The initial management of newly recognized atrial fibrillation and atrial flutter (AF) lasting over 48 hours is generally heart rate control along with anticoagulation to prevent future embolic events. Once rate control is achieved by emergency physicians, decisions on the timing of the rhythm control are often left to admission cardiologists. For cases in which AF duration is shorter than 48 hours, patients are often managed similarly. Recent studies, however, show that many of these patients can benefit from ED cardioversion (EDCV) to achieve normal sinus rhythm with discharge from the ED to home.
Potential for Significant Savings
In a study published in the Western Journal of Emergency Medicine, my colleagues and I examined 300 AF patients who came to the ED for care and were screened for timing of symptom onset. EDCV was considered if nursing or physician notes documented onset of AF symptoms within 48 hours of ED presentation in patients younger than 85. The median charges for EDCV patients were $5,460, compared with $23,202 for those admitted with no attempt at cardioversion. Median charges for patients whose final ED rhythm was normal were $5,641; for those remaining in AF, median charges were $30,299.
A surprising finding from our study was that the resource savings produced by simply attempting EDCV, regardless of the results, were also significant. Admitted patients remaining in AF following cardioversion attempts still had hospital charges that were $8,628 lower than those admitted with no EDCV attempt.
Efficient & Effective
The longer a heart remains in AF, the more the atrium becomes conditioned to accept this rhythm. The sooner after the onset of AF that cardioversion is attempted, the more likely the procedure is to be successful and the greater the chance that the patient will maintain normal sinus rhythm following discharge. Using EDCV as rapidly as possible can offer many benefits, especially reducing the need for anticoagulation and avoiding any of the risks associated with hospitalization. EDCV could produce substantial savings to hospitals if it was more universally applied to appropriately selected patients.
With the safety of EDCV in managing recent onset AF having been established in previous research, many EDs are now using this more aggressive approach as a part of their standard care. The data from our study further support the cost effectiveness of EDCV for a patient population that continues to grow each year.
Readings & Resources (click to view)
Sacchetti A, Williams J, Levi S, Akula D. Impact of emergency department management of atrial fibrillation on hospital charges. West J Emerg Med. 2013;14:55-57. Available at: http://escholarship.org/uc/item/5gk6c9qp#page-2.
Barrett TW, Martin AR, Storrow AB, et al. A clinical prediction model to estimate risk for 30-day adverse events in emergency department patients with symptomatic atrial fibrillation. Ann Emerg Med. 2011;57:1-12.
Stiell IG, Clement CM, Brison RJ, et al. Variation in management of recent-onset atrial fibrillation and flutter among academic hospital emergency departments. Ann Emerg Med. 2011;57:13-21.
Stiell IG, Clement CM, Perry JJ, et al. An aggressive protocol for rapid management and discharge of emergency department patients with recent-onset episodes of atrial fibrillation and flutter. CJEM. 2010;12:181-191.
Stead LG, Vaidyanathan L. Evidence-based Emergency Medicine/Systematic Review Abstract. Rhythm control with electrocardioversion for atrial fibrillation and flutter. Ann Emerg Med. 2009;54:745-747.
von Besser K, Mills AM. Is discharge to home after emergency department cardioversion safe for the treatment of recent-onset atrial fibrillation? Ann Emerg Med. 2011;58:517-520.