January 31, 2020
2 min read

Electrical cardioversion alone or with procainamide confers similar outcomes for AF

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Jeffrey J. Perry

Sinus rhythm was restored in an effective, safe and rapid manner using drug-shock or shock-only strategies among patients in the ED with acute atrial fibrillation, according to results of the RAFF-2 trial published in The Lancet.

“Both treatments were safe with no serious long-term side effects in either group of patients,” Jeffrey J. Perry, MD, MSc, CCFP-EM, senior scientist at The Ottawa Hospital and professor at the University of Ottawa in Canada, told Healio. “Therefore, cardioversion is a safe and effective option to manage recent-onset atrial fibrillation patients in the emergency department, and we were able to safely discharge the vast majority of these patients home following cardioversion.”

ED visit for acute AF

Ian G. Stiell, MD, senior scientist at The Ottawa Hospital and distinguished professor at the University of Ottawa, and colleagues analyzed data from 396 patients with acute AF who visited the ED at 11 academic hospitals in Canada between July 2013 and October 2018. No patients were lost to follow-up.

Patients were assigned pharmacological cardioversion with IV procainamide followed by electrical cardioversion if necessary (n = 204; mean age, 60 years; 66% men) or placebo infusion with electrical cardioversion (n = 192; mean age, 60 years; 66% men. Researchers also assigned pad positions for those who received cardioversion to compare anteroposterior (n = 117) with anterolateral positions (n = 127).

The primary outcome was defined as conversion to and maintenance of sinus rhythm for a minimum of 30 minutes after randomization up to the time immediately after three shocks.

Of the patients assigned the drug-shock strategy, 96% converted to sinus rhythm compared with 92% of those assigned the shock-only strategy (P = .07).

Discharge rates were similar in the drug-shock group compared with the shock-only group (97% vs. 95%, respectively; P = .6). Conversion occurred in 52% of patients assigned the drug-shock strategy who received the drug infusion only.

Researchers did not observe any serious adverse events in both groups during follow-up.

Conversion to sinus rhythm was similar in patients assigned the anterolateral position vs. the anteroposterior position (94% vs. 92%; P = .68).

“The most important finding from this study is that either approach to immediate rhythm control in the emergency department leads to a very high proportion of patients being discharged in sinus rhythm without serious adverse events,” Stiell and colleagues wrote.


“Our study team used procainamide as our pharmacologic treatment,” Perry said in an interview. “Very few studies have compared different antiarrhythmic agents head-to-head for recent-onset atrial fibrillation to determine the optimal pharmacologic treatment. Further study could compare different pharmacological treatment options.”

Perry added how he approaches this topic with his patients, saying, “While I prefer the drug-shock option as it uses fewer resources and works half of the time, ultimately I am in favor of letting patients determine which of these two effective strategies they would prefer.”

Shared decision-making

In a related editorial, Giorgio Costantino, MD, associate professor in the department of clinical sciences and community health at Università Degli Studi di Milano in Italy, and Monica Solbiati, MD, PhD, senior researcher in the department of clinical sciences at Università Degli Studi di Milano, wrote: “This study adds important evidence to the management of hemodynamically stable patients with acute atrial fibrillation. However, because no cardioversion strategy was shown to be superior, the answer might be that patients and clinicians should share this decision, considering the preference of the patient, the experience of the clinicians and the pros and cons of each strategy.” – by Darlene Dobkowski

For more information:

Jeffrey J. Perry, MD, MSc, CCFP-EM, can be reached at jperry@toh.ca.

Disclosures: The trial was funded by the Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research. The authors of the study and of the editorial report no relevant financial disclosures.