Rate Control Versus Electrical Cardioversion Trial 7–Acute Cardioversion Versus Wait and See - RACE 7 ACWAS

Apr 18, 2019
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Author/Summarized by Author:
Anthony A. Bavry, MD,MPH,FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
Netherlands Organization for Health Research and Development
Date Published:
03/18/2019
Date Updated:
04/18/2019
Original Posted Date:
04/03/2019
References

Contribution To Literature:

The RACE 7 ACWAS trial showed that delayed cardioversion was noninferior to early cardioversion at the presence of normal sinus rhythm at 4 weeks. 

Description:

The goal of the trial was to evaluate delayed compared with early cardioversion among patients with recent-onset atrial fibrillation.


Study Design

  • Randomized
  • Parallel

Patients with new-onset atrial fibrillation were randomized to delayed cardioversion (n = 218) versus early cardioversion (n = 219). Patients randomized to delayed cardioversion received rate controlling agents and underwent cardioversion in 48 hours, if needed. Transesophageal echocardiography was not performed in any patient. Long-term anticoagulation was recommended according to the patient’s estimated stroke risk.

  • Total number of enrollees: 437
  • Duration of follow-up: 4 weeks
  • Mean patient age: 65 years
  • Percentage female: 40%
  • Percentage with diabetes: 10%

Inclusion criteria:

  • Onset of atrial fibrillation <36 hours
  • Hemodynamically stable

Other salient features/characteristics:

  • In the delayed cardioversion group, 69% spontaneously converted to normal sinus rhythm before 48 hours

Principal Findings:

The primary outcome, presence of normal sinus rhythm at 4 weeks, occurred in 91% of the delayed cardioversion group compared with 94% of the early cardioversion group (p = 0.005 for noninferiority).

Secondary outcomes:

  • Ischemic stroke or transient ischemic attack: one patient in the delayed group vs. one patient in the early group
  • Cardiovascular complications: 10 patients in the delayed group vs. eight patients in the early group

Interpretation:

Among patients with recent-onset atrial fibrillation, delayed cardioversion was noninferior to early cardioversion at maintaining atrial fibrillation at 4 weeks. Spontaneous cardioversion occurred in the majority of patients randomized to a delayed strategy before electrical or pharmacological cardioversion was required. This trial does not apply to patients in whom the duration of atrial fibrillation is unknown. Regardless of whether a rate or rhythm control strategy is selected, the patient’s risk for stroke needs to be estimated and anticoagulation initiated, if appropriate.


References:

Pluymaekers NA, Dudink EA, Luermans JG, et al., on behalf of the RACE 7 ACWAS Investigators. Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation. N Engl J Med 2019;380:1499-508.

Editorial: Healey JS, McIntyre WF. The RACE to Treat Atrial Fibrillation in the Emergency Department. N Engl J Med 2019;380:1578-9.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Noninvasive Imaging, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Echocardiography/Ultrasound

Keywords: Anti-Arrhythmia Agents, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Brain Ischemia, Echocardiography, Transesophageal, Electric Countershock, Ischemic Attack, Transient, Secondary Prevention, Risk, Secondary Prevention, Stroke, Thrombolytic Therapy, Vascular Diseases


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