Should we cardiovert everyone with recent-onset fast AF?
Background: Cardioverting a patient who presents with recent-onset fast AF is great. You consent them, sedate them, shock them, and they wake up feeling better and (often) go home. You feel awesome - quick action, visible result, everyone happy. But how necessary is it to get these patients back into sinus rhythm on their initial visit? And how many will cardiovert without any intervention? The RACE-7 trial can help us answer these questions.
The paper: A total of 437 patients were randomised over a 4-year period across 15 EDs in the Netherlands. Each presented with recent-onset (within the last 36 hours) stable AF and were randomised to immediate or delayed cardioversion. Those in the delayed group received rate-controlling medication in the ED and were followed up at 48 hours. If they were still in AF, they were cardioverted at this time. In the immediate cardioversion group, sinus rhythm was restored in 94% of cases (16% spontaneous, 38% chemical, 40% electrical). In the delayed group, 69% had spontaneously cardioverted by the time of follow up, and the remaining 28% were successfully cardioverted at this time (4% chemical, 24% electrical). There was no significant difference in the authors' primary endpoint (the presence of sinus rhythm after 4 weeks), but for me the interesting part of this study is the rate of spontaneous cardioversion in both groups.
The bottom line: These data suggest that the majority of patients presenting with recent-onset stable AF will spontaneously cardiovert by 48 hours. Maybe we should give them a chance before reaching for the defib pads.
"I think this backs up our usual practice: most get rate control or IV fluids and they often slow down/convert. I'm not always convinced that the change in rate/rhythm is anything to do with what we've done to the patient but that they just slow down/convert on their own! This study lends support to this practice."
(Dr Dwynwen Roberts, ED Consultant)
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