A Multicenter Randomized Trial to Evaluate a Chemical‐first or Electrical‐first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation

Abstract

Background Emergency department (ED) patients with uncomplicated atrial fibrillation (AF) of less than 48 hours may be safely managed with rhythm control. Although both chemical‐first and electrical‐first strategies have been advocated, there are no comparative effectiveness data to guide clinicians. Methods At six urban Canadian centers, ED patients ages 18 to 75 with uncomplicated symptomatic AF of less than 48 hours and CHADS2 score of 0 or 1 were randomized using concealed allocation in a 1:1 ratio to one of the following strategies: 1) chemical cardioversion with procainamide infusion, followed by electrical countershock if unsuccessful; or 2) electrical cardioversion, followed by procainamide infusion if unsuccessful. The primary outcome was the proportion of patients discharged within 4 hours of arrival. Secondary outcomes included ED length‐of‐stay (LOS); prespecified ED‐based adverse events; and 30‐day ED revisits, hospitalizations, strokes, deaths, and quality of life (QoL). Results Eighty‐four patients were analyzed: 41 in the chemical‐first group and 43 in the electrical‐first group. Groups were balanced in terms of age, sex, vital signs, and CHADS2 scores. All patients were discharged home, with 83 (99%) in sinus rhythm. In the chemical‐first group, 13 of 41 patients (32%) were discharged within 4 hours compared to 29 of 43 patients (67%) in the electrical‐first group (p = 0.001). In the chemical‐first group, the median ED LOS was 5.1 hours (interquartile range [IQR] = 3.5 to 5.9 hours) compared to 3.5 hours (IQR = 2.4 to 4.6 hours) in the electrical‐first group, for a median difference of 1.2 hours (95% confidence interval = 0.4 to 2.0 hours, p < 0.001). No patients experienced stroke or death. All other outcomes, including adverse events, ED revisits, and QoL, were similar. Conclusion In uncomplicated ED AF patients managed with rhythm control, chemical‐first and electrical‐first strategies both appear to be successful and well tolerated; however, an electrical‐first strategy results in a significantly shorter ED LOS.

2021 CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist

“…These are the most common acute arrhythmia cases requiring care in the ED. Canadian emergency physicians are known for publishing widely on this topic and for managing these patients quickly and efficiently in the ED [2,3,4]. The 2018 Checklist project was funded by a research grant from the Cardiac Arrhythmia Network and the resultant guidelines were formally endorsed by the Canadian Association of Emergency Physicians (CAEP).…”

“…Early in 2021 the same Checklist Advisory Committee reconvened (with one additional academic cardiologist) to discuss updates based upon new evidence [3,4,11], the 2018 and 2020 CCS guidelines [12,13], and several commentaries that had expressed the concern of the Canadian ED community [14,15]. The Advisory Committee met twice virtually and reached consensus on updates through repeated email exchanges.…”

“…These are the most common acute arrhythmia cases requiring care in the ED. Canadian emergency physicians are known for publishing widely on this topic and for managing these patients quickly and efficiently in the ED [ 2 , 3 , 4 ].…”

Electrical or pharmacologic cardioversion for atrial fibrillation in the ED?

“…A recent Canadian study compared electrical vs. chemical cardioversion for the management of atrial fibrillation in the ED [1]. In the chemical group, 32% of patients were discharged from the ED within 4 h vs. 67% in the electrical group.…”

Multi-scale Entropy Evaluates the Proarrhythmic Condition of Persistent Atrial Fibrillation Patients Predicting Early Failure of Electrical Cardioversion

“…Furthermore, in hemodynamically stable patients ECV has also shown some advantages regarding the other common treatment to restore SR in initial stages of AF, i.e., pharmacological cardioversion. Indeed, ECV is able to restore SR quicker and more effectively, then reducing hospitalization time [ 13 ]. It is therefore not surprising the recent trend towards ECV in emergency departments to return AF patients back to SR [ 14 ].…”