scholarly journals Procainamide for the acute management of atrial fibrillation and flutter in the emergency department: a systematic review

2020 ◽  
Vol 43 (2) ◽  
pp. 21
Author(s):  
Fiona Tran ◽  
Daniela Junqueira ◽  
Jillian Meyer ◽  
Kevin Zhou ◽  
Maria Tan ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Cohort Studies ◽  
Normal Sinus Rhythm ◽  
Data Extraction ◽  
Grey Literature ◽  
Electrical Cardioversion ◽  
Chemical Agent ◽  
Relative Risks ◽  
Normal Sinus

Introduction: Chemical or electrical cardioversion are utilized for acute atrial fibrillation or flutter (AFF) management in the emergency department (ED). Procainamide is a common chemical agent used in Canada; however, there are substantial practice variations. Method: Systematic search of five databases and grey literature completed. Randomized controlled trials (RCTs) and prospective controlled cohort studies including adults with acute AFF comparing procainamide with other cardioversion strategies were eligible. Two independent reviewers performed study selection and data extraction. Relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random-effects model. The protocol was registered with PROSPERO (CRD42019142080). Results: From 3847 potential citations, 6 studies were included (four RCTs and two cohort studies). Procainamide was less effective in achieving conversion to normal sinus rhythm (NSR) at 1st attempt compared to other chemical (RR 0.76; 95% CI: 0.65 to 0.90) and electrical (RR 0.72; 95% CI: 0.56 to 0.92) options. Procainamide in a drug-shock approach was as effective as electrical cardioversion alone in restoring NSR (RR 1.04; 95% CI 1.00 to 1.08). The occurrence of hypotension was higher in patients receiving procainamide compared to electrical cardioversion (RR 1.87; 95% CI: 1.14 to 3.06). Deaths and strokes were not well-reported. Conclusion: Procainamide is less effective than other chemical options and electrical cardioversion strategies to restore NSR. The efficacy of procainamide in a drug-shock approach is similar to electrical alone at restoring NSR. The evidence shows that hypotension is a common procainamide adverse effect suggesting that electrical cardioversion as a first approach is preferable.

scholarly journals LO07: Procainamide for the acute management of atrial fibrillation and flutter in the emergency department: a systematic review

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S9-S9
Author(s):  
F. Tran ◽  
D. Junqueira ◽  
M. Tan ◽  
B. Rowe
Keyword(s):  
Atrial Fibrillation ◽  
Systematic Review ◽  
Emergency Department ◽  
Adverse Events ◽  
Cohort Studies ◽  
Normal Sinus Rhythm ◽  
Grey Literature ◽  
Electrical Cardioversion ◽  
Chemical Agent ◽  
Serious Adverse Events

Introduction: Management of acute atrial fibrillation or flutter (AFF) in the emergency department (ED) can be performed with chemical or electrical cardioversion. Procainamide is the most common chemical agent used in Canada; however, there is substantial practice variation. The objective of this systematic review was to provide comparative evidence on return to normal sinus rhythm (NSR) and adverse events to better support clinical decisions. Methods: Systematic search of five electronic databases and grey literature. Randomized controlled trials (RCTs) and prospective controlled cohort studies including adults (≥17 years) with recent-onset of AFF comparing intravenous procainamide with other cardioversion strategies (e.g., electrical cardioversion, placebo or other antiarrhythmic drugs) were eligible. Two independent reviewers performed study selection and data extraction. Relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random-effects model. The protocol was registered with PROSPERO (CRD42019142080). Results: From 4060 potentially relevant citations, 7 studies were considered eligible and three RCTs and two cohort studies included in the analysis. Procainamide was less effective in promoting return to NSR at 1st attempt compared to other chemical (RR 0.76; 95% CI: 0.65 to 0.90) and electrical (RR 0.58; 95% CI: 0.53 to 0.64) options. Electrical cardioversion was more effective in restoring NSR compared to procainamide when used as 2nd attempt in one RCT (RR 0.46; 95% CI: 0.23 to 0.92). Pre-specified serious adverse events were assessed and reported by two studies showing that hypotension was more common in patients receiving procainamide in comparison with electrical cardioversion (RR 20.57; 95% CI: 1.59 to 265.63). Treatment discontinuation due to adverse events was infrequently reported with only two studies reporting that no patients withdrew from the study following treatment with procainamide. The remaining studies provided incomplete data reporting on adverse events. Conclusion: Shared decision-making for patients with acute AFF in the ED requires knowledge of the effectiveness and safety of comparative interventions. Overall, procainamide is less effective than other chemical options and electrical cardioversion strategies to restore NSR. Evidence shows that hypotension is a concern when procainamide is administered; however, the overall adverse events information provided from the studies is suboptimal.

