal sinus rhythm success for different energy levels and attempts for atrial fibrillation is presented in Table 1. Atrial flutter cases are not include in the table because all but 2 cases were converted at 200 joules or less. For patients undergoing emergency department cardioversion for atrial fibrillation or flutter an initial attempt at 200 joules should be considered. If unsuccessful then repeat attempts should consider energy levels over 300 joules.Tabled 1Conversion Success Rates For Energy Levels For Atrial FibrillationCardioversion Success (%)<200 j200 j201-299 j300-360 jp valueFirst Attempt2 (60%)232 (95.9%)4 (100%)11 (100%)0.008Second Attempt05 (38.5%)5 (71.4%)5 (55%)0.35Third Attempt01 (50%)03 (37.3%)0.69 Open table in a new tab

Is Emergency Department Cardioversion of Recent-onset Atrial Fibrillation Safe and Effective?

BackgroundAtrial fibrillation (AF) is a very common dysrhythmia presenting to Emergency Departments (EDs). Controversy exists regarding the optimal clinical therapy for these patients, which typically focuses on rhythm rate-control and admission or cardioversion and discharge home. Clinical QuestionIs ED cardioversion of recent-onset atrial fibrillation safe, effective, and does it result in positive meaningful patient outcomes? Evidence ReviewFive observation studies with nearly 1600 ED patients with atrial fibrillation treated with either rate-control or cardioversion were reviewed and results compiled. ResultsOverall, ED cardioversion for recent-onset AF seems safe and effective, with success rates ranging from 85.5% to 97% in these studies. Although further research should seek to identify patients at low risk for thromboembolic complication, more rigorously assess patient satisfaction, and show cost savings, emergency physicians should feel comfortable using this approach in select patients. ConclusionED cardioversion for recent-onset AF seems safe and effective.

Recent‐onset Atrial Fibrillation: The Case for Emergency Department Cardioversion

Recent‐onset Atrial Fibrillation: The Case for Emergency Department Cardioversion

Factors Associated With 90-Day Death After Emergency Department Discharge for Atrial Fibrillation

More than 10% of patients treated in the emergency department (ED) for atrial fibrillation die within a year of the visit. We sought to describe the post-ED care of an older population of atrial fibrillation patients who were discharged home from the ED and to assess patient characteristics and processes of care associated with risk of death within 90 days of discharge. This retrospective cohort analysis included patients aged 65 years or older with a primary ED diagnosis of atrial fibrillation who were treated at all nonpediatric EDs in the province of Ontario, Canada, between April 2007 and March 2010. Only the index emergency visit for each patient was included, and patients admitted to the hospital were excluded. We evaluated the association of postdischarge outpatient care and medications, ED cardioversion, and site volumes of atrial fibrillation patients with adjusted hazard of 90-day death. Among 12,772 qualifying index ED visits, there were 417 (3.3%; 95% confidence interval [CI] 3.0% to 3.6%) deaths within 90 days of the visit. Patients with no follow-up care had a significantly increased hazard of death (hazard ratio [HR] 2.27; 95% CI 1.50 to 3.43) relative to those who consulted a family physician, as did patients prescribed a calcium-channel blocker (HR 1.55; 95% CI 1.15 to 2.09) relative to a β-blocker. A filled warfarin prescription was associated with a lower hazard of death (HR 0.70; 95% CI 0.51 to 0.95). Higher site volumes (HR 0.66; 95% CI 0.41 to 1.08), cardioversion (HR 0.69; 95% CI 0.42 to 1.15), and follow-up care by a specialist only (HR 0.75; 95% CI 0.51 to 1.12) were not associated with 90-day mortality. Among older atrial fibrillation patients discharged from the ED in the province of Ontario, lack of follow-up care had the strongest association with subsequent mortality. If validated, these results suggest that as proportionately more of these patients are discharged from EDs in future, the focus should go beyond ED care itself to the care subsequent to the emergency visit.

Impact of ED management on hospital quality measures: the negative case of atrial fibrillation

ObjectiveEmergency department (ED) cardioversion and discharge of atrial fibrillation (AF) is an evolving treatment. Emergency department cardioversion patients have few comorbidities, and their discharge directly from the ED leads to a sicker in-patient population of AF patients. This study examines whether the quality care markers, hospital charges (HC) and length of stay (LOS), negatively reflect the practice of ED cardioversion. MethodsMedian HC and LOS were determined for 2 different quality assessment reporting models. In a standard model (SM), patients discharged from the ED were not included in any hospital statistics and only admitted, or observation patients were used to calculate the HC and LOS of AF patients. In an inclusive model (IM), patients discharged from the ED were also included in the hospital statistics but given the same LOS as observation patients. Differences across medians were analyzed using Wilcoxon rank sum tests. ResultsA total of 312 patients were evaluated for AF over an 18-month period. Of these, 197 (62%) were admitted, 21 (7%) were placed in observation status, and 95 (31%) were discharged from the ED. Median values for LOS were 3 days (interquartile range [IQR], 1-5) for the SM and 1 day (IQR, 0-4) for the IM. Median values for HC were $33062 (IQR, $19267-$60614) for the SM and $20059 (IQR, $4249-$47195) for the IM. ConclusionEmergency department cardioversion selects out a less sick cohort of patients whose removal from a hospital's admission numbers negatively skews quality performance profiles.

