Ian G Stiell1,2, Marco L A Sivilotti3, Monica Taljaard4, David Birnie5, Alain Vadeboncoeur6, Corinne M Hohl7, Andrew D McRae8, Judy Morris9, Eric Mercier10, Laurent Macle6, Robert J Brison3, Venkatesh Thiruganasambandamoorthy11,12, Brian H Rowe13, Bjug Borgundvaag14, Catherine M Clement15, Jennifer Brinkhurst15, Erica Brown15, Marie-Joe Nemnom15, George A Wells16, Jeffrey J Perry11,12. 1. Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. istiell@ohri.ca. 2. Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada. istiell@ohri.ca. 3. Department of Emergency Medicine, Queen's University, Kingston, ON, Canada. 4. Clinical Epidemiology Program, Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada. 5. Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada. 6. Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada. 7. Department of Emergency Medicine, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada. 8. Department of Emergency Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada. 9. Department of Family Medicine and Emergency Medicine, Université de Montréal, Montréal, QC, Canada. 10. Department of Family Medicine and Emergency Medicine, Centre de Recherche du CHU de Québec, Université Laval, Québec, QC, Canada. 11. Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. 12. Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada. 13. Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, AB, Canada. 14. Division of Emergency Medicine, Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada. 15. Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada. 16. University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada.
Abstract
BACKGROUND: Acute atrial flutter has one-tenth the prevalence of acute atrial fibrillation in the emergency department (ED) but shares many management strategies. Our aim was to compare conversion from acute atrial flutter to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (Drug-Shock), and electrical cardioversion alone (Shock-Only). METHODS: We conducted a randomized, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with IV procainamide followed by electrical cardioversion if necessary, and placebo infusion followed by electrical cardioversion. We enrolled stable patients with a primary diagnosis of acute acute atrial flutter at 11 academic EDs. The primary outcome was conversion to normal sinus rhythm. FINDINGS:From July 2013 to October 2018, we enrolled 76 patients, and none were lost to follow-up. Comparing the Drug-Shock to the Shock-Only group, conversion to sinus rhythm occurred in 33 (100%) versus 40 (93%) (absolute difference 7.0%; 95% CI - 0.6 to 14.6; P = 0.25). Median time to conversion from start of infusion in the Drug-Shock group was 24 min (IQR 21-82) but only 9 (27%) cases were converted with IV procainamide. Patients in both groups had similar outcomes at 14 days; there were no strokes or deaths. INTERPRETATION: This trial found that the Drug-Shock strategy is potentially superior but that either approach to immediate rhythm control in the ED for patients with acute acute atrial flutter is highly effective, rapid, and safe in restoring sinus rhythm and allowing patients to go home and return to normal activities. Unlike the case of atrial fibrillation, we found that IV procainamide alone was infrequently effective.
RCT Entities:
BACKGROUND: Acute atrial flutter has one-tenth the prevalence of acute atrial fibrillation in the emergency department (ED) but shares many management strategies. Our aim was to compare conversion from acute atrial flutter to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (Drug-Shock), and electrical cardioversion alone (Shock-Only). METHODS: We conducted a randomized, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with IV procainamide followed by electrical cardioversion if necessary, and placebo infusion followed by electrical cardioversion. We enrolled stable patients with a primary diagnosis of acute acute atrial flutter at 11 academic EDs. The primary outcome was conversion to normal sinus rhythm. FINDINGS: From July 2013 to October 2018, we enrolled 76 patients, and none were lost to follow-up. Comparing the Drug-Shock to the Shock-Only group, conversion to sinus rhythm occurred in 33 (100%) versus 40 (93%) (absolute difference 7.0%; 95% CI - 0.6 to 14.6; P = 0.25). Median time to conversion from start of infusion in the Drug-Shock group was 24 min (IQR 21-82) but only 9 (27%) cases were converted with IV procainamide. Patients in both groups had similar outcomes at 14 days; there were no strokes or deaths. INTERPRETATION: This trial found that the Drug-Shock strategy is potentially superior but that either approach to immediate rhythm control in the ED for patients with acute acute atrial flutter is highly effective, rapid, and safe in restoring sinus rhythm and allowing patients to go home and return to normal activities. Unlike the case of atrial fibrillation, we found that IV procainamide alone was infrequently effective.
Authors: Ian G Stiell; Marco L A Sivilotti; Monica Taljaard; David Birnie; Alain Vadeboncoeur; Corinne M Hohl; Andrew D McRae; Brian H Rowe; Robert J Brison; Venkatesh Thiruganasambandamoorthy; Laurent Macle; Bjug Borgundvaag; Judy Morris; Eric Mercier; Catherine M Clement; Jennifer Brinkhurst; Connor Sheehan; Erica Brown; Marie-Joe Nemnom; George A Wells; Jeffrey J Perry Journal: Lancet Date: 2020-02-01 Impact factor: 79.321
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