Early or delayed cardioversion in recent-onset atrial fibrillation

Nikki A.h.a. Pluymaekers, Elton A.m.p. Dudink, Justin G.l.m. Luermans, Joan G. Meeder, Timo Lenderink, Jos Widdershoven, Jeroen J.j. Bucx, Michiel Rienstra, Otto Kamp, Jurren M. Van Opstal, Marco Alings, Anton Oomen, Charles J. Kirchhof, Vincent F. Van Dijk, Hemanth Ramanna, Anho Liem, Lukas R. Dekker, Brigitte A.b. Essers, Jan G.p. Tijssen, Isabelle C. Van GelderHarry J.g.m. Crijns*

*Corresponding author for this work

Research output: Contribution to journalArticleScientificpeer-review

Abstract

Background
Patients with recent-onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion. However, whether immediate restoration of sinus rhythm is necessary is not known, since atrial fibrillation often terminates spontaneously.

Methods
In a multicenter, randomized, open-label, noninferiority trial, we randomly assigned patients with hemodynamically stable, recent-onset (<36 hours), symptomatic atrial fibrillation in the emergency department to be treated with a wait-and-see approach (delayed-cardioversion group) or early cardioversion. The wait-and-see approach involved initial treatment with rate-control medication only and delayed cardioversion if the atrial fibrillation did not resolve within 48 hours. The primary end point was the presence of sinus rhythm at 4 weeks. Noninferiority would be shown if the lower limit of the 95% confidence interval for the between-group difference in the primary end point in percentage points was more than −10.


Results
The presence of sinus rhythm at 4 weeks occurred in 193 of 212 patients (91%) in the delayed-cardioversion group and in 202 of 215 (94%) in the early-cardioversion group (between-group difference, −2.9 percentage points; 95% confidence interval [CI], −8.2 to 2.2; P=0.005 for noninferiority). In the delayed-cardioversion group, conversion to sinus rhythm within 48 hours occurred spontaneously in 150 of 218 patients (69%) and after delayed cardioversion in 61 patients (28%). In the early-cardioversion group, conversion to sinus rhythm occurred spontaneously before the initiation of cardioversion in 36 of 219 patients (16%) and after cardioversion in 171 patients (78%). Among the patients who completed remote monitoring during 4 weeks of follow-up, a recurrence of atrial fibrillation occurred in 49 of 164 patients (30%) in the delayed-cardioversion group and in 50 of 171 (29%) in the early-cardioversion group. Within 4 weeks after randomization, cardiovascular complications occurred in 10 patients and 8 patients, respectively.

Conclusions
In patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.
Original languageEnglish
Pages (from-to)1499-1508
JournalNew England Journal of Medicine
Volume380
Issue number16
DOIs
Publication statusPublished - 2019

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Keywords

  • ABLATION
  • ANTICOAGULATION
  • CATHETER
  • DESIGN
  • DEVICE
  • ECHOCARDIOGRAPHY
  • GUIDELINES
  • SPONTANEOUS CONVERSION
  • STROKE
  • TEMPORAL RELATIONSHIP

