R.E.B.E.L.EM - July 09, 2020 - By Salim Rezaie
Paper: Stiell IG et al. Electrical Versus Pharmacological Cardioversion for Emergency Department Patients with Acute Atrial Fibrillation (RAFF2): A Partial Factorial Randomised Trial. Lancet 2020. PMID: 32007169
"Clinical Question: Is a pharmacological cardioversion first approach more successful than an electrical cardioversion first approach in acute atrial fibrillation?
Author Conclusion: “Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes.”
Clinical Take Home Point: Both the drug-shock and shock-only strategies led to similar conversion rates and rates of discharge home. Length of stay was similar between groups; however this doesn’t reflect real-world application where a shock first approach would not get a 30 minute infusion of placebo for the purpose of blinding. Ultimately either approach is fine based on provider comfort, patient preference and departmental considerations."