Effectiveness and safety of electrical cardioversion for acute-onset atrial fibrillation in the emergency department: a real-world 10-year single center experience

Objective Despite limited evidence, electrical cardioversion of acute-onset atrial fibrillation (AAF) is widely performed in the emergency department (ED). The aim of this study was to describe the effectiveness and safety of electrical cardioversion of AAF performed by emergency physicians in the ED. Methods All episodes of AAF electrically cardioverted in the ED were retrieved from the database for a 10-year period. Most patients not already receiving anticoagulants were given enoxaparin before the procedure (259/419). Procedural complications were recorded, and the patients were followed-up for 30 days for cardiovascular and hemorrhagic complications. Results Four hundred nineteen eligible cases were identified; men represented 69%, and mean age was 61±13 years. The procedure was effective in 403 cases (96.2%; 95.4% in women, 96.5% in men), with considerable differences with respect to the age of the patients, the procedure being effective in 100% of patients aged 18 to 39 and only 68.8% in those >80 years. New ED visits (33/419) were identified within 30 days (31 due to atrial fibrillation/atrial flutter recurrence, 1 due to iatrogenic hypokalemia, 1 due to hypertensive emergency). No strokes, major bleeding, life-threatening arrhythmias or peripheral thromboembolism were recorded. Nine small and mild skin burns were observed. Conclusion Electrical cardioversion is an effective and safe procedure in the vast majority of patients, albeit less effective in patients aged >80 years. It appears reasonable to avoid anticoagulation in low-risk patients with AAF and administer peri-procedural heparin to all remaining patients. Long-term anticoagulation should be planned on an individual basis, after assessment of thromboembolic and hemorrhagic risk.