Electrical-First Strategy for AF Results in Shorter Hospitalization

The patients were randomized to either chemical cardioversion with procainamide infusion, followed by electrical countershock if unsuccessful; or to electrical cardioversion, followed by procainamide infusion if unsuccessful. The primary outcome was the proportion of patients discharged within four hours of arrival.

In all, 41patients in the chemical‐first group and 43 in the electrical‐first group were treated, with group composition balanced in terms of age, sex, vital signs, and CHADS2 scores. The results revealed that in the chemical‐first group, 32% were discharged within four hours of ED admittance, compared to 67% in the electrical‐first group. In the chemical‐first group, median LOS was 5.1 hours, compared to 3.5 hours in the electrical‐first group. No patients experienced stroke or death, and 99% were discharged with normal sinus rhythm. The study was published in the September 2019 issue of Academic Emergency Medicine.

“While both chemical‐first and electrical‐first cardioversion of uncomplicated AF appear very low risk, we sought to determine if one strategy resulted in the achievement of sinus rhythm and resulting discharge more quickly,” concluded lead author Frank Scheuermeyer, MD, MHSc, of UBC, and colleagues. “An electrical‐first strategy results in a significantly shorter ED LOS. This could benefit patients by restoring normal physiology more quickly to minimize ED resource use.”

The 2011 Canadian Cardiovascular Society (CCS) guidelines permit either rate or rhythm control for AF dysrhythmia patients encountered in the ED; the majority of patients undergo rhythm control, with one of two strategies employed. Chemical cardioversion can be attempted first, typically with procainamide infusion; if this approach restores sinus rhythm, the patient is discharged. If unsuccessful, procedural sedation and electrical countershock are administered. Alternatively, the sequence can be reversed.

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