Atrial Fibrillation: Pharmacological vs Electrical

Hey guys. Hopefully better late than never! I am on virtual Journal Club this month. Thanks Pierre for the reminder.

In the busy Muskoka ED department. Patients coming in with atrial fibrillation requiring cardioversion. Chemical vs Electrical vs combination of both. Which option allows for the best outcome and what allows for me to keep the best flow in the department?

Electrical versus pharmacological cardioversion for emergency department patients with acute atrial brillation (RAFF2):
a partial factorial randomised trial

Lancet 2020; 395: 339–49

The Question:

1. compare the sinus conversion of pharmacological cardioversion followed by electrical cardioversion to electrical cardioversion along
2. effectiveness anteroposterior vs anterolateral pad placement

Methods:
Group 1: procainamide 15mg/kg (max 1500mg over 30min) wait 30minutes and then electrical cardioversion vs placebo infusion and then electrical cardioversion. Around 200 patients assigned to each group.

Results:
96% of patients in drug-shock group converted vs 92% in the shock group. 52% in the drug shock group converted after infusion (in the drug-shock group) and 9% after the placebo infusion.

Adverse events: transient hypotension more common in the drug-shock group (resolved with fluids) and one cardiac arrest in the shock only group (not synchronized cardioversion)

Time in the ED:
Similar in both groups (however, electrical cardioversion received placebo infusion, so likely not accurate representation)

For Pad placement: no different between anteroposterior vs anterolateral.

For more intense analysis of the article check out RebelEM: https://rebelem.com/raff2-electrical-vs-pharmacological-cardioversion-for-ed-patients-with-acute-atrial-fibrillation/

Question:
So… would you use procainamide infusion and potentially save 50% of the Afib procedural sedations in the department?