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A Multicenter Randomized Trial to Evaluate a Chemical‐first or Electrical‐first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation
Author(s) -
Scheuermeyer Frank X.,
Andolfatto Gary,
Christenson Jim,
VillaRoel Cristina,
Rowe Brian
Publication year - 2019
Publication title -
academic emergency medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.221
H-Index - 124
eISSN - 1553-2712
pISSN - 1069-6563
DOI - 10.1111/acem.13669
Subject(s) - medicine , interquartile range , electrical cardioversion , atrial fibrillation , sinus rhythm , cardioversion , emergency department , randomized controlled trial , procainamide , adverse effect , randomization , anesthesia , psychiatry
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 CHADS 2 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 CHADS 2 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 .