For Acute A-fib, Wait-and-See Approach May Spare Many Patients From Cardioversion
These practice-changing results allow more flexibility for patients and physicians, relieving the burden of crowded EDs, one observer says.
LISBON, Portugal—Patients presenting to the emergency department (ED) with new, symptomatic A-fib do not necessarily need to undergo immediate cardioversion, as is now common practice, the RACE 7 ACWAS trial indicates.
A wait-and-see approach—giving rate control medications, sending patients home, and bringing them back the next day to determine the need for cardioversion—was noninferior to immediate cardioversion in the ED in terms of the rate of sinus rhythm at 4 weeks, which was 91% in the delayed group and 94% in the immediate group (P = 0.005 for noninferiority).
Moreover, Harry Crijns, MD, PhD (Maastricht University Medical Center, the Netherlands), reported here at the European Heart Rhythm Association Congress 2019, the wait-and-see strategy was associated with more spontaneous conversions to sinus rhythm, less need for acute cardioversions, and shorter overall time spent in the ED, without safety concerns or detriments to quality of life.
“Cardioversion, along with its potential complications, may be avoided with the wait-and-see strategy, and also, the burden to the emergency department can be significantly reduced,” Crijns said during his presentation.
“Furthermore, spontaneous conversions of atrial fibrillation to sinus rhythm may be observed, which leads to fewer misclassifications of persistent atrial fibrillation, and that may enhance appropriate rhythm control in patients with atrial fibrillation,” he said. Additionally, Crijns said, patients who have their A-fib resolve without cardioversion “may broaden their insight into treatment options” and realize “that they have a choice.”
The findings were published simultaneously online in the New England Journal of Medicine, with lead authors Nikki Pluymaekers, MD, and Elton Dudink, MD, PhD (both Maastricht University Medical Center).
Immediate Cardioversion Frequently Performed
It’s common for patients presenting with symptomatic A-fib to undergo immediate pharmacological or electrical cardioversion to get back into sinus rhythm, but it’s not clear whether that’s necessary because A-fib often goes away spontaneously.
RACE 7 ACWAS trial, conducted at 15 Dutch hospitals, was designed to explore that question. It included 437 adult patients (mean age 65 years; 40% women) with recent-onset, hemodynamically stable, and symptomatic A-fib of less than 36 hours.
Those randomized to the wait-and-see approach initially received rate control medication, after which they were discharged home and asked to come back the next day for an ECG. If the A-fib hadn’t resolved within 48 hours, the patients underwent cardioversion. In the other arm of the trial, immediate cardioversion was performed using medications, preferably flecainide, with electrical cardioversion used if there were contraindications to that approach or if patients were not responding or had not responded to drug cardioversion. All patients were assessed for stroke risk and started on appropriate oral anticoagulation if they were not already receiving treatment.
The wait-and-see approach was noninferior to the early cardioversion for the primary endpoint of sinus rhythm at 4 weeks. Patients in the delayed arm spontaneously converted to sinus rhythm within 48 hours in 69% of cases, with 28% of patients requiring cardioversion. In the immediate group, conversion occurred spontaneously in just 16% and after treatment in 78%.
Hospitalization during the index presentation was infrequent in both groups—only three patients in the wait-and-see group and five in the early group were admitted. The median duration of the index visit (which included the next-day visit for the ECG in the wait-and-see group) was shorter in the wait-and-see group (120 vs 158 minutes).
Patients in both groups fared similarly during follow-up, with 7% of each group visiting the ED because of recurrent A-fib. Cardiovascular complications were infrequent, occurring in 10 and eight patients in the wait-and-see and immediate groups, respectively. There were no deaths and no differences in disease-specific quality of life.
Among the subset of patients who completed remote monitoring during the 4 weeks of follow-up recurrence of A-fib was observed in 30% of patients in the wait-and-see group and 29% of those in the early cardioversion group.
An Attractive Approach
Commenting for TCTMD, Roy Beinart, MD (Sheba Medical Center, Tel Hashomer, Israel), who served as a discussant following Crijns’ presentation, said the wait-and-see approach is attractive both for patients and for healthcare systems.
Patients who come to the ED with symptomatic A-fib are in a panic, Beinart said, “and if you see them and you say, ‘It’s fine, most probably you’ll be converted to sinus rhythm by yourself. Let’s see you tomorrow,’ it’s a reassuring message.”
For hospitals, Beinart said, the need to perform acute cardioversions in the ED is resource-intensive, and if it can be avoided in some cases, it would lighten the burden and improve workflow.
Asked whether the wait-and-see approach should be implemented more widely, Beinart stressed the importance of bringing the patient into the decision-making process. This is another option for treatment, but the approach “has to be aligned with the patient perspective and his wishes,” he said, adding that some patients might prefer to go the standard route.
“I think that some of the patients will not like the issue of not being treated immediately for the disorder and being discharged and followed up the next day, but I would say that the great proportion of patients will consider this kind of [wait-and-see] approach,” Beinart said.
Still, he said, this trial will likely help push recommendations in the guidelines toward this strategy.
In an accompanying editorial, Jeff Healey, MD, and William McIntyre, MD (both Population Health Research Institute, McMaster University, Hamilton, Canada), say the trial findings “greatly simplify the current controversy regarding the safety of cardioversion between 12 and 48 hours after the onset of atrial fibrillation.”
The wait-and-see approach may become the favored strategy for most patients with recent-onset A-fib, “unless they have a history of persistent atrial fibrillation or there are barriers to implementing this approach,” they add.
On the other hand, Healey and McIntyre say, “Early cardioversion remains an option for patients who have had atrial fibrillation for more than 36 hours if they are receiving long-term anticoagulation, have been classified as low risk on transesophageal echocardiography, or have a low risk of stroke and atrial fibrillation with a duration of 36 to 48 hours. Early cardioversion remains an option for any patient with hemodynamic instability.”
Pluymaekers NAHA, Dudink EAMP, Luermans JGLM, et al. Early or delayed cardioversion in recent-onset atrial fibrillation. N Engl J Med. 2019;Epub ahead of print.
Healey JS, McIntyre WF. The RACE to treat atrial fibrillation in the emergency department. N Engl J Med. 2019;Epub ahead of print.
- The study was supported by a grant from the Netherlands Organization for Health Research and Development-Health Care Efficiency Research Program and by the Maastricht University Medical Center. Boehringer Ingelheim provided some of the remote monitoring devices.
- Crijns reports receiving grants from the Dutch Heart Foundation.
- Healey reports receiving grants and personal fees from Bristol-Myers Squibb/Pfizer, Medtronic, and Boston Scientific and personal fees from Servier.
- McIntyre reports receiving personal fees from Servier, Bayer, and Bristol-Myers Squibb/Pfizer.
- Beinart reports no relevant conflicts of interest.