Impact of Emergency Department Management of Atrial Fibrillation on Hospital Charges

IntroductionEmergency department (ED) cardioversion (EDCV) and discharge of patients with recent onset atrial fibrillation or atrial flutter (AF) has been shown to be a safe and effective management strategy. This study examines the impact of such aggressive ED management on hospital charges.Methods:A random sample of 300 AF patients were identified from an ED electronic data base and screened for timing of onset of their symptoms. Patients were considered eligible for EDCV if either nursing or physician notes documented an onset of symptoms less than 48 hours prior to ED presentation and the patient was less than 85 years of age. An explicit chart review was then performed to determine patient management and disposition. Cardioversion attempts were defined as ED administration of procainamide, flecainide, propafenone, ibutilide, amiodarone or direct current cardioversion (DCCV). Total hospital charges for each patient were obtained from the hospital billing office. Differences across medians were analyzed utilizing through Wilcoxon rank sum tests and chi square.Results:A total of 51 patients were included in the study. EDCV was attempted on 24 (47%) patients, 22 (92%) were successfully cardioverted to normal sinus rhythm (NSR). An additional 12 (23%) spontaneously converted to NSR. Twenty (91%) of those successfully cardioverted were discharged from the ED along with 4 (33%) of those spontaneously converting. Pharmacologic cardioverson was attempted in six patients and was successful in three (50%), one after failed DCCV attempt. Direct current cardioversion was attempted in 21 (88%) and was successful in 19 (90%), two after failed pharmacologic attempts. Median charges for patients cardioverted and discharged from the ED were $5,460 (IQR $4,677–$6,190). Median charges for admitted patients with no attempt at cardioversion were $23,202 (IQR $19,663–$46,877). Median charges for patients whose final ED rhythm was NSR were $5,641 (IQR $4,638–$12,339) while for those remaining inAF median charges were $30,299 (IQR $20,655 – $69,759).Conclusion:ED cardioversion of recent onset AF patients results in significant hospital savings.

“Wait and See” Approach to the Emergency Department Cardioversion of Acute Atrial Fibrillation

Objective. Acute atrial fibrillation often spontaneously resolves. This study aimed to investigate the outcomes and satisfaction of an evidence-based ED protocol employing a “wait and see” approach. Methods. A prospective observational cohort study of adult patients presenting to the Emergency Department with stable acute atrial fibrillation was performed. Patients were excluded if they were considered to be unstable, need hospitalization, or poor candidates for ED procedural sedation. Routine care was provided on the index visit, and suitable candidates were discharged and asked to return to the ED the following day for possible electrical cardioversion. Outcome measures included spontaneous reversion to sinus rhythm, success of cardioversion, length of stay, adverse event and return visits for AF within 30 days, and patient satisfaction. Results. Thirty five patient encounters were analysed over a 21-month period. Twenty two of the 35 patients (63%) had spontaneous resolution of atrial fibrillation upon presentation for potential cardioversion. All of the remaining patients underwent successful cardioversion to normal sinus rhythm without significant adverse events recorded. No patients required hospitalization. Three patients (9%) returned to the ED within 30 days for recurrence of atrial fibrillation. All patients were reported to be “very satisfied” with this approach. Conclusion. A “wait and see” approach to the ED electrical cardioversion of atrial fibrillation showed that almost two-thirds of patients had spontaneous resolution without requiring cardioversion or observation in the ED or hospital. All patients were successfully reverted to normal sinus rhythm and had a high degree of satisfaction.

35: Impact of Emergency Department Management of Atrial Fibrillation on Hospital Resource Utilization

Emergency department cardioversion (EDCV) and discharge of patients with recent onset atrial fibrillation or atrial flutter (AF) has been shown to be a safe and effective management strategy. This study examines the impact of such aggressive ED management on hospital resource utilization.

