Methodology: 4.5/5
Usefulness: 4/5

Stiell IG, et al. Lancet. 2020 Feb 1;395(10221):339-349

Editorial: Atrial fibrillation cardioversion in the emergency department. 

Question and Methods: This partial factorial randomized trial aimed to determine which rhythm control strategy was superior; procainamide followed by electrical cardioversion if needed compared with electrical cardioversion alone. It also sought to determine whether anterolateral or antero-posterior pad placement was superior.

Findings: There was no difference in the rate of conversion to sinus rhythm between the drug-shock and shock only groups which were both highly successful (96% and 92% respectively, p 0.066). There was also no significant difference in cardioversion rates based on pad placement.

Limitations: The only chemical cardioversion agent used was procainamide.

Interpretation: The evidence equally supports drug-shock and shock only strategies for achieving rhythm control in acute atrial fibrillation. For most patient’s, the drug-shock approach may be optimal given lower resource utilization.

By: Dr. Michael Hale


  • Dr. Rosenberg is an emergency physician at the Ottawa Hospital, assistant professor at the University of Ottawa, and Director of the Digital Scholarship and Knowledge Dissemination Program.