Emergency department cardioversion of acute atrial fibrillation

Abstract

I read with great interest the Article by Ian Stiell and colleagues.1Stiell IG Sivilotti MLA Taljaard M et al.Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial.Lancet. 2020; 395: 339-349Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar The findings of this well designed trial will add substantially to the literature on the topic of cardioversion for patients with acute atrial fibrillation presenting to an emergency department. One point made in the Article deserves clarification. Inadvertently perhaps, the authors appear to overstate the benefits of emergency department cardioversion, and this might cause some confusion about the management of patients with acute atrial fibrillation. The benefits of emergency department cardioversion of acute atrial fibrillation are still yet to be completely defined. Stiell and colleagues1Stiell IG Sivilotti MLA Taljaard M et al.Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial.Lancet. 2020; 395: 339-349Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar state that rapid cardioversion in the emergency department “[resolves] acute symptoms” and “obviates the need for anticoagulation in low-risk patients”. However, some patients at low risk might have atrial fibrillation with mild associated symptoms that do not affect daily activity, and they might choose not to undergo cardioversion. Guidelines2Kirchhof P Benussi S Kotecha D et al.2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.Eur Heart J. 2016; 37: 2893-2962Crossref PubMed Scopus (5124) Google Scholar, 3January CT Wann LS Calkins H et al.2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the heart rhythm society in collaboration with the society of thoracic surgeons.Circulation. 2019; 140: e125-e151Crossref PubMed Scopus (1306) Google Scholar, 4Andrade JG Verma A Mitchell LB et al.2018 Focused update of the Canadian Cardiovascular society guidelines for the management of atrial fibrillation.Can J Cardiol. 2018; 34: 1371-1392Summary Full Text Full Text PDF PubMed Scopus (154) Google Scholar advise that patients at low risk (with low CHA2DS2-VASc scores) do not require long-term anticoagulation, and the forgoing of thromboprophylaxis does not depend on successful cardioversion in the emergency department. Nevertheless, emergency department cardioversion for atrial fibrillation within 48 h could prevent the need for short-term anticoagulation or invasive testing in those patients at low risk who might instead decide later—outside the 48 h window—that they would prefer to be in sinus rhythm. Patients who decide to postpone cardioversion and subsequently miss the 48 h window will require anticoagulation for 3 weeks or transoesophageal echocardiography to exclude thrombus before undergoing cardioversion.2Kirchhof P Benussi S Kotecha D et al.2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.Eur Heart J. 2016; 37: 2893-2962Crossref PubMed Scopus (5124) Google Scholar, 3January CT Wann LS Calkins H et al.2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the heart rhythm society in collaboration with the society of thoracic surgeons.Circulation. 2019; 140: e125-e151Crossref PubMed Scopus (1306) Google Scholar, 4Andrade JG Verma A Mitchell LB et al.2018 Focused update of the Canadian Cardiovascular society guidelines for the management of atrial fibrillation.Can J Cardiol. 2018; 34: 1371-1392Summary Full Text Full Text PDF PubMed Scopus (154) Google Scholar The obviation of pre-procedural anticoagulation or transoesophageal echocardiography before postponed cardioversion is an important clarification of a proposed benefit of immediate emergency department cardioversion of acute atrial fibrillation. I am a consultant for InCarda Therapeutics. Emergency department cardioversion of acute atrial fibrillationWe applaud Ian Stiell and colleagues1 for their well designed and executed trial comparing two common methods of cardioversion for stable emergency department patients with acute atrial fibrillation. Their efficacy and safety results will better inform the shared decision-making conversations we undertake with our emergency department patients eligible for elective cardioversion. Full-Text PDF Emergency department cardioversion of acute atrial fibrillationIan Stiell and colleagues1 hypothesised that procainamide with eventual direct-current (DC) shock would be superior to immediate DC shock in patients with recent-onset atrial fibrillation at the emergency department, but this could not be proven in their study. By contrast, procainamide could enhance cardioversion in persistent atrial fibrillation, which is more resilient to DC shock than recent-onset paroxysmal atrial fibrillation.2 Full-Text PDF Emergency department cardioversion of acute atrial fibrillation — Authors' replyWe thank Nikki Pluymaekers and colleagues, David Vinson and colleagues, and Ian DeSouza for their thoughtful comments on the results of the RAFF2 study.1 Full-Text PDF