Patients presenting to the emergency department with recent-onset atrial fibrillation (AF) do not benefit more from early cardioversion compared with a wait-and-see approach in achieving a return to sinus rhythm at 4 weeks. The results of the RACE 7 ACWAS multicentre, randomized, noninferiority trial were presented at the European Heart Rhythm Association Congress 2019, and simultaneously published in the NEJM.
Patients presenting to the hospital with symptomatic and recent-onset (<36 h) AF were randomly assigned to be managed by a wait-and-see approach (n = 218; delayed-cardioversion group) or to the standard care of early cardioversion (n = 219; early-cardioversion group). The wait-and-see approach involved the administration of rate-control medication for symptom relief; if AF was still present 48 h after symptom onset, patients were referred for cardioversion.
At the 4-week follow-up, 91% of patients in the delayed-cardioversion group and 94% of patients in the early-cardioversion group were in sinus rhythm (between-group difference −2.9 percentage points, 95% CI −8.2 to 2.2, P = 0.005 for noninferiority).
In the early-cardioversion group, 16% of patients experienced a spontaneous return to sinus rhythm before initiation of cardioversion, whereas sinus rhythm was achieved in 78% of patients who underwent cardioversion. In the delayed-cardioversion group, 69% of patients experienced a spontaneous return to sinus rhythm within 48 h, compared with 28% of patients who required cardioversion.
“The approaches to treating patients with recent-onset [AF] in the emergency department vary greatly,” remark the investigators. The RACE 7 ACWAS findings suggest that many patients with stable, symptomatic AF do not necessarily need to undergo immediate cardioversion, thus reducing the risk of potential complications.
References
Original article
Pluymaekers, N. A. H. A. et al. Early or delayed cardioversion in recent-onset atrial fibrillation. N. Engl. J. Med. https://doi.org/10.1056/NEJMoa1900353 (2019)
Further reading
Dobrev, D. et al. Postoperative atrial fibrillation: mechanisms, manifestations and management. Nat. Rev. Cardiol. https://doi.org/10.1038/s41569-019-0166-5 (2019)
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Huynh, K. Delaying cardioversion for recent-onset AF. Nat Rev Cardiol 16, 322 (2019). https://doi.org/10.1038/s41569-019-0192-3
Published:
Issue Date:
DOI: https://doi.org/10.1038/s41569-019-0192-3