News | 1 April 2019

'Wait and see' method is effective in atrial fibrillation

Waiting is just as effective as acute cardioversion and has benefits

When atrial fibrillation has recently been detected, it is just as effective to wait 48 hours as to apply acute cardioversion (with an electrical shock or intravenous drip with medication). This is because in nearly 70 per cent of cases, the heart rhythm recovers spontaneously. This is the conclusion of cardiologists at the Heart+Vascular Center of Maastricht UMC+ following a study of nearly 450 patients who presented at the Accident and Emergency (A&E) units of 15 different hospitals in the Netherlands. The research results were recently published in the prestigious New England Journal of Medicine. The findings may lead to new guidelines, due to the advantages of the wait-and-see method.

iStockiStockAtrial fibrillation is a cardiac arrhythmia characterised by irregular contraction of the heart. This is due to a disturbance of the electrical impulse conduction and it can eventually lead to stroke and heart failure. If the arrhythmia is detected within 48 hours, patients are considered for acute cardioversion at an A&E unit. This has the aim of restoring the heart's normal rhythm and is performed with the help of an intravenous drip with medication or an electrical shock under anaesthetic. However, it now appears that simply waiting 48 hours is just as effective a method.

Spontaneous recovery
For the study, 437 patients with atrial fibrillation were divided into two treatment groups. All the patients had presented at A&E within 36 hours of the start of their arrhythmia. One group of patients was treated with acute cardioversion at the A&E unit, while the experimental wait-and-see method was used with the second group. In the second group, the heart rhythm recovered spontaneously in 69 per cent of the patients. 'Delayed' cardioversion was necessary for only 28 per cent of the group within 48 hours after the symptoms started. In contrast, virtually all those in the first, acute group underwent cardioversion immediately after arrival at A&E. However, in 16 per cent of those patients, the heart's rhythm had recovered by itself even before medical staff could perform cardioversion. Altogether, there was a comparable success rate of around 95 per cent in both treatment groups.

However, the wait-and-see method has a number of benefits for patients, compared with the usual procedure. In many cases, cardioversion can be avoided, which means that fewer complications are to be expected. Furthermore, patients can return home after a short period of observation. This contrasts with an acute cardioversion treatment which, after all, takes time to prepare. The drastic reduction in the number of cardioversion procedures also relieves pressure on A&E. Moreover, the patient finds out that his or her heart can recover by itself, which can boost confidence. Finally, by first waiting, cardiologists can better estimate the nature of the atrial fibrillation, reach a better diagnosis, and consequently provide a more targeted treatment. The new information obtained by the Maastricht cardiologists may lead to changes in the current guidelines.