Cite this

Pluymaekers, N. A. H. A., Dudink, E. A. M. P., Luermans, J. G. L. M., Meeder, J. G., Lenderink, T., Widdershoven, J., ... Crijns, H. J. G. M. (2019). Early or delayed cardioversion in recent-onset atrial fibrillation. New England Journal of Medicine, 380(16), 1499-1508. https://doi.org/10.1056/NEJMoa1900353
Pluymaekers, Nikki A.h.a. ; Dudink, Elton A.m.p. ; Luermans, Justin G.l.m. ; Meeder, Joan G. ; Lenderink, Timo ; Widdershoven, Jos ; Bucx, Jeroen J.j. ; Rienstra, Michiel ; Kamp, Otto ; Van Opstal, Jurren M. ; Alings, Marco ; Oomen, Anton ; Kirchhof, Charles J. ; Van Dijk, Vincent F. ; Ramanna, Hemanth ; Liem, Anho ; Dekker, Lukas R. ; Essers, Brigitte A.b. ; Tijssen, Jan G.p. ; Van Gelder, Isabelle C. ; Crijns, Harry J.g.m. / Early or delayed cardioversion in recent-onset atrial fibrillation. In: New England Journal of Medicine. 2019 ; Vol. 380, No. 16. pp. 1499-1508.
@article{5a5f41edcf45413ab4a93461be684ac4,
title = "Early or delayed cardioversion in recent-onset atrial fibrillation",
abstract = "BackgroundPatients with recent-onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion. However, whether immediate restoration of sinus rhythm is necessary is not known, since atrial fibrillation often terminates spontaneously.MethodsIn a multicenter, randomized, open-label, noninferiority trial, we randomly assigned patients with hemodynamically stable, recent-onset (<36 hours), symptomatic atrial fibrillation in the emergency department to be treated with a wait-and-see approach (delayed-cardioversion group) or early cardioversion. The wait-and-see approach involved initial treatment with rate-control medication only and delayed cardioversion if the atrial fibrillation did not resolve within 48 hours. The primary end point was the presence of sinus rhythm at 4 weeks. Noninferiority would be shown if the lower limit of the 95{\%} confidence interval for the between-group difference in the primary end point in percentage points was more than −10.ResultsThe presence of sinus rhythm at 4 weeks occurred in 193 of 212 patients (91{\%}) in the delayed-cardioversion group and in 202 of 215 (94{\%}) in the early-cardioversion group (between-group difference, −2.9 percentage points; 95{\%} confidence interval [CI], −8.2 to 2.2; P=0.005 for noninferiority). In the delayed-cardioversion group, conversion to sinus rhythm within 48 hours occurred spontaneously in 150 of 218 patients (69{\%}) and after delayed cardioversion in 61 patients (28{\%}). In the early-cardioversion group, conversion to sinus rhythm occurred spontaneously before the initiation of cardioversion in 36 of 219 patients (16{\%}) and after cardioversion in 171 patients (78{\%}). Among the patients who completed remote monitoring during 4 weeks of follow-up, a recurrence of atrial fibrillation occurred in 49 of 164 patients (30{\%}) in the delayed-cardioversion group and in 50 of 171 (29{\%}) in the early-cardioversion group. Within 4 weeks after randomization, cardiovascular complications occurred in 10 patients and 8 patients, respectively.ConclusionsIn patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.",
keywords = "ABLATION, ANTICOAGULATION, CATHETER, DESIGN, DEVICE, ECHOCARDIOGRAPHY, GUIDELINES, SPONTANEOUS CONVERSION, STROKE, TEMPORAL RELATIONSHIP",
author = "Pluymaekers, {Nikki A.h.a.} and Dudink, {Elton A.m.p.} and Luermans, {Justin G.l.m.} and Meeder, {Joan G.} and Timo Lenderink and Jos Widdershoven and Bucx, {Jeroen J.j.} and Michiel Rienstra and Otto Kamp and {Van Opstal}, {Jurren M.} and Marco Alings and Anton Oomen and Kirchhof, {Charles J.} and {Van Dijk}, {Vincent F.} and Hemanth Ramanna and Anho Liem and Dekker, {Lukas R.} and Essers, {Brigitte A.b.} and Tijssen, {Jan G.p.} and {Van Gelder}, {Isabelle C.} and Crijns, {Harry J.g.m.}",
note = "(Funded by the Netherlands Organization for Health Research and Development and others; RACE 7 ACWAS ClinicalTrials.gov number, NCT02248753.",
year = "2019",
doi = "10.1056/NEJMoa1900353",
language = "English",
volume = "380",
pages = "1499--1508",
journal = "The New England Journal of Medicine",
issn = "0028-4793",
publisher = "Massachussetts Medical Society",
number = "16",

}

Pluymaekers, NAHA, Dudink, EAMP, Luermans, JGLM, Meeder, JG, Lenderink, T, Widdershoven, J, Bucx, JJJ, Rienstra, M, Kamp, O, Van Opstal, JM, Alings, M, Oomen, A, Kirchhof, CJ, Van Dijk, VF, Ramanna, H, Liem, A, Dekker, LR, Essers, BAB, Tijssen, JGP, Van Gelder, IC & Crijns, HJGM 2019, 'Early or delayed cardioversion in recent-onset atrial fibrillation', New England Journal of Medicine, vol. 380, no. 16, pp. 1499-1508. https://doi.org/10.1056/NEJMoa1900353

Early or delayed cardioversion in recent-onset atrial fibrillation. / Pluymaekers, Nikki A.h.a.; Dudink, Elton A.m.p.; Luermans, Justin G.l.m.; Meeder, Joan G.; Lenderink, Timo; Widdershoven, Jos; Bucx, Jeroen J.j.; Rienstra, Michiel; Kamp, Otto; Van Opstal, Jurren M.; Alings, Marco; Oomen, Anton; Kirchhof, Charles J.; Van Dijk, Vincent F.; Ramanna, Hemanth; Liem, Anho; Dekker, Lukas R.; Essers, Brigitte A.b.; Tijssen, Jan G.p.; Van Gelder, Isabelle C.; Crijns, Harry J.g.m.

In: New England Journal of Medicine, Vol. 380, No. 16, 2019, p. 1499-1508.

Research output: Contribution to journalArticleScientificpeer-review

TY - JOUR

T1 - Early or delayed cardioversion in recent-onset atrial fibrillation

AU - Pluymaekers, Nikki A.h.a.

AU - Dudink, Elton A.m.p.

AU - Luermans, Justin G.l.m.

AU - Meeder, Joan G.

AU - Lenderink, Timo

AU - Widdershoven, Jos

AU - Bucx, Jeroen J.j.

AU - Rienstra, Michiel

AU - Kamp, Otto

AU - Van Opstal, Jurren M.

AU - Alings, Marco

AU - Oomen, Anton

AU - Kirchhof, Charles J.

AU - Van Dijk, Vincent F.

