Physicians' Academy for Cardiovascular Education

Delayed cardioversion non-inferior to early cardioversion in recent-onset AF

Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation

Literature - Pluymaekers NAHA, Dudink EAMP, Luermans JGLM et al. - New Eng J Med 2019: DOI: 10.1056/NEJMoa1900353

Introduction and methods

Patients with recent-onset symptomatic atrial fibrillation (AF) are commonly treated immediately with pharmacologic or electrical cardioversion to restore sinus rhythm [1-3]. However, it is unclear whether immediate restoration of sinus rhythm is necessary, since AF often ends spontaneously [4-9]. A wait-and-see strategy consisting of administration of rate-control drugs and delayed cardioversion only if necessary may prevent hospitalization and overtreatment. This non-inferiority trial compared a wait-and-see approach to early cardioversion for achieving sinus rhythm in patients with recent-onset symptomatic AF.

The randomized RACE 7 ACWAS (Rate Control versus Electrical Cardioversion Trial 7–Acute Cardioversion versus Wait and See) trial was conducted in the cardiology departments of 15 hospitals in the Netherlands. Adults (aged ≥18 years) who had presented to the emergency department with hemodynamically stable, symptomatic, recent-onset (<36 hours), first-detected or recurrent AF, without signs of myocardial ischemia or a history of persistent AF (lasting >48 hours) were enrolled from October 2014 through September 2018. After enrollment, 437 participants were randomized 1:1 to either the wait-and-see approach (delayed-cardioversion group) (n=218) or to usual care of early cardioversion (early-cardioversion group) (n=219). The wait-and-see approach consisted of treatment with rate-control drugs, which were given in increasing doses to obtain relief of symptoms and a heart rate of ≤110 beats/min, and delayed cardioversion if needed. Early conversion consisted of pharmacologic cardioversion, preferably with flecainide. In case of contraindications to or previously unsuccessful pharmacologic cardioversion, electrical cardioversion was done.

The primary endpoint was the presence of sinus rhythm on ECG recorded at 4 weeks. At 4 weeks, quality of life (QoL) was assessed using the Atrial Fibrillation Effect on QoL questionnaire (AFEQT), with scores ranging from 0-100 and higher scores indicating a better QoL.

Main results

Delayed vs. early cardioversion and endpoints

Treatment effects of delayed vs. early cardioversion

Delayed cardioversion non-inferior to early cardioversion in recent-onset AF


This randomized trial showed non-inferiority of a wait-and-see strategy, consisting of treatment with rate-control drugs and later cardioversion if needed, when compared to early cardioversion, in achieving sinus rhythm at 4 weeks after index visit among patients presenting to the emergency department with recent-onset symptomatic AF. In patients with delayed cardioversion, spontaneous conversion was frequently observed, which reduced the need for immediate pharmacologic or electrical cardioversion.


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