Cost-effective management of acute atrial fibrillation: Role of rate control, spontaneous conversion, medical and direct current cardioversion, transesophageal echocardiography, and antiembolic therapy

Management strategies for the acute treatment of atrial fibrillation (AF) i nclude: (1) the use of intravenous drugs for rate control, (2) drug termina tion, or (3) direct current (DC) cardioversion. Delays in cardioversion can promote atrial remodeling and add thromboembolic risk. Rate control awaiti ng spontaneous or pharmacologic conversion may be a cost-effective strategy in patients presenting with recent onset of symptoms. Early DC cardioversi on con be cost-effective and minimize antiembolic therapy issues in the acu te setting, In patients presenting with AF of unknown or >48 hours' duratio n, rate control and therapeutic warfarin for 3-4 weeks followed by medical or DC cardioversion is standard practice, However, delays in conversion pro mote atrial remodeling that makes restoration of sinus rhythm more difficul t and increases the likelihood of postcardioversion AF recurrence. Transeso phageal echocardiography can identify patients at low risk for a cardiovers ion-related embolic event and allows cardioversion to be performed earlier, thereby minimizing atrial remodeling. (C) 2000 by Excerpta Medico, Inc.