OBJECTIVES: To estimate – from the German SHI perspective – economic consequences of using the low-molecular-weight heparin enoxaparin subcutaneously (ENOX) instead of intravenous unfractionated heparin followed by oral phenprocoumon (UFH/PPC) for anticoagulation in patients undergoing TEE-guided early electrocardioversion from nonvalvular atrial fibrillation (AF). METHODS: As ENOX is noninferior to UFH/PPC in preventing deaths and ischemic, embolic, and hemorrhagic events [Stellbrink C, et al. ACE trial. Circulation 2004], a cost-minimization analysis (CMA) was performed. The target variable 'incremental cost for ENOX versus UFH/PPC' was quantified using a modelling approach based on decision-tree technique. The CMA encompassed 28 (26–30) treatment days with phase I of 5 (3–8) days comprising diagnostics, initiation of anticoagulation, and cardioversion. Phase II with the remaining days comprised continued anticoagulation. Resource use was verified by a survey in the in- and outpatient sectors. Costs were given by SHI expenses and were quantified by multiplying utilised resource items by the price or tariff of each item, according to German healthcare regulations. RESULTS: In the base-case analysis, phase I was outpatient based for the majority of ENOX patients opposed to inpatient treatment for all UFH/PPC patients, whereas phase II was entirely outpatient based for both patient groups. There were savings of 579€ per patient with ENOX (892€) compared to UFH/PPC (1471€). Comprehensive sensitivity analyses (impact analysis, Monte Carlo simulation) showed the robustness of the model. Expenses for the inpatient-based phase I with UFH/PPC had by far the greatest influence on the extent of savings obtained. Simultaneous random variation of all model parameters within their empirically given intervals revealed savings obtained by ENOX in 93% of 10,000 simulated comparisons versus UFH/PPC. CONCLUSIONS: In TEE-guided early electrocardioversion of nonvalvular AF, anticoagulation with ENOX offers SHI in Germany an enormous saving potential when used instead of UFH/PPC.