CLINICAL RESEARCH
Spontaneous conversion of patients with atrial fibrillation scheduled for electrical cardioversion
An ACUTE trial ancillary study
S. Ahmed Tejan-Sie, MD*,
R. Daniel Murray, PhD*,
Ian W. Black, MD ,
Susan E. Jasper, RN*,
Carolyn Apperson-Hansen, MStat ,
Jianbo Li, MS, PhD,
Elizabeth A. Lieber, BA,
Richard A. Grimm, DO*,
Allan L. Klein, MD*,* ACUTE Investigators
* Departments of Cardiovascular Medicine, Cleveland, Ohio, USA
Biostatistics and Epidemiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
Department of Medicine, University of Sydney, Sydney, Australia
* Reprint requests and correspondence: Dr. Allan L. Klein, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Desk F-15, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA.
kleina{at}ccf.org
OBJECTIVES: This study was designed to determine the characteristics and outcomes of spontaneous conversion (SC) to sinus rhythm (SR) in patients with atrial fibrillation (AF) of more than two days.
BACKGROUND: The Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) multicenter study was a prospective trial in which transesophageal echocardiography (TEE)-guided treatment was compared with conventional anticoagulation treatment for the management of patients with AF >2 days undergoing direct current cardioversion (DCC). In an ancillary analysis, we evaluated the baseline and outcome data in patients who underwent SC to SR before scheduled DCC.
METHODS: We identified 1,041 patients for this analysis after excluding patients on pre-existing antiarrhythmic agents. Patients with SC in the TEE-guided and conventional groups were first compared then pooled and compared with non-spontaneous conversion (No-SC) patients.
RESULTS: Overall, 167 of 1,041 (16%) patients underwent SC, with twice as many in the conventional compared with the TEE-guided group (110/523 [21%] vs. 57/518 [11%]; p < 0.001). When compared with No-SC patients, a higher proportion of SC patients maintained SR at eight weeks (87.2% vs. 48.9%, p < 0.001), without statistically significant differences in bleeding, thromboembolism or mortality. Multivariate predictors of SC were shorter duration of AF, New York Heart Association (NYHA) functional class 1 or 2, smaller left atrial size, and absence of left atrial spontaneous echo contrast.
CONCLUSIONS: Spontaneous conversion was associated with shorter duration of AF, lower NYHA class, smaller left atrial size, and absence of left atrial spontaneous echo contrast. There was a better SR outcome in the SR group, but no differences in the other clinical end points. The conventional treatment strategy allowed greater opportunity for SC. In the absence of favorable predictors of SC, the TEE-guided approach should be considered.
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Abbreviations and Acronyms
| | ACUTE | = Assessment of Cardioversion Using Transesophageal Echocardiography study | | AF | = atrial fibrillation | | DCC | = direct-current cardioversion | | LA | = left atrial | | LVEF | = left ventricular ejection fraction | | No-SC | = non-spontaneous conversion | | NYHA | = New York Heart Association | | SC | = spontaneous conversion | | SR | = sinus rhythm | | TEE | = transesophageal echocardiography | | TTE | = transthoracic echocardiogram |
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