Electrical or Chemical Cardioversion for Atrial Fibrillation in the Emergency Department?

Emergency department (ED) management of patients with atrial fibrillation (AF) is highly variable. As part of a sustained effort to determine best practices, this research group compared pharmacologic cardioversion followed by electrical cardioversion, if needed, versus electrical cardioversion alone.

Stable adult ED patients with acute AF (clear symptom onset 3–48 hours prior to arrival or 3–168 hours prior to arrival if anticoagulated for at least 4 weeks) were randomized to infusions of procainamide (15 mg/kg) or a placebo given over 30 minutes. Patients with persistent AF 30 minutes after the infusion ended received up to three biphasic shocks of at least 200 J each. The main outcome was achievement of sinus rhythm for at least 30 minute…