OBJECTIVES: We aimed at estimating and comparing the total management costs of patients admitted to the emergency department (ED) with recent (<48 hours) atrial fibrillation (AF) between three types of cardioversion: direct current cardioversion (DCC), intravenous amiodarone or intravenous vernakalant. METHODS: A decision analytic model was developed to mimic the pathways of patients admitted via the ED with recent AF and to calculate an average AF management cost per strategy. The cardioversion success rates were based on published observational studies (DCC 90%, amiodarone 68%, vernakalant 70%). In case of successful conversion the patient was released directly from the ED to home (DCC 50%, amiodarone 25%, vernakalant 100%) or admitted to the hospital for a median of 1 day (DCC) or 2 days (amiodarone) reflecting cardioversion-specific times to sinus rhythm. After a failed pharmacological cardioversion, patients were assumed to receive a DCC; failed DCC was followed by intravenous amiodarone. The associated inpatient costs were retrieved from the IMS Hospital Disease Database (HDD2011). ED treatments were costed using the national healthcare payer tariffs. Univariate and probabilistic sensitivity analyses were performed. RESULTS: The total AF management costs from ED to discharge were estimated at €952 (DCC), €1,894 (amiodarone) and €1.354 (vernakalant). Given the relative frequencies of amiodarone (55%) and DCC (45%) to treat recent FA in Belgian ED, the weighted average management cost was €1.470 (+ €116/treatment vs. vernakalant). The break-even situation is reached when 75% of successfully treated vernakalant patients avoid the hospitalization (base case 100%). Based on a probabilistic sensitivity analysis, vernakalant was cost saving in 55% of the 1,000 simulations vs. current management. CONCLUSIONS: In patients with recent AF, the rapid mode of action of vernakalant increases the chance of obtaining sinus rhythm within 48 hours, and its use was cost saving compared to the current average Belgian practice.