Same-Day Discharge After Intravenous Sotalol Loading in Patients With Atrial Fibrillation

Interview With Imdad Ahmed, MD, MBA, CPE, FACC, FHRS, FACP

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EP LAB DIGEST. 2025;26(5).

Interview by Jodie Elrod

Imdad Ahmed, MD, MBA, CPE, FACC, FHRS, FACP, and colleagues recently evaluated a protocol using intravenous (IV) sotalol initiation followed by same-day discharge and outpatient mobile cardiac monitoring for patients with atrial fibrillation (AF). Conducted in a community hospital setting, the study demonstrated favorable safety outcomes and suggests that a carefully structured protocol may offer an alternative to the traditional 2- to 3-day hospitalization required for oral sotalol initiation. In this episode of The EP Edit, Dr Ahmed discusses the rationale behind the strategy, key findings, and practical considerations for implementation.

Can you start with a brief introduction about yourself?

My name is Imdad Ahmed, and I serve as director of the Comprehensive Arrhythmia Center at Mercyhealth, a healthcare system serving southern Wisconsin and northern Illinois. I have been with Mercyhealth since 2016, after completing my electrophysiology fellowship at Yale New Haven Hospital in Connecticut.

What led you to initiate—or to formally study—an IV sotalol loading strategy with same-day discharge in a community hospital setting?

As you know, oral sotalol has been used for a long time. It has been common practice to admit patients to the hospital for 2 to 3 days based on FDA recommendations. That process requires a lot of resources, including occupying a telemetry or ICU bed for 2 to 3 nights, as well as involvement from nurses and physicians caring for the patient. Most of these patients are simply sitting in the hospital taking medication and being monitored. So it is a fairly exhaustive and expensive process.

When IV sotalol was introduced and approved by the FDA, there was a lot of discussion about how we could achieve the same effectiveness with the same drug without having to keep patients in the hospital for 2 to 3 nights and utilize all of those resources.

Once I reviewed the clinical trial data and the safety data, it occurred to me that perhaps we could use this drug in my practice setting without requiring patients to stay in the hospital for 2 to 3 nights. I practice in a community teaching hospital, and we do not have unlimited resources. Our bed capacity is relatively limited. During COVID, we had a real eye-opening experience—we realized just how limited our resources actually were. These patients really could not stay in the hospital unnecessarily.

A lot of thought went into finding alternatives to the traditional model of keeping patients hospitalized versus sending them home the same day. I had previously done a project involving same-day discharge after AF ablation, and the outcomes were excellent. There was no difference in outcomes, and patients did very well.

That led me to think about this patient population. I reviewed the published clinical trial data, saw the safety profile, and started asking myself: How can I utilize IV sotalol without keeping patients in the hospital for 2 or 3 nights?

That is how the thought process started. It evolved into a research project focused on developing a strategy and workflow that would allow patients to receive the benefits and effectiveness of the drug while achieving the same level of safety and outcomes that we would expect from a traditional 2- to 3-day hospitalization.

Can you walk us through how you structured your protocol—such as patient selection, ECG monitoring during infusion, and the transition to outpatient mobile monitoring? 

We went through a very stepwise process because, in a community teaching hospital, we needed to bring together all the necessary resources. We started with a written protocol outlining exactly how we would do this. We reviewed that protocol during multiple meetings.

I supervised the entire process. We involved nurse practitioners, ICU- and CCU-trained nurses who administer the infusion, and our pharmacy team. We held multiple meetings with all stakeholders and developed a written strategy outlining who would do what throughout the process.

Once we had a written protocol and clearly defined responsibilities, we began selecting patients. We see patients in the clinic and review the entire process with them. It is extremely important that patients actively participate and understand what is happening. This is very much a shared decision-making process.

We want to ensure patients are compliant and fully understand the plan. After selecting appropriate patients, we review everything with them in detail. We then obtain a pharmacy consultation on an outpatient basis to make sure patients can obtain the medication, assess for potential drug-drug interactions, and evaluate renal function and creatinine clearance. All of those details are reviewed by the pharmacy team.

Before bringing patients to the hospital for the IV infusion, we obtain an ECG, perform blood work, and provide detailed education in the clinic.

Once patients arrive at the hospital, they receive the IV infusion according to a strict protocol. They are continuously monitored on telemetry, and we obtain ECGs every 15 minutes during the infusion.

After the infusion is completed, we wait 4 hours and obtain another ECG. We then administer the first oral dose. Two hours later, we obtain an additional ECG and discharge the patient home with an event monitor.