Managing Emergency Department Patients with Recent-onset Atrial Fibrillation

BackgroundThe management of emergency department (ED) patients with presumed recent-onset atrial fibrillation or flutter≤48h in duration varies widely. Objective and MethodWe conducted a prospective study across three affiliated community EDs within a large integrated health care delivery system to describe the management of patients with recent-onset atrial fibrillation or flutter, to determine the safety and effectiveness of ED cardioversion, and to measure the incidence of thromboembolism 30 days after discharge. ResultsWe enrolled 206 patients with convenience sampling between June 2005 and November 2007. Mean age was 64.0±14.4 years (range 21–96 years). Patients were grouped for analysis into four categories based on whether cardioversion was 1) spontaneous in the ED (59; 28.6%); 2) attempted with electrical or pharmacological means (115; 56.3%), with success in 110 (95.7%); 3) hoped for during a short stint of home observation (16; 7.8%, 11 of which spontaneously converted to sinus rhythm within 24h); or 4) contraindicated (16; 7.8%). Of the entire group, 183 (88.8%) patients were discharged home. Adverse events requiring ED interventions were reported in 6 (2.9%; 95% confidence interval [CI] 1.1–6.2%) patients, all of whom recovered. Two (1.0%; 95% CI 0.1–3.5%) patients were found to have an embolic event on 30-day follow-up. ConclusionsOur approach to ED patients with presumed recent-onset atrial fibrillation or flutter seems to be safe and effective, with a high rate of cardioversion and discharge to home coupled with a low ED adverse event and 30-day thromboembolic event rate.

Synchronized emergency department cardioversion of atrial dysrhythmias saves time, money and resources

The strategy of elective synchronized cardioversion (EDCV) of new onset atrial fibrillation/flutter (AF/flutter) compares favorably to that of Emergency Department (ED) rate control and inpatient admission. This 1-year study comprised consecutive ED synchronized cardioversions performed on patients with new onset (< 48 h) AF/flutter; all were hemodynamically stable. A control group was obtained by chart review of all patients meeting the inclusion criteria admitted in the same year who were managed with rate control in the ED and inpatient admission. Thirty ED cardioversions were performed on 24 patients. Twenty-nine of 30 (97%) of ED cardioversions were successful. The mean hospital length of stay (LOS) for the EDCV group, including those admitted, was 22.8 h (95% CI: 1.7–44.0) compared to the control group: 55.6 h (all admitted) (95% CI: 41.6–69.6). Median LOS for the entire EDCV group was 4 h, compared with 39.3 h for the controls ( p < 0.001). There was also a significant difference in median hospital charge, including ED care: EDCV group: $1598 vs. controls $4271 ( p < 0.001). All of the study patients were contacted by telephone a minimum of 4 weeks after cardioversion to assess for complications, recidivism, and satisfaction. There were no complications in the EDCV group, and all expressed satisfaction with the procedure. Elective synchronized cardioversion in the ED is an effective strategy for management of new-onset AF/flutter and is associated with significant decreases in charges and length of stay as well as a high degree of patient satisfaction.

Sedation for cardioversion in the emergency department: Analysis of effectiveness in four protocols

Study objective We compare effectiveness, adverse effects, and recovery times of propofol, etomidate, and midazolam (with and without flumazenil) for cardioversion in the emergency department (ED). Methods Thirty-two hemodynamically stable adult patients undergoing cardioversion in the ED were randomly assigned to receive etomidate (n=9), propofol (n=9), midazolam (n=8), or midazolam followed by flumazenil (n=6). For all patients, we measured induction time, awakening time, total recuperation time, global time, and adverse effects. Arterial pressure, cardiac and respiratory rate, and peripheral oxygen saturation were monitored throughout the procedure. Descriptive and nonparametric tests were used. Results Demographic data were similar in all groups. Deep sedation and successful cardioversion were achieved in all cases. Hemodynamic assessment at baseline, after induction, after cardioversion, and at recovery demonstrated no significant difference between the 4 groups. Induction time was short in all groups. Awakening time was longer in the midazolam group (median 21 minutes, range 1 to 42 minutes) compared with that of the other groups (etomidate group: median 9.5 minutes, range 5 to 11 minutes; propofol group: median 8 minutes, range 3 to 15 minutes; midazolam/flumazenil group: median 3 minutes, range 2 to 5 minutes), and the same occurred with total recuperation time (etomidate group: median 14 minutes, range 5 to 20 minutes; propofol group: median 10 minutes, range 5 to 15 minutes; midazolam group: median 45 minutes, range 20 to 60 minutes; midazolam/flumazenil group: median 5 minutes, range 2 to 90 minutes). All patients in the midazolam/flumazenil group but 1 became resedated after flumazenil was discontinued. Four patients who had received etomidate exhibited myoclonus, which was pronounced and seizure-like in 1 case. Conclusion Four sedative regimens (propofol, etomidate, midazolam, and midazolam/flumazenil) were uniformly effective in facilitating ED cardioversion in hemodynamically stable adults. Propofol was well tolerated and lacked the myoclonus, prolonged sedation, and resedation noted with the latter 3 respective groups. Larger studies are needed to generalize these conclusions.