scholarly journals “Wait and See” Approach to the Emergency Department Cardioversion of Acute Atrial Fibrillation

2011 ◽  
Vol 2011 ◽  
pp. 1-4 ◽  
Author(s):  
Brian Doyle ◽  
Mark Reeves
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Sinus Rhythm ◽  
Normal Sinus Rhythm ◽  
Routine Care ◽  
Spontaneous Resolution ◽  
Electrical Cardioversion ◽  
Normal Sinus ◽  
Degree Of Satisfaction ◽  
Wait And See

Objective. Acute atrial fibrillation often spontaneously resolves. This study aimed to investigate the outcomes and satisfaction of an evidence-based ED protocol employing a “wait and see” approach.Methods. A prospective observational cohort study of adult patients presenting to the Emergency Department with stable acute atrial fibrillation was performed. Patients were excluded if they were considered to be unstable, need hospitalization, or poor candidates for ED procedural sedation. Routine care was provided on the index visit, and suitable candidates were discharged and asked to return to the ED the following day for possible electrical cardioversion. Outcome measures included spontaneous reversion to sinus rhythm, success of cardioversion, length of stay, adverse event and return visits for AF within 30 days, and patient satisfaction.Results. Thirty five patient encounters were analysed over a 21-month period. Twenty two of the 35 patients (63%) had spontaneous resolution of atrial fibrillation upon presentation for potential cardioversion. All of the remaining patients underwent successful cardioversion to normal sinus rhythm without significant adverse events recorded. No patients required hospitalization. Three patients (9%) returned to the ED within 30 days for recurrence of atrial fibrillation. All patients were reported to be “very satisfied” with this approach.Conclusion. A “wait and see” approach to the ED electrical cardioversion of atrial fibrillation showed that almost two-thirds of patients had spontaneous resolution without requiring cardioversion or observation in the ED or hospital. All patients were successfully reverted to normal sinus rhythm and had a high degree of satisfaction.

scholarly journals Atrial Fibrillation Caused by Intractable Hiccups: A Unique Cause and Cure

2022 ◽  
Vol 2022 ◽  
pp. 1-4
Author(s):  
Joshua H. Arnold ◽  
Neil Brandon
Keyword(s):  
Myocardial Infarction ◽  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Normal Sinus Rhythm ◽  
Electrical Cardioversion ◽  
Traditional Treatment ◽  
Cardiac Pathology ◽  
Normal Sinus ◽  
First Time ◽  
Intractable Hiccups

We present the case of a 61-year-old male who developed persistent hiccups concurrently with the onset of atrial fibrillation (AF). The hiccups were refractory to traditional treatment but resolved immediately upon electrical cardioversion (ECV) to normal sinus rhythm (NSR). The patient has remained in NSR and free of hiccups. The potential etiologies for hiccups are numerous and varied, and the management of persistent hiccups can be difficult. Cardiac associations including myocardial infarction and pericarditis have been described, while few cases of first-time onset of atrial fibrillation leading to hiccups have been documented. This case discusses a unique instance demonstrating a connection between hiccups and cardiac pathology and an overview of its management.

scholarly journals LO100: Electrical vs chemical cardioversion in patients with acute atrial fibrillation: a multicenter parallel group randomized controlled clinical trial

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S64-S65
Author(s):  
F.X. Scheuermeyer ◽  
G. Andolfatto ◽  
J. Christenson ◽  
S. Couperthwaite ◽  
C. Villa-Roel ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Adverse Events ◽  
Health Outcomes ◽  
Normal Sinus Rhythm ◽  
Patient Characteristics ◽  
Electrical Cardioversion ◽  
Controlled Clinical Trial ◽  
Primary Method ◽  
Electrical Shock ◽  
Normal Sinus