AU - Ramanna, Hemanth

AU - Liem, Anho

AU - Dekker, Lukas R.

AU - Essers, Brigitte A.b.

AU - Tijssen, Jan G.p.

AU - Van Gelder, Isabelle C.

AU - Crijns, Harry J.g.m.

N1 - (Funded by the Netherlands Organization for Health Research and Development and others; RACE 7 ACWAS ClinicalTrials.gov number, NCT02248753.

PY - 2019

Y1 - 2019

N2 - BackgroundPatients with recent-onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion. However, whether immediate restoration of sinus rhythm is necessary is not known, since atrial fibrillation often terminates spontaneously.MethodsIn a multicenter, randomized, open-label, noninferiority trial, we randomly assigned patients with hemodynamically stable, recent-onset (<36 hours), symptomatic atrial fibrillation in the emergency department to be treated with a wait-and-see approach (delayed-cardioversion group) or early cardioversion. The wait-and-see approach involved initial treatment with rate-control medication only and delayed cardioversion if the atrial fibrillation did not resolve within 48 hours. The primary end point was the presence of sinus rhythm at 4 weeks. Noninferiority would be shown if the lower limit of the 95% confidence interval for the between-group difference in the primary end point in percentage points was more than −10.ResultsThe presence of sinus rhythm at 4 weeks occurred in 193 of 212 patients (91%) in the delayed-cardioversion group and in 202 of 215 (94%) in the early-cardioversion group (between-group difference, −2.9 percentage points; 95% confidence interval [CI], −8.2 to 2.2; P=0.005 for noninferiority). In the delayed-cardioversion group, conversion to sinus rhythm within 48 hours occurred spontaneously in 150 of 218 patients (69%) and after delayed cardioversion in 61 patients (28%). In the early-cardioversion group, conversion to sinus rhythm occurred spontaneously before the initiation of cardioversion in 36 of 219 patients (16%) and after cardioversion in 171 patients (78%). Among the patients who completed remote monitoring during 4 weeks of follow-up, a recurrence of atrial fibrillation occurred in 49 of 164 patients (30%) in the delayed-cardioversion group and in 50 of 171 (29%) in the early-cardioversion group. Within 4 weeks after randomization, cardiovascular complications occurred in 10 patients and 8 patients, respectively.ConclusionsIn patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.

AB - BackgroundPatients with recent-onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion. However, whether immediate restoration of sinus rhythm is necessary is not known, since atrial fibrillation often terminates spontaneously.MethodsIn a multicenter, randomized, open-label, noninferiority trial, we randomly assigned patients with hemodynamically stable, recent-onset (<36 hours), symptomatic atrial fibrillation in the emergency department to be treated with a wait-and-see approach (delayed-cardioversion group) or early cardioversion. The wait-and-see approach involved initial treatment with rate-control medication only and delayed cardioversion if the atrial fibrillation did not resolve within 48 hours. The primary end point was the presence of sinus rhythm at 4 weeks. Noninferiority would be shown if the lower limit of the 95% confidence interval for the between-group difference in the primary end point in percentage points was more than −10.ResultsThe presence of sinus rhythm at 4 weeks occurred in 193 of 212 patients (91%) in the delayed-cardioversion group and in 202 of 215 (94%) in the early-cardioversion group (between-group difference, −2.9 percentage points; 95% confidence interval [CI], −8.2 to 2.2; P=0.005 for noninferiority). In the delayed-cardioversion group, conversion to sinus rhythm within 48 hours occurred spontaneously in 150 of 218 patients (69%) and after delayed cardioversion in 61 patients (28%). In the early-cardioversion group, conversion to sinus rhythm occurred spontaneously before the initiation of cardioversion in 36 of 219 patients (16%) and after cardioversion in 171 patients (78%). Among the patients who completed remote monitoring during 4 weeks of follow-up, a recurrence of atrial fibrillation occurred in 49 of 164 patients (30%) in the delayed-cardioversion group and in 50 of 171 (29%) in the early-cardioversion group. Within 4 weeks after randomization, cardiovascular complications occurred in 10 patients and 8 patients, respectively.ConclusionsIn patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.

KW - ABLATION

KW - ANTICOAGULATION

KW - CATHETER

KW - DESIGN

KW - DEVICE

KW - ECHOCARDIOGRAPHY

KW - GUIDELINES

KW - SPONTANEOUS CONVERSION

KW - STROKE

KW - TEMPORAL RELATIONSHIP

U2 - 10.1056/NEJMoa1900353

DO - 10.1056/NEJMoa1900353

M3 - Article

VL - 380

SP - 1499

EP - 1508

JO - The New England Journal of Medicine

JF - The New England Journal of Medicine

SN - 0028-4793

IS - 16

ER -

Pluymaekers NAHA, Dudink EAMP, Luermans JGLM, Meeder JG, Lenderink T, Widdershoven J et al. Early or delayed cardioversion in recent-onset atrial fibrillation. New England Journal of Medicine. 2019;380(16):1499-1508. https://doi.org/10.1056/NEJMoa1900353