Treatment of Stable Atrial Fibrillation in the Emergency Department: A Population-Based Comparison of Electrical Direct-Current versus Pharmacological Cardioversion or Conservative Management

OBJECTIVE: To compare the success rates and short-term complications of three treatment approaches, pharmacological and direct-current cardioversion (DCC), or 'wait-and-watch' among stable atrial fibrillation (AF) patients in the emergency department (ED). METHODS: All AF-related ED admissions during a 1-year period were retrospectively reviewed, and those meeting criteria of eligibility for immediate cardioversion, based on clinical stability, AF duration and adequacy of anticoagulation, were included. The propensity score approach generalized for the three groups was used to adjust for the observational non-randomized study nature. RESULTS: Among 374 eligible patients, the rate of successful cardioversion was higher in DCC than in pharmacological or wait-and-watch groups (78.2, 59.2 and 37.9% respectively, p < 0.001), with corresponding percentages of patients discharged from ED (52.9, 47.9 and 32.1%, p < 0.01) and respective odds ratios of 6.00, 2.47 and 1, adjusting for seniority of the treating physician, age, gender and patient comorbidities. DCC was 2.43 times more effective than pharmacological treatment in achieving sinus rhythm (95% confidence interval = 1.36-4.33, p = 0.003). Rehospitalization within 14 days due to probable AF-treatment-related complications of home-discharged patients was 3.4%. CONCLUSIONS: DCC was found to be the most effective treatment, with few short-term complications following conversion of stable AF patients to sinus rhythm in the ED.