Electrical or Chemical-First Cardioversion of A-fib?

Written by Clay Smith

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For new onset atrial fibrillation (a-fib), an electrical-first approach reduced ED length of stay compared to a chemical-first approach.

Why does this matter?
With RACE 7, one might ask if there is need to cardiovert anyone with new onset a-fib or rather take a wait-and-see approach, as most spontaneously convert to NSR. But, many patients are profoundly symptomatic with a-fib, and restoration of NSR is a reasonable goal. As such, is it faster to chemically or electrically provide rhythm control?

Get into the rhythm
This was a multi-center RCT comparing chemical first to electrical first management of new onset a-fib. In all, 84 patients were randomized. The electrical first group was discharged home in under 4 hours 67% of the time, compared to the chemical first (procainamide) group at 32%. Procainamide converted 54% (22 of 41), and all failures crossed over and were then successfully converted electrically. Electrical cardioversion converted 88% (38 of 43), with 4 of the 5 failures crossing over and converting with procainamide. Adverse events were the same in each group, as were 3 and 30-day outcomes.

A Multicenter Randomized Trial to Evaluate a Chemical-first or Electrical-first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation. Acad Emerg Med. 2019 Aug 19. doi: 10.1111/acem.13669. [Epub ahead of print]

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Reviewed by Thomas Davis

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