Patient-Oriented Evidence That Matters

Early Cardioversion No Better Than Delayed Cardioversion for Recent-Onset Symptomatic Atrial Fibrillation


Am Fam Physician. 2019 Nov 15;100(10):648.

Clinical Question

Is it necessary to immediately restore sinus rhythm by early cardioversion in patients who present to the emergency department with recent-onset symptomatic atrial fibrillation?

Bottom Line

For patients presenting to the emergency department with recent-onset symptomatic atrial fibrillation, early cardioversion is no better than delayed cardioversion in achieving sinus rhythm within four weeks. The delayed approach results in more spontaneous conversions to sinus rhythm, avoiding cardioversion altogether, without increasing the rate of cardiovascular complications. (Level of Evidence = 1b)


Atrial fibrillation can often terminate spontaneously without the need for pharmacologic or electrical cardioversion. In this study, investigators included adults who presented to the emergency department with new or recurrent symptomatic atrial fibrillation of recent onset (less than 36 hours). The patients were randomized into a delayed cardioversion group (n = 218) or a standard early cardioversion group (n = 219). In the early group, patients received immediate pharmacologic cardioversion with flecainide (or electrical cardioversion if flecainide was contraindicated or unsuccessful) and were discharged when stable. In the delayed group, patients received rate-controlling medications, were discharged when clinically stable, and were given outpatient follow-up the next day. If they remained in atrial fibrillation, they were then referred back to the emergency department for delayed cardioversion. The two groups were balanced at baseline: mean age was 65 years, approximately 40% were taking anticoagulants, and two-thirds had a CHA2DS2-VASc score of 2 or higher. Only three patients in the delayed group and five in the early group required hospitalization; all others were discharged from the emergency department. The median duration of the index emergency department visit was 158 minutes in the early group and 120 minutes in the delayed group. The primary outcome

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

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This series is coordinated by Sumi Sexton, MD, Editor-in-Chief.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.



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