Impact of streamlined cardiology referrals on timely pulmonary vein isolation for patients with atrial fibrillation presenting to the emergency room

Abstract Introduction Evidence indicates that pulmonary vein isolation (PVI) is more effective than antiarrhythmic medications in maintaining sinus rhythm in atrial fibrillation (AF) and enhancing quality of life¹. As such, PVI is recommended as a first-line rhythm control treatment for paroxysmal AF patients². Recent research highlights that early rhythm control may be associated with better clinical outcomes³. However, significant barriers in patient education and healthcare logistics hinder the widespread adoption of this approach in clinical practice. Purpose To evaluate the effect of streamline cardiology referral for patients presenting with AF to the emergency room (ER). Methods In January 2021 a special clinic was introduced to enable speedy cardiology follow-up for patients presenting to the ER with the first episode of any supraventricular tachycardia (SVT). This analysis included patients with AF who weren’t previously referred for PVI. Patients with known permanent AF, those who previously underwent PVI and those with other SVTs referred to the clinic were excluded from the study. Data was anonymously collected from hospital medical records. Results Between January 2021 and May 2024, a total of 103 patients with AF were evaluated (63.5 ± 12.7 years-old, 48.5% female). Of these, 73 (70.9%) presented to the ER with the first episode of AF before being referred. The majority were diagnosed with paroxysmal AF (91.3%), followed by persistent (4.9%) and permanent AF (3.9%). The average wait time from the ER to cardiology consultation was 31 ± 30 days. PVI was recommended after the first consultation for 35.0% of patients, following additional assessments in 8.7% or after experiencing AF recurrence in 5.8% of cases. Notably, 25.2% of patients chose not to undergo the PVI. The decision against recommending ablation was primarily influenced by a single episode of AF in 56.6% of cases, perceived low chances of success in 22.6%, presence of permanent AF in 11.3%, ongoing evaluations in 7.5% and the comorbidity concerns in 1.9% of patients. Ultimately, 29 ablations were performed (28.2% of the cohort) with 13 ablations conducted following a single episode of AF. The average time from ER to PVI was 9.0 ± 6.6 months, while the time from the first documented AF episode to PVI was 27.3 ± 53.7 months—significantly shorter than the institutional PVI registry average of 48.7 ± 60.9 months (p=0.02). Conclusion This initiative led to a notable reduction in the time from the first documented AF episode to PVI compared to historical data. Despite challenges such as patient reluctance and various clinical factors influencing treatment decisions, this can help initiate early rhythm control and potentially improve patients outcomes. Further efforts are needed to address barriers to patient acceptance and optimise the referral process to maximise the benefits of early intervention.