The event monitor is monitored continuously in real time, and my nurse practitioners and other members of the care team have access to the data. In many ways, we are monitoring patients as if they were still in the hospital.

Over the next 2 to 3 days, we remain in constant communication with patients by phone. We review their QTc, assess their rhythm, determine whether any arrhythmias are occurring, and advise them about taking subsequent doses. Essentially, we continue supervising them remotely with continuous monitoring.

This is a highly structured protocol. Everyone involved knows exactly what they are responsible for.

I then decided to formally evaluate the results by retrospectively reviewing more than 50 patients to see how we had performed. We recently presented these findings at the American College of Cardiology meeting and published them in EP Lab Digest.¹

We found that the strategy was safe. There were no adverse events, and patients did very well. Based on our relatively small sample size, we believe this approach is both feasible and safe. However, it still needs to be validated in larger patient populations. Nevertheless, it demonstrates that this is something that can be done.

Your study showed higher conversion rates with 120 mg dosing and lower success in patients previously treated with propafenone, along with higher readmission rates in the high-dose group. How should clinicians interpret these findings when selecting patients and determining dosing strategies?

We determined dosing based on pharmacy guidance, creatinine clearance, FDA recommendations, QTc intervals, and potential drug-drug interactions.

It has been shown that when patients can tolerate a higher dose, effectiveness tends to be better. However, we also need to recognize that some patients cannot tolerate higher doses because of bradycardia, QTc prolongation, drug interactions, or limitations related to renal function and creatinine clearance. These decisions must be individualized.

The higher conversion rates are probably directly related to the greater effectiveness of the higher dose. However, patients who had previously failed to convert or did not respond well to propafenone likely represent a population with more advanced AF.

I do not think this finding has anything to do with sotalol itself. Rather, it reflects the characteristics of the patient population. These are patients who did not respond to a Class IC antiarrhythmic drug. Some had already undergone AF ablation and remained refractory to both medical therapy and ablation. Many likely had significant atrial remodeling due to persistent AF. 

So the poorer outcomes in these patients are probably related to advanced disease and the overall severity of their condition rather than to sotalol itself.

What we have learned is that patient selection is important. Factors such as left atrial size, duration of AF, and earlier treatment all matter. Again, I think these findings reflect disease progression and refractoriness to therapy rather than any limitation of sotalol.

Your study is the first to quantify 30-day readmission rates after same-day IV sotalol initiation. How do those data inform the safety profile of this approach and its feasibility for broader adoption in community hospital settings?

When discussing our study, it is important to remember that this was conducted in a community hospital setting and involved a relatively small sample size. That said, I believe it is feasible to implement a same-day discharge strategy with IV sotalol, provided there is a very careful and meticulous protocol in place. In our study, the approach appeared safe, although it still needs to be validated in larger patient populations and across multiple practice settings.

Our study demonstrates both feasibility and safety within our patient population. Since publishing the study, we have continued using the same strategy, and thus far we have not observed any adverse events in the patients we have treated.

Based on our experience, if physicians follow a careful, well-planned strategy with a written protocol involving physicians, nurse practitioners, nurses, clinic staff, and pharmacists—and if they carefully select compliant patients—I believe this approach is feasible and likely to be safe. However, larger studies are still needed.

For others considering a similar model, what are 2 or 3 practical lessons you’ve learned that make this approach safe and workable?

For anyone considering this protocol, careful planning is absolutely essential. There should be a written protocol, a written strategy, and clearly defined responsibilities outlining who is responsible for each step of the process. There should also be specific criteria for patient selection.

Before implementation, planning should involve physicians, nurse practitioners, other health care providers, clinic nurses, ICU or CCU nurses who will administer the infusion, and pharmacists.

There should be a written protocol describing how the process will be carried out and how drug initiation will occur. There should also be a protocol outlining how adverse events will be managed.

In addition, there must be a clear monitoring strategy. If a patient's QT interval becomes prolonged or if bradycardia develops, there should be predefined plans in place—especially for weekends, holidays, and overnight coverage.

Once that strategy is established and everyone is aligned, I believe this approach is feasible and likely to be safe. However, careful monitoring, thoughtful planning, and detailed written protocols are essential.

The transcripts have been edited for clarity and length.

Reference

1.     Mylavarapu R, Parekh Z, Cox E, Zhan W, Ahmed I. Mobile cardiac monitoring with same-day discharge after loading with intravenous sotalol is safe and effective in patients with atrial fibrillation. EP LAB DIGEST. 2026;26(2):21-25.