Use of Single Lead ECG to Assist Cardioversion in Atrial Fibrillation in the Emergency Department ( SELECTED ): Proof of Concept Study

OBJECTIVE: Recent onset atrial fibrillation is common in emergency departments and treated with resource- and time-intensive electrical cardioversion despite most patients spontaneously reverting to sinus rhythm within 48 h. We investigated whether discharging patients with a portable electrocardiograph to monitor rhythm was feasible and could improve emergency department workflow. METHODS: This single-centre proof-of-concept study recruited adults presenting to the emergency department with recent onset, haemodynamically stable, sustained atrial fibrillation, with a clear onset time within 24 h and who owned a smartphone able to pair with the AliveCor single-lead electrocardiograph. Patients were discharged on rate-control and anticoagulant medication where appropriate. Portable electrocardiograph transmissions were sent six-hourly to assess spontaneous reversion to sinus rhythm. If patients remained in atrial fibrillation by 48 h, they represented to the emergency department for direct current cardioversion. Patients continued to send electrocardiograph transmissions for 4 weeks to monitor rhythm. RESULTS: Most (91%; n = 21/23) patients spontaneously reverted from atrial fibrillation to sinus rhythm within 48 h of symptom-onset, with only two patients returning for direct current cardioversion. All patients remained in sinus rhythm at 4-week follow-up. Patients found the device easy to use and appreciated not returning for cardioversion. CONCLUSIONS: Selected patients presenting to emergency departments with recent onset atrial fibrillation can be discharged home with an expectation that they will revert spontaneously to sinus rhythm, potentially reducing unnecessary electrical cardioversion. Remote electrocardiograph monitoring was feasible for identifying patients who failed to revert to sinus rhythm, allowing timely recall to the emergency department for scheduled cardioversion.