Introduction: Patients with atrial fibrillation (AF) of <48 hours duration often present to Emergency Departments (ED). Electrical or chemical cardioversion can be employed to restore normal sinus rhythm (NSR). Current guidelines make no recommendations between these two methods and the management decisions are left to the discretion of the treating physician. The objective of this study was to compare these two approaches in terms of ED length of stay (LOS), success (conversion to NSR) and health related outcomes. Methods: At six western Canadian EDs, eligible adult patients were assigned to one of two groups following concealed allocation and using a centralized computer-generated randomization method: electrical cardioversion (EC) first (followed by chemical cardioversion [CC] if the primary method failed) or CC first (followed by EC if the primary method failed). Baseline evaluation/interview and 3/30 day telephone contact were completed and documented using the REDCap data-platform. Adverse events were externally adjudicated in a blinded-fashion. An intention to treat analysis was performed. Results: Overall, 84 patients participated in the study (EC: 43; CC: 41); the median age was 60 years (interquartile range [IQR]: 50, 66), and 38% were female. The baseline patient characteristics in both groups were similar. The median LOS between randomization and conversion to NSR (intervention LOS) was 1.0 hrs (IQR: 0.8, 2.7) in EC vs. 3.1 hrs (IQR: 2.0, 3.9) in CC (p<0.001); more patients in EC were discharged from the ED within 4 hours than in the CC group (65% vs. 32%; p=0.002). The majority of EC patients (84%) converted to NSR after the first attempt while half of the patients did so in the CC group (49%). No differences were observed in terms of adverse events (26% vs. 24%; mostly minimal), hospitalizations (0%), and patients’ health outcomes (physician/ED visits, admissions, stroke) and status (SF-8) at 3 and 30 days, in groups EC and CC groups, respectively. Conclusion: Electrical cardioversion was associated with a statistically significant and clinically meaningful reduction in the LOS when compared to cardioversion using chemical management. Similarities in the proportions of success, adverse events and health outcomes between the groups would support the use of electrical shock as the first approach for cardioversion in clinical practice.

scholarly journals Intravenous amiodarone for acute pharmacological conversion of atrial fibrillation in the emergency department

CJEM ◽  
2002 ◽  
Vol 4 (06) ◽  
pp. 414-420 ◽  
Author(s):  
Richard S. Slavik
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Normal Sinus Rhythm ◽  
High Dose ◽  
Class Iii ◽  
Recent Onset ◽  
Normal Sinus ◽  
Published Evidence ◽  
Intravenous Amiodarone ◽  
Meta Analyses

ABSTRACTAtrial fibrillation (AF) is the most common arrhythmia seen in patients presenting to the emergency department (ED). Pharmacological conversion of atrial fibrillation to normal sinus rhythm (NSR) may be a feasible management strategy in selected patients. Recent guidelines have recommended intravenous amiodarone, a class III antiarrhythmic agent, for the conversion of AF to NSR. The purpose of this review is to examine the published evidence for the efficacy of IV amiodarone for the acute conversion of AF to NSR in the ED. Currently available data from 11 randomized, controlled trials and 3 meta analyses do not support the use of conventional doses of IV amiodarone for acute conversion in the ED. High dose IV or combined IV and oral administration may be effective as early as 8 hours in patients with recent-onset AF of ≤48 hour duration in patients without contraindications to these high dose regimens. There are no data to support the use of IV amiodarone for acute conversion in patients with an ejection fraction of &lt;40% or clinical heart failure, so its use in these scenarios should be limited to symptomatic patients who are refractory to electrical conversion. More well-designed studies are required to determine the role of IV amiodarone for the acute conversion of AF in the ED.

scholarly journals A perfect refractory electrical storm by acute toxicity of accidental aconitine intake

2021 ◽  
Vol 17 (2) ◽  
Author(s):  
Francesca Menichetti ◽  
Paola Bartolucci ◽  
Maria Luisa Matteucci ◽  
Luigi Gori ◽  
Alessandra Ieri ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Direct Current ◽  
Normal Sinus Rhythm ◽  
Correct Diagnosis ◽  
Electrical Storm ◽  
Qrs Complex ◽  
Accidental Ingestion ◽  
Normal Sinus

A 51-years-old male presented with drooling, hematemesis and diarrhea in emergency department after accidental ingestion of homemade aconitine tincture. Examination revealed shock and initial ECG showed atrial fibrillation. The patient suddenly developed a pulseless wide QRS complex tachycardia requiring resuscitation maneuvers. The rhythm varied from monomorphic ventricular tachycardia to torsade de point to ventricular fibrillation. Repeated direct-current cardioversions were unsuccessful. After intravenous electrolyte correction and anti-arrhythmic drugs administration, a last direct-current shock was finally successful. Bradycardia and ventricular excitability persisted over 12 hours with gradual normalization. Patient was discharged in normal sinus rhythm without any medication and on follow-up he was totally asymptomatic. With the increasing popularity of traditional medicine, clinicians should be alerted to the risk of herbal substances with low margins of safety like Aconitum in order to allow correct diagnosis and treatment. The general public should be educated that herbal medicine is not always safe.

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