Clinical Research in Cardiology

, Volume 102, Issue 10, pp 713–723 | Cite as

Types and outcomes of cardioversion in patients admitted to hospital for atrial fibrillation: results of the German RHYTHM-AF Study

  • Anselm K. Gitt
  • Wenefrieda Smolka
  • Galin Michailov
  • Alexandra Bernhardt
  • David Pittrow
  • Thorsten Lewalter
Original Paper



Atrial fibrillation (AF) accounts for approximately one-third of hospitalizations for cardiac rhythm disturbances. Little is known about the characteristics of current use of cardioversion (CV) and its success rates in clinical practice in Germany.


As part of the international RHYTHM-AF Study, 655 consecutive patients with documented AF (mean age 68.3 ± 10.5 years, 64.9 % males) who were considered candidates for CV were prospectively enrolled in 22 German hospitals (21 academic/teaching and 1 non-teaching). CV was considered successful if sinus rhythm or atrial rhythm was obtained within 1 day after start of pharmacological CV (PCV) or if sinus rhythm was achieved and maintained for at least 10 min after electrical CV (ECV).


Patients with AF considered for CV had ECG in 94.4 %, Holter ECG in 25.8 %, and transesophageal echocardiography (TEE) in 73.1 % of cases. They underwent ECV (after mean 16 h, range 4–48), in 65.3 % and PCV in 6.7 % of patients (amiodarone in 47.7 %, flecainide in 27.3 %, propafenone in 2.3 %) as first CV procedure. No CV was performed in 27.9 %, mainly due to spontaneous CV or pathologic TEE. Primary success rates were 86.7 % for electrical CV and 54.5 % for pharmacological CV. More patients in the ECV group compared to the PCV group received oral anticoagulation at discharge (79.2 vs. 59.1 %, p < 0.001), and at 60 days (77.5 vs. 56.8 %, p < 0.001). Further, at 60 days the proportion of patients in sinus rhythm was not different between groups (ECV 76.8 % vs. PCV 77.3 %).


In large academic centres in Germany, the preferred CV method is electrical, mainly due to its easy access and to its higher success rate for the initial restoration of sinus rhythm. Considering the limitations of the open-label, non-randomised study design, overall short-term success rates appeared higher after ECV compared to PCV during hospitalisation, but not after 60 days.


Atrial fibrillation Observational Registry Pharmacological conversion Electrical conversion Outcomes 



The study was financially supported by Merck & Co., Inc., and its subsidiaries. The Institut für Herzinfarktforschung Ludwigshafen received grant/research support from Merck to collect and analyse the data of this study.

Conflict of interest

A.K.G. has been a consultant for and served on the speakers’ bureau of MSD. D.P. and T.L. have provided consultancy for MSD and other manufacturers of cardiovascular drugs. W.S. and G.M. are full-time employees of MSD Germany. A.B. states that there is no conflict of interest.


