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A randomized, controlled comparison of electrical versus pharmacological cardioversion for emergency department patients with acute atrial flutter

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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.

Résumé

Contexte

Le flutter auriculaire aigu a un dixième de la prévalence de la fibrillation auriculaire aiguë aux services d’urgence (SU) mais partage de nombreuses stratégies de gestion. Notre objectif était de comparer la conversion du flutter auriculaire aigu en rythme sinusal entre la cardioversion pharmacologique suivie de la cardioversion électrique (Drug-Shock) et la cardioversion électrique seule (Shock-Only).

Méthodes

Nous avons effectué une comparaison randomisée, en aveugle et contrôlée par placebo d’une tentative de cardioversion pharmacologique avec le procaïnamide IV suivie d’une cardioversion électrique si nécessaire, et une perfusion de placebo suivie d’une cardioversion électrique. Nous avons inscrit des patients stables avec un diagnostic primaire de flutter auriculaire aigu aigu dans 11 services d’urgence universitaires. Le résultat principal était la conversion à un rythme sinusal normal.

Résultats

De juillet 2013 à octobre 2018, nous avons inscrit 76 patients qui ont tous poursuivi le suivi médical jusqu’au terme prévu. En comparant le groupe Drug-Shock au groupe Shock-Only, la conversion au rythme sinusal s’est produite dans 33 (100%) contre 40 (93%) (différence absolue 7,0%; IC à 95% − 0.6 à 14,6; P = 0,25). Le temps médian de conversion depuis le début de la perfusion dans le groupe Drug-Shock était de 24 min (IQR 21–82) mais seulement 9 (27%) cas ont converti avec le procaïnamide IV. Les patients des deux groupes ont eu des résultats similaires à 14 jours; il n’y a pas eu d’accident vasculaire cérébral ni de décès.

Interprétation

Cet essai a révélé que la stratégie Drug-Shock s’est avérée potentiellement supérieure, mais quelle que soit l’approche du contrôle immédiat du rythme cardiaque aux urgences pour les patients atteints de flutter auriculaire aigu aigu, elles sont, tous les deux, très efficaces, rapides et sûres pour rétablir le rythme sinusal et permettre aux patients de rentrer chez eux et reprendre leurs activités normales. Contrairement au cas de la fibrillation auriculaire, nous avons constaté que le procaïnamide IV seul était rarement efficace.

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Acknowledgements

We gratefully acknowledge the invaluable assistance of the following individuals from the study sites: Hôpital de l’Enfant-Jésus (Quebec, Quebec): Suzy Lavoie, RN; Institut de Cardiologie de Montréal (Montreal, Quebec): Véronique Roy, RN; Hôpital du Sacré-Coeur de Montréal (Montreal, Quebec): Chantal Lanthier, RN; Kingston Health Sciences Centre (Kingston, Ontario): Nicole O’Callaghan, MSc, Vlad Latiu, MD; Mount Sinai Hospital (Toronto, Ontario): Shelley McLeod, MSc, Cameron Thompson, MSc; Foothills Medical Centre (Calgary, Alberta): Heidi Boyda, PhD, Tristan Holotnak, BSc, MPH, Katrina Koger, BSc; University of Alberta Hospital (Edmonton, Alberta): Natalie Runham, RN, Pamela Pang, RN; Vancouver General Hospital: Vi Ho, MD, Rupinder Brar, MD. In addition, we thank the following individuals from the coordinating centre in Ottawa, Ontario: Ottawa Hospital Research Institute: Angela Marcantonio, Tami Clavet RN, Maureen Lowe RN, Elias Horner, Kelsey Seal, Laura Salter, Kassidy Rideout, Matthew Lukasik, Emma Lee, and James-Jules Linton; Ottawa Methods Centre: My-Linh Tran, Helen Wang, and Dong Vo. We are also very grateful to the hundreds of ED nurses and physicians whose efforts made this project very successful.

Funding

This study was funded by peer-reviewed grants from the Heart and Stroke Foundation of Canada (G-13–0002756) and the Canadian Institutes of Health Research (MOP-142226). ClinicalTrials.gov Identifier: NCT01891058; Sponsor: Ottawa Hospital Research Institute. Dr. Perry is supported by a Mid-Career Investigator Award from the Heart and Stroke Foundation of Ontario. Dr. Hohl is supported by a Michael Smith Foundation Health Professional Investigator award. Dr. Thiruganasambandamoorthy was supported by a Heart and Stroke National New Investigator Award and is currently supported by Physician’ Services Incorporated Foundation Mid-Career Clinical Researcher Award. The funding agencies had no role in the study design, collection, analysis, or manuscript preparation. Peer-reviewed grants from Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research.

Author information

Authors and Affiliations

  1. Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada

    Ian G. Stiell, Venkatesh Thiruganasambandamoorthy & Jeffrey J. Perry

  2. Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada

    Ian G. Stiell, Venkatesh Thiruganasambandamoorthy & Jeffrey J. Perry

  3. Department of Emergency Medicine, Queen’s University, Kingston, ON, Canada

    Marco L. A. Sivilotti & Robert J. Brison

  4. Clinical Epidemiology Program, Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada

    Monica Taljaard

  5. Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada

    David Birnie

  6. Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada

    Alain Vadeboncoeur & Laurent Macle

  7. Department of Emergency Medicine, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada

    Corinne M. Hohl

  8. Department of Emergency Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada

    Andrew D. McRae

  9. Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, AB, Canada

    Brian H. Rowe

  10. Department of Family Medicine and Emergency Medicine, Université de Montréal, Montréal, QC, Canada

    Judy Morris

  11. Division of Emergency Medicine, Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada

    Bjug Borgundvaag

  12. Department of Family Medicine and Emergency Medicine, Centre de Recherche du CHU de Québec, Université Laval, Québec, QC, Canada

    Eric Mercier

  13. Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada

    Catherine M. Clement, Jennifer Brinkhurst, Erica Brown & Marie-Joe Nemnom

  14. University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada

    George A. Wells

Authors
  1. Ian G. Stiell
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  2. Marco L. A. Sivilotti
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  3. Monica Taljaard
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  4. David Birnie
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  9. Eric Mercier
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  10. Laurent Macle
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  15. Catherine M. Clement
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  16. Jennifer Brinkhurst
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  18. Marie-Joe Nemnom
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  19. George A. Wells
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  20. Jeffrey J. Perry
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Contributions

The author contributions were as follows: IS and JP conceived the idea and prepared the manuscript and secured research funding. CC managed the budget, contracts, and personnel. JB coordinated the study and supervised data collection. JB, and EB supervised in the recruitment of patients and management of data. MT and M-JN conducted the statistical analyses. All authors supervised the conduct of the trial and data collection or drafted the manuscript and/or contributed to its revision, and all approved the final version. IS is guarantor.

Corresponding author

Correspondence to Ian G. Stiell.

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Conflict of interest

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Data sharing

We do not have consent from patients or hospital research ethics boards to share individual case data. We will, however, make summary data available to corresponding investigators.

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Stiell, I.G., Sivilotti, M.L.A., Taljaard, M. et al. A randomized, controlled comparison of electrical versus pharmacological cardioversion for emergency department patients with acute atrial flutter. Can J Emerg Med 23, 314–324 (2021). https://doi.org/10.1007/s43678-020-00067-7

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  • DOI: https://doi.org/10.1007/s43678-020-00067-7

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