Electrical vs. Pharmacological Cardioversion for ED Patients With Acute AF - RAFF2

Feb 24, 2020
Font Size
A
A
A
Author/Summarized by Author:
Dharam J. Kumbhani, MD, SM, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research
Date Published:
02/01/2020
Date Updated:
02/24/2020
Original Posted Date:
02/24/2020
References

Contribution To Literature:

The RAFF2 trial showed that a procainamide infusion + shock approach is similar to a shock first approach among low-risk patients presenting to the ED with acute onset of AF.

Description:

The goal of the trial was to compare the safety and efficacy of procainamide + electrical cardioversion (DCCV) vs. DCCV alone among patients presenting with acute atrial fibrillation (AF) to the emergency department (ED). Further, among patients requiring DCCV, they sought to assess if anterolateral and anteroposterior positioning of the pads was equally efficacious and safe.

Study Design

Eligible patients with acute AF were randomized in a 1:1 factorial design to:

Protocol 1: Attempted pharmacological cardioversion with intravenous procainamide (15 mg/kg over 30 minutes) followed by electrical cardioversion (up to three shocks each of ≥200 J) if necessary (n = 204) vs. placebo infusion followed by electrical cardioversion (n = 192).

Protocol 2: Among patients requiring DCCV after 30 minutes of Protocol 1, an open-label comparison of the anterolateral (n = 127) versus anteroposterior (n = 117) pad positions was performed.

  • Total screened: 11,096
  • Total number of enrollees: 1,996
  • Duration of follow-up: in-hospital
  • Mean patient age: 60 years
  • Percentage female: 34%

Inclusion criteria:

  • Stable patients presenting with a primary diagnosis of acute AF of at least 3 hours’ duration
  • Symptoms necessitated early management
  • Pharmacological or electrical cardioversion considered an appropriate and safe option

Exclusion criteria:

  • Permanent AF
  • Deemed hemodynamically unstable and required immediate cardioversion (including patients with hypotension [systolic blood pressure <100 mm Hg], rapid ventricular pre-excitation, acute coronary syndrome, or pulmonary edema)
  • Primary presentation for another condition (e.g., pneumonia, pulmonary embolism, sepsis)
  • Converted spontaneously before randomization

Other salient features/characteristics:

  • Duration of arrhythmia: 15 hours
  • CHADS2 score ≥2: 44%
  • Baseline medications: oral anticoagulants: 33%, antiarrhythmia drugs: 6.5%, antiplatelets: 27%

Principal Findings:

The primary outcome for drug + shock vs. shock alone, conversion to normal sinus rhythm (NSR), was 96% vs. 92% (p = 0.07).

The primary outcome for anterolateral vs. anteroposterior placement of pads, conversion to NSR, was 94% vs. 92% (p = 0.68).

Secondary outcomes for drug + shock vs. shock alone:

  • Conversion by drug alone: 52% vs. 9%
  • ED length of stay: 7.1 vs. 7.6 hours (p = 0.42)
  • Subset with 14-day electrocardiogram (78%): NSR: 95% vs. 95%
  • Return to ED for AF/atrial flutter: 10% vs. 11%

Secondary outcomes for anterolateral vs. anteroposterior placement of pads:

  • Adverse events: 10% vs. 10% (p = 0.97)

Interpretation:

The results of this trial indicate that a drug + shock approach is similar to a shock first approach among low-risk patients presenting to the ED with acute onset of AF; approximately 50% of patients converted to NSR in the drug + shock approach with intravenous procainamide alone. Both approaches were felt to be relatively safe. Among patients needing cardioversion, placement of pads in anterolateral or anteroposterior position resulted in similar efficacy. These results are helpful for clinicians—unclear if propafenone, flecainide, or ibutilide would have similar efficacy and safety as procainamide.

References:

Stiell IG, Sivilotti MI, Taljaard M, et al. Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial. Lancet 2020;395:339-49.

Editorial Comment: Costantino G, Solbiati M. Atrial fibrillation cardioversion in the emergency department. Lancet 2020;395:313-4.

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

Keywords: Anticoagulants, Arrhythmia, Sinus, Arrhythmias, Cardiac, Anti-Arrhythmia Agents, Atrial Fibrillation, Atrial Flutter, Electric Countershock, Electrocardiography, Emergency Service, Hospital, Length of Stay, Procainamide, Secondary Prevention


< Back to Listings