  1. 1.
    Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al (2006) ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol 48:e149–e246CrossRefGoogle Scholar
  2. 2.
    Friberg J, Buch P, Scharling H, Gadsbphioll N, Jensen GB (2003) Rising rates of hospital admissions for atrial fibrillation. Epidemiology 14:666–672PubMedCrossRefGoogle Scholar
  3. 3.
    Kirch W, Pittrow D, Bosch RF, Kohlhaussen A, Willich SN, Rosin L et al (2010) Health-related quality of life of patients with atrial fibrillation managed by cardiologists: MOVE study. Dtsch Med Wochenschr 135(Suppl 2):S26–S32PubMedCrossRefGoogle Scholar
  4. 4.
    Vidaillet H, Granada JF, Chyou PH, Maassen K, Ortiz M, Pulido JN et al (2002) A population-based study of mortality among patients with atrial fibrillation or flutter. Am J Med 113:365–370PubMedCrossRefGoogle Scholar
  5. 5.
    Wang TJ, Larson MG, Levy D, Vasan RS, Leip EP, Wolf PA et al (2003) Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. Circulation 107:2920–2925PubMedCrossRefGoogle Scholar
  6. 6.
    Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S et al (2010) Guidelines for the management of atrial fibrillation: The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 31:2369–2429PubMedCrossRefGoogle Scholar
  7. 7.
    Crijns H, Bash L, Chazelle F, Le Heuzey J, Lewalter T, Lip G et al (2012) RHYTHM-AF: design of an international registry on cardioversion of atrial fibrillation and characteristics of participating centers. BMC Cardiovasc Disord 12:85PubMedCrossRefGoogle Scholar
  8. 8.
    Nieuwlaat R, Capucci A, Camm AJ, Olsson SB, Andresen D, Davies DW et al (2005) Atrial fibrillation management: a prospective survey in ESC Member Countries: the Euro Heart Survey on Atrial Fibrillation. Eur Heart J 26:2422–2434PubMedCrossRefGoogle Scholar
  9. 9.
    Bonnemeier H, Bosch RF, Kohlhaussen A, Rosin L, Willich SN, Pittrow D et al (2011) Presentation of atrial fibrillation and its management by cardiologists in the ambulatory and hospital setting: MOVE cross-sectional study. Curr Med Res Opin 27:995–1003PubMedCrossRefGoogle Scholar
  10. 10.
    Bosch RF, Kirch W, Theuer JD, Pittrow D, Kohlhaussen A, Willich SN et al (2012) Atrial fibrillation management, outcomes and predictors of stable disease in daily practice: Prospective non-interventional study. Int J Cardiol doi: 10.1016/j.ijcard.2012.03.053 (online first)
  11. 11.
    Nabauer M, Gerth A, Limbourg T, Schneider S, Oeff M, Kirchhof P et al (2009) The Registry of the German Competence NETwork on Atrial Fibrillation: patient characteristics and initial management. Europace 11:423–434PubMedCrossRefGoogle Scholar
  12. 12.
    Van Gelder IC, Crijns HJ, Tieleman RG, Brugemann J, De Kam PJ, Gosselink AT et al (1996) Chronic atrial fibrillation. Success of serial cardioversion therapy and safety of oral anticoagulation. Arch Intern Med 156:2585–2592PubMedCrossRefGoogle Scholar
  13. 13.
    Burton JH, Vinson DR, Drummond K, Strout TD, Thode HC, McInturff JJ (2004) Electrical cardioversion of emergency department patients with atrial fibrillation. Ann Emerg Med 44:20–30PubMedCrossRefGoogle Scholar
  14. 14.
    Page RL, Kerber RE, Russell JK, Trouton T, Waktare J, Gallik D et al (2002) Biphasic versus monophasic shock waveform for conversion of atrial fibrillation: the results of an international randomized, double-blind multicenter trial. J Am Coll Cardiol 39:1956–1963PubMedCrossRefGoogle Scholar
  15. 15.
    Mittal S, Ayati S, Stein KM, Schwartzman D, Cavlovich D, Tchou PJ et al (2000) Transthoracic cardioversion of atrial fibrillation: comparison of rectilinear biphasic versus damped sine wave monophasic shocks. Circulation 101:1282–1287PubMedCrossRefGoogle Scholar
  16. 16.
    Kirchhof P, Eckardt L, Loh P, Weber K, Fischer RJ, Seidl KH et al (2002) Anterior–posterior versus anterior–lateral electrode positions for external cardioversion of atrial fibrillation: a randomised trial. Lancet 360:1275–1279PubMedCrossRefGoogle Scholar
  17. 17.
    Meinertz T, Kirch W, Rosin L, Pittrow D, Willich SN, Kirchhof P (2011) Management of atrial fibrillation by primary care physicians in Germany: baseline results of the ATRIUM registry. Clin Res Cardiol 100:897–905PubMedCrossRefGoogle Scholar
  18. 18.
    Wasmer K, Kobe J, Dechering D, Milberg P, Pott C, Vogler J et al (2013) CHADS(2) and CHA(2)DS (2)-VASc score of patients with atrial fibrillation or flutter and newly detected left atrial thrombus. Clin Res Cardiol 102:139–144PubMedCrossRefGoogle Scholar
  19. 19.
    Kleemann T, Becker T, Strauss M, Schneider S, Seidl K (2009) Prevalence of left atrial thrombus and dense spontaneous echo contrast in patients with short-term atrial fibrillation <48 hours undergoing cardioversion: value of transesophageal echocardiography to guide cardioversion. J Am Soc Echocardiogr 22:1403–1408PubMedCrossRefGoogle Scholar
  20. 20.
    Seidl K, Rameken M, Drogemuller A, Vater M, Brandt A, Schwacke H et al (2002) Embolic events in patients with atrial fibrillation and effective anticoagulation: value of transesophageal echocardiography to guide direct-current cardioversion. Final results of the Ludwigshafen Observational Cardioversion Study. J Am Coll Cardiol 39:1436–1442PubMedCrossRefGoogle Scholar
  21. 21.
    Seidl K, Senges J (2003) Cardioversion related thromboembolism: value of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. Card Electrophysiol Rev 7:392–396PubMedCrossRefGoogle Scholar
  22. 22.
    Hendriks JM, de Wit R, Crijns HJ, Vrijhoef HJ, Prins MH, Pisters R et al (2012) Nurse-led care vs. usual care for patients with atrial fibrillation: results of a randomized trial of integrated chronic care vs. routine clinical care in ambulatory patients with atrial fibrillation. Eur Heart J 33:2692–2699PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Anselm K. Gitt
    • 1
    • 2
  • Wenefrieda Smolka
    • 3
  • Galin Michailov
    • 3
  • Alexandra Bernhardt
    • 1
  • David Pittrow
    • 4
  • Thorsten Lewalter
    • 5
  1. 1.Stiftung Institut für Herzinfarktforschung LudwigshafenLudwigshafenGermany
  2. 2.Med. Klinik BHerzzentrum LudwigshafenLudwigshafenGermany
  3. 3.Medical DepartmentMSD GermanyHaarGermany
  4. 4.Institut für Klinische PharmakologieTechnische Universität DresdenDresdenGermany
  5. 5.Isar Herzzentrum MünchenMunichGermany

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