Can we safely use a wait and see approach for patients with recent onset atrial fibrillation? (original) (raw)
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Signa Vitae
Rhythm control in atrial fibrillation (AF) improves haemodynamic status and symptoms. However, there are few data related to revisit of patients who have undergone cardioversion in the Emergency Department (ED). The aim of the study was to compare ED revisit within 30 days according to the effectiveness of cardioversion and analyse the variables related to effective cardioversion. We undertook a multicentre, observational, cohort study with a 30-day follow-up. Older adults with AF presenting to 5 EDs in Spain and undergoing cardioversion were included. The primary endpoint was revisit to the ED within 30 days, and univariate and multivariate analyses were carried out according to the effectiveness of cardioversion. We enrolled 336 patients who underwent cardioversion in the ED. Following the index visit, 7.4% revisited the ED within 30 days, with no differences with respect to the effectiveness of cardioversion (hazard ratio: 0.87; 95%confidence interval (CI) 0.31–2.43). In the mult...
Clinical Research in Cardiology, 2013
Background Atrial fibrillation (AF) accounts for approximately one-third of hospitalizations for cardiac rhythm disturbances. Little is known about the characteristics of current use of cardioversion (CV) and its success rates in clinical practice in Germany. Methods As part of the international RHYTHM-AF Study, 655 consecutive patients with documented AF (mean age 68.3 ± 10.5 years, 64.9 % males) who were considered candidates for CV were prospectively enrolled in 22 German hospitals (21 academic/teaching and 1 nonteaching). CV was considered successful if sinus rhythm or atrial rhythm was obtained within 1 day after start of pharmacological CV (PCV) or if sinus rhythm was achieved and maintained for at least 10 min after electrical CV (ECV).
American heart journal, 2017
Current standard of care for patients with recent-onset atrial fibrillation (AF) in the emergency department aims at urgent restoration of sinus rhythm, although paroxysmal AF is a condition that resolves spontaneously within 24 hours in more than 70% of the cases. A wait-and-see approach with rate-control medication only and when needed cardioversion within 48 hours of onset of symptoms is hypothesized to be noninferior, safe, and cost-effective as compared with current standard of care and to lead to a higher quality of life. The ACWAS trial (NCT02248753) is an investigator-initiated, randomized, controlled, 2-arm noninferiority trial that compares a wait-and-see approach to the standard of care. Consenting adults with recent-onset symptomatic AF in the emergency department without urgent need for cardioversion are eligible for participation. A total of 437 patients will be randomized to either standard care (pharmacologic or electrical cardioversion) or the wait-and-see approach,...
Management of acute atrial fibrillation in the emergency department
European Journal of Emergency Medicine, 2013
This review examined recent-onset atrial fibrillation in the emergency department and concluded that atrial fibrillation cardioversion was feasible and direct current cardioversion was probably the best option. Potential for missed data, uncertain quality of heterogeneous evidence and a general paucity of evidence mean the authors' conclusions should be interpreted with caution as their reliability is unclear. Authors' objectives To examine treatments for recent-onset atrial fibrillation in the emergency department. Searching MEDLINE and Web of Science were searched between 2000 and December 2011 for articles published in English or Spanish. Search terms were reported. Reference lists of eligible studies were handsearched. Study selection Eligible studies assessed the effectiveness and safety of sinus rhythm control treatments in patients with atrial fibrillation episodes of short duration (<48 hours) who presented at the emergency department. Outcomes of interest were time to conversion, length of stay in the emergency department, safety and relapses or readmissions. Studies were excluded if they were of patients with postsurgical or post-myocardial infarction atrial fibrillation, secondary and unstable atrial fibrillation and studies that did not report rates of sinus rhythm conversion. Unpublished studies and abstracts were excluded. Included studies were conducted in Europe, USA, Australia and Israel. Comparisons were direct current cardioversion assessment, various pharmacological treatments, pharmacological cardioversion, spontaneous cardioversion, routine admission care, conservative treatment, rate control strategies, home observation (wait and see) and placebo. Two reviewers independently screened studies for inclusion. Methods of synthesis Data were presented in tables and as a narrative synthesis based on treatment and outcome type. Results of the review Fourteen trials (2,765 patients, range 46 to 376) were included in the review: eight were prospective randomised controlled trials (RCTs), four were prospective non-RCTs and two were retrospective non-RCTs. Follow-up ranged from 24 hours to six months. Conversion to sinus rhythm and time to conversion: Four out of five trials showed that direct current cardioversion was statistically significantly more effective in restoring sinus rhythm when compared to pharmacological drugs or conservative management. Flecainide and propafenone showed statistically significant higher conversion rates and shorter time to conversion compared to amiodarone (three trials). A fourth trial showed that amiodarone was superior to magnesium in terms of
Wait and see" approach to the emergency department cardioversion of acute atrial fibrillation
Emergency medicine international, 2011
Objective. Acute atrial fibrillation often spontaneously resolves. This study aimed to investigate the outcomes and satisfaction of an evidence-based ED protocol employing a "wait and see" approach. Methods. A prospective observational cohort study of adult patients presenting to the Emergency Department with stable acute atrial fibrillation was performed. Patients were excluded if they were considered to be unstable, need hospitalization, or poor candidates for ED procedural sedation. Routine care was provided on the index visit, and suitable candidates were discharged and asked to return to the ED the following day for possible electrical cardioversion. Outcome measures included spontaneous reversion to sinus rhythm, success of cardioversion, length of stay, adverse event and return visits for AF within 30 days, and patient satisfaction. Results. Thirty five patient encounters were analysed over a 21-month period. Twenty two of the 35 patients (63%) had spontaneous resol...
