Home-based cardioversion of atrial fibrillation: moving patient care out of the hospital

This invited commentary refers to ‘Elective cardioversion of atrial fibrillation at home by advanced practice providers: a feasibility study in the Dutch Emergency Medical Service—design and pilot results’, by R. van Vliet et al., https://doi.org/10.1093/eurjcn/zvaf140. Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in adults globally and associated with substantial morbidity and mortality.1 In the coming years, the overall prevalence of AF is expected markedly to increase,2 largely due to a growing and aging population, prolonged survival of predisposing conditions, an increasing prevalence of predisposing risk factors for AF such as hypertension and obesity, and intensified efforts to screen for undiagnosed AF.1,3 Although it can present entirely asymptomatic, two-thirds of AF patients experience symptoms, and many of them need rhythm control treatment beyond rate control to alleviate symptoms and improve quality of life.4 As AF is a chronic disease in the vast majority of cases, it constitutes a significant burden not only for the patients, but also for healthcare systems and health economics. With the increasing number of AF patients the demand for healthcare services and associated costs will rise, while the workforce within the healthcare systems is decreasing or at least stagnating5 and the economic resources are limited. This situation requires thinking new ways of delivering care to patients to optimize use of healthcare resources without worsening the quality of care. One approach is Hospital-at-Home (HaH), which is an emerging concept that aims to provide hospital-level care within the patient’s home instead of the hospital. This concept experienced a particular boom since the COVID-19 pandemic. HaH models can contribute to improving outcomes and potentially lowering healthcare costs.6 Electrical cardioversion (ECV) of AF by synchronized direct current electrical shock, which was already introduced in the early 1960s, is one of the cornerstones in the management of atrial fibrillation or flutter in symptomatic patients who require a rhythm control strategy. The procedure is readily available, has a high overall success rate, is easy to perform, and is generally safe,7 which could make it a candidate for a HaH approach. Van Vliet et al. present interesting data from a feasibility study of home-based ECV performed by emergency medical service (EMS) advanced practice providers, which were supported by an ambulance nurse and a driver both trained in advanced life support (ALS).8 Their study demonstrated that the procedure was technically and logistically feasible. Nevertheless, some questions remain and there is still much work to be done, before this approach may be integrated into routine clinical practice. The feasibility study included a relatively selected and healthy population of AF patients without severe co-morbidities. Future studies should clarify whether this approach is also feasible in hemodynamically stable AF patients with greater co-morbidity—a group we frequently encounter in daily practice. Furthermore, future studies should enrol a larger patient cohort to enhance the generalizability of the results. In the study, patients were monitored for one hour after the procedure and contacted by phone after four and 24 h for follow-up and monitoring of adverse events. A post-procedural observation of one hour may appear relatively short. Larger studies should assess, whether this time frame is sufficient or whether a longer observation period is needed so that potential adverse events beyond one hour can be immediately detected and appropriately treated. Moreover, such studies should include a more systematic follow-up. Standardized assessment tools may improve the evaluation of objective findings such as skin redness or burns and other possible complications and thereby minimize the risk of overlooking/missing certain complications. The use of patient-reported outcomes measures (PROMs) such as standardized questionnaires can help shedding a more differentiated light on the patients’ experience of the procedure. Another unresolved question is which shock energy would be the most efficient to deliver. A study by Schmidt et al. demonstrated that a maximum-fixed shock approach was more effective in converting patients with the first shock than the low-energy escalating shock approach, which was applied in the present study, while there was no difference between the two approaches regarding safety.9 Before introducing home-based ECV into routine clinical practice, it would also be necessary to perform detailed health economic evaluations, which should compare this approach with the, often nurse-led, ECV in the outpatient clinic or specialized cardioversion clinics, which is widely used today. This evaluation must include all parts of the procedure, including staff salaries, costs of driving between the patients’ residences, and time spent on the single patient. Moreover, even if home-based ECV seems to work in the setting of the Dutch healthcare system, it has to be shown whether the approach is feasible in other healthcare settings, which might be different from the Dutch, not only regarding the education and skills of the staff. Overall, the authors should be congratulated that they were keen to think new ways. This is a good starting point, but there are still many unanswered questions and a lot of work ahead. Axel Brandes (Conceptualization [lead], Writing—original draft [lead], Writing—review & editing [lead]), Nedim Tojaga (Writing—review & editing [equal]), and Andreas Sjøholm-Christensen (Writing—review & editing [equal]) This article did not receive any funding. No new data were generated or analysed in support of this commentary.