Atzema Clare L, Stiell Ian G, Chong Alice, Austin Peter C
Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
ICES, Toronto, Ontario, Canada.
J Am Coll Emerg Physicians Open. 2025 Mar 4;6(2):100072. doi: 10.1016/j.acepjo.2025.100072. eCollection 2025 Apr.
Guideline recommendations for the emergency department cardioversion of patients with acute atrial fibrillation/flutter have recently changed. This was related to several studies that found a higher-than-expected risk of subsequent stroke or systemic embolism in cardioverted atrial fibrillation/flutter patients. We sought to confirm an elevated rate of stroke, systemic embolism, or death following emergency department cardioversion to normal sinus rhythm compared with similar patients who were not converted.
This retrospective cohort study combined 4 datasets of atrial fibrillation/flutter patients seen at 25 emergency departments in Ontario, Canada, 2000-2012, who were all eligible for cardioversion. We linked patients to province-wide datasets to determine the primary outcome, a composite of stroke, systemic embolism, or all-cause death. To adjust for baseline differences between patients who cardioverted vs those who did not, we used overlap weights based on the propensity score. The latter included 28 variables, including oral anticoagulant prescriptions.
Of 2521 patients, 2060 (81.7%) converted to sinus rhythm in the emergency department, and 1055 (41.8%) left on anticoagulation. Twelve (0.48%) patients met the primary outcome at 30 days and ≤5 (≤0.2%) at 7 days. In the weighted sample, at 30 days, the primary outcome occurred in 0.37% (95% CI, 0.04%-0.78%) of cardioverted patients vs 0.23% (95% CI, 0.00%-0.60%) in those not cardioverted; the absolute risk increase was 0.13% (95% CI, -0.36% to 0.69%; = .61), and the number needed to harm was 747.
In atrial fibrillation/flutter patients eligible for cardioversion at 25 emergency departments, the rate of subsequent stroke or systemic embolism and death was very low. After adjusting for risk factors and post-conversion oral anticoagulant use, the rate of subsequent stroke and systemic embolism and death was not significantly higher in patients who cardioverted vs those who did not.
近期，急性心房颤动/心房扑动患者急诊科心脏复律的指南建议发生了变化。这与多项研究有关，这些研究发现心脏复律后的心房颤动/心房扑动患者发生后续卒中或全身性栓塞的风险高于预期。我们试图证实，与未进行心脏复律的类似患者相比，急诊科心脏复律为正常窦性心律后的患者卒中、全身性栓塞或死亡发生率升高。
这项回顾性队列研究合并了2000年至2012年在加拿大安大略省25个急诊科就诊的心房颤动/心房扑动患者的4个数据集，这些患者均符合心脏复律条件。我们将患者与全省范围的数据集进行关联，以确定主要结局，即卒中、全身性栓塞或全因死亡的综合情况。为了调整进行心脏复律与未进行心脏复律患者之间的基线差异，我们使用了基于倾向评分的重叠权重。后者包括28个变量，包括口服抗凝剂处方。
在2521例患者中，2060例（81.7%）在急诊科转为窦性心律，1055例（41.8%）继续接受抗凝治疗。12例（0.48%）患者在30天时达到主要结局，7天时≤5例（≤0.2%）。在加权样本中，30天时，心脏复律患者中主要结局的发生率为0.37%（95%CI，0.04%-0.78%），未进行心脏复律的患者为0.23%（95%CI，0.00%-0.60%）；绝对风险增加为0.13%（95%CI，-0.36%至0.69%；P = 0.61），伤害所需人数为747。
在25个急诊科符合心脏复律条件的心房颤动/心房扑动患者中，后续卒中或全身性栓塞及死亡的发生率非常低。在调整风险因素和心脏复律后口服抗凝剂的使用情况后，进行心脏复律的患者与未进行心脏复律的患者相比，后续卒中和全身性栓塞及死亡的发生率并没有显著更高。