Arrhythmia & Electrophysiology Review, 2020
The exact frequency and clinical determinants of spontaneous conversion (SCV) in patients with symptomatic recent-onset AF are unclear. The aim of this systematic review is to provide an overview of the frequency and determinants of SCV of AF in patients presenting at the emergency department. A comprehensive literature search for studies about SCV in patients presenting to the emergency department with AF resulted in 25 articles – 12 randomised controlled trials and 13 observational studies. SCV rates range between 9–83% and determinants of SCV also varied between studies. The most important determinants of SCV included short duration of AF (<24 or <48 hours), low number of episodes, normal atrial dimensions and absence of previous heart disease. The large variation in SCV rate and determinants of SCV was related to differences in duration of the observation period, inclusion and exclusion criteria and in variables used in the prediction models.
BMC cardiovascular disorders, 2017
Elective cardioversion (ECV) of atrial fibrillation (AF) is a standard procedure to restore sinus rhythm. However, predictors for ineffective ECV (failure of ECV or recurrence of AF within 30 days) are unknown. We investigated 1998 ECVs performed for AF lasting >48 h in 1,342 patients in a retrospective multi-center study. Follow-up data were collected from 30 days after ECV. Median number of cardioversions was one per patient with a range of 1-10. Altogether 303/1998 (15.2%) ECVs failed. Long (>5 years) AF history and over 30 days duration of the index AF episode were independent predictors for ECV failure and low (<60/min) ventricular rate of AF predicted success of ECV. In patients with successful ECVs an early recurrence of AF was detected in 549 (32.4%) cases. Female gender, high (>60/min) ventricular rate, renal failure and antiarrhythmic agents at discharge were the independent predictors for recurrence. In total ECV was ineffective in 852 (42.6%) cases. Female ge...
Proceedings of the Latvian Academy of Sciences. Section B. Natural, Exact, and Applied Sciences., 2021
Atrial fibrillation (AF) conversion to sinus rhythm by electrical cardioversion (ECV) is followed by the challenge of preventing arrhythmia recurrence, especially in high-risk patients. The properties of class IC, class III and also class II antiarrhythmic medications have been established, but not all effects have been studied. The aim of the study was to compare efficacy of class IC and class III antiarrhythmic medications, and additionally medication with a class II mechanism of action, or taken concomitantly with a beta-blocker, for post-cardioversion sinus rhythm maintenance in patients with high-risk AF. A total of 112 patients who underwent successful ECV in Latvian Centre of Cardiology were included. Data was acquired by a face-to-face interview and 1-, 3-, 6-month follow-up interviews. Comparing class IC (used by 34.8%) and class III (used by 65.2%) drugs, there was no statistically significant difference between six-month sinus rhythm maintenance rates (53.8% vs. 63.0%, p ...
CJEM, 2012
ABSTRACTObjective:It is believed that when patients present to the emergency department (ED) with recent-onset atrial fibrillation or flutter (RAFF), controlling the ventricular rate before cardioversion improves the success rate. We evaluated the influence of rate control medication and other variables on the success of cardioversion.Methods:This secondary analysis of a medical records review comprised 1,068 patients with RAFF who presented to eight Canadian EDs over 12 months. Univariate analysis was performed to find associations between predictors of conversion to sinus rhythm including use of rate control, rhythm control, and other variables. Predictive variables were incorporated into the multivariate model to calculate adjusted odds ratios (ORs) associated with successful cardioversion.Results:A total of 634 patients underwent attempted cardioversion: 428 electrical, 354 chemical, and 148 both. Adjusted ORs for factors associated with successful electrical cardioversion were ...