Early or delayed cardioversion in recent-onset atrial fibrillation


Background: Often atrial fibrillation terminates spontaneously and occasionally recurs; therefore, the advantage of immediate electric or pharmacologic cardioversion over watchful waiting and subsequent delayed cardioversion is not clear.

Dr. Rami Abdo of Division of Hospital Medicine, Duke University Health System, Durham, NC

Dr. Rami Abdo

Study design: Multicenter, randomized, open-label, noninferiority trial.

Setting: 15 hospitals in the Netherlands (3 academic, 8 nonacademic teaching, and 4 nonteaching).

Synopsis: Randomizing 437 patients with early-onset (less than 36 hours) symptomatic AFib presenting to 15 hospitals, the authors showed that, at 4 weeks’ follow-up, a similar number of patients remained in sinus rhythm whether they were assigned to an immediate cardioversion strategy or to a delayed one where rate control was attempted first and cardioversion was done if patients remained in fibrillation after 48 hours. Specifically the presence of sinus rhythm occurred in 94% in the early cardioversion group and in 91% of the delayed one (95% confidence interval, –8.2 to 2.2; P = .005 for noninferiority). Both groups received anticoagulation per current standards.

This was a noninferiority, open-label study that was not powered enough to study harm between the two strategies. It showed a 30% incidence of recurrence of AFib regardless of study assignment. Hospitalists should not feel pressured to initiate early cardioversion for new-onset AFib. Rate control, anticoagulation (if applicable), prompt follow-up, and early discharge (even from the ED) seem to be a safe and practical approach.

Bottom line: In patients presenting with symptomatic recent-onset AFib, delayed cardioversion in a wait-and-see approach was noninferior to early cardioversion in achieving sinus rhythm at 4 weeks’ follow-up.

Citation: Pluymaekers NA et al. Early or delayed cardioversion in recent-onset atrial fibrillation. N Engl J Med.

    2019 Apr 18;380(16):1499-508.

    Dr. Abdo is a hospitalist at Duke University Health System.

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