The wait-and-see approach involved giving rate control medications and eventual cardioversion if the AF was not resolved by 48 hours.
The primary endpoint was the presence of sinus rhythm at 4 weeks. However, there were other important secondary measures they captured such as rate of spontaneous resolution, resource utilisation, recurrence of AF, safety etc.
By 4 weeks both groups were about the same and within their prespecified non-inferiority margin. Sinus rhythm was present in 91% of the delayed group vs. 94%.
So, it doesn’t matter?
Perhaps it does… In the delayed group, the rate of spontaneous resolution was 70%! This begs the question, why do we bother with such an early aggressive approach to AF when it very often spontaneously resolves. Can we limit the potential harms of antiarrhythmic medications and procedural sedations and let nature take its course?
These findings are consistent with prior research… Doyle B et al. Heck, I may not ever get published in the NEJM but at least I have been referenced!
What do I do?
This is the time for shared decision making. Pull up a chair and have a chat to the patient. It also depends on how symptomatic the patient is, their prior experiences, rates of recurrence, and dare I say, a busy department.
Quick… don’t just do something, stand there!
Covering: Pluymaekers N, Crazy Dutch Name, Dudink J, Luermans J, et al. Early or Delayed Cardioversion in Recent-Onset of Atrial Fibrillation. N Engl J Med 2019;380:1499-1508. [link to article]
Dr Brian Doyle is an emergency physician originally from the United States but now very much calls Tasmania his home. Unfortunately, it will now be a bit more difficult to deport him from the country as he passed his Australian citizenship test a few years ago. (He was able to answer that Phar Lap won the Melbourne rather than the Davis Cup). His main interests are mostly the clinical aspects of emergency medicine but also in education, ultrasound and critical appraisal of the literature. He spends much of his time annoying people to help out with conferences.