The Canadian Cardiovascular Society 2018 guideline update for atrial fibrillation – A different perspective

Stiell, Ian G.; McMurtry, M. Sean; McRae, Andrew; Parkash, Ratika; Scheuermeyer, Frank; Atzema, Clare; Skanes, Allan C.

doi:10.1017/cem.2019.399

Cited by 12 publications

(9 citation statements)

References 28 publications

(35 reference statements)

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“…Recent guideline changes apply equally to both arrhythmias and consider the safety of cardioversion as well as the need for post-discharge anticoagulation [24,25]. Physicians should be familiar with current recommendations [26]. Future studies may compare the relative effectiveness and safety of managing acute atrial flutter with electrical cardioversion versus other drugs.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2021

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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. Keywords Emergency department • Atrial flutter • Cardioversion • Procainamide RésuméContexte 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).

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Section: Discussionmentioning

confidence: 99%

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

et al. 2021

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“…Early in 2021 the same Checklist Advisory Committee reconvened (with one additional academic cardiologist) to discuss updates based upon new evidence [3,4,11], the 2018 and 2020 CCS guidelines [12,13], and several commentaries that had expressed the concern of the Canadian ED community [14,15]. The Advisory Committee met twice virtually and reached consensus on updates through repeated email exchanges.…”

Section: Background and Methodsmentioning

confidence: 99%

2021 CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist

et al. 2021

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A. Assessment and risk stratification 1. Is AF/AFL with rapid ventricular response a primary arrhythmia or secondary to medical causes? A. Rapid rate secondary to medical causes (usually in patients with pre-existing/permanent AF) e.g., sepsis, bleeding, PE, heart failure, ACS, etc.: • Investigate and treat underlying causes aggressively • Cardioversion may be harmful • Avoid aggressive rate control B. Primary arrhythmia, e.g., sudden onset of AF/AFL

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“…For patients who are CHADS-65 negative, the Canadian Cardiovascular Society has made a weak recommendation based on low-quality evidence that 4 weeks of anticoagulation may be considered after acute rhythm control by drug or shock. This is controversial and the CAEP Checklist authors believe that this recommendation ought not be considered either mandatory or the standard of care, but rather an opportunity to apply patient-focused clinical judgment [6,7].…”

Section: Which Patients Require Anticoagulation To Decrease Long-term Stroke Risk?mentioning

confidence: 99%

Just the facts: atrial fibrillation or flutter in patients who are candidates for rhythm control

2021

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Clinical scenarioA 64-year-old man presents to the emergency department (ED) with palpitations that started at rest six hours ago. He denies chest pain or shortness of breath and endorses a similar event 5 months ago that quickly resolved spontaneously. He takes perindopril for hypertension. He has a heart rate of 150 beats per minute and blood pressure 124/78 mm Hg. He looks well, is in no distress, has irregularly irregular but otherwise normal heart sounds, and a normal respiratory exam. His electrocardiogram (ECG) shows atrial fibrillation at a rate of 148 beats per minute with no signs of ischemia.

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The Canadian Cardiovascular Society 2018 guideline update for atrial fibrillation – A different perspective

Cited by 12 publications

References 28 publications

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

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

2021 CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist

Just the facts: atrial fibrillation or flutter in patients who are candidates for rhythm control

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