Methodology Score: 4.5/5
Usefulness Score: 4/5
Stiell IG, et al. BMJ. 2025 Nov 11;391:e085632. doi: 10.1136/bmj-2025-085632.
Question and Methods: This is a multi-center, open-label, patient randomised trial comparing the effectiveness and safety of cardioversion with intravenous vernakalant and intravenous procainamide in patients with acute atrial fibrillation in the emergency department.
Findings: IV vernakalant was superior to procainamide with higher conversion rates (62.4% vs 48.3%; absolute risk difference 15.0%, 95% CI 4.6–25.0) and 50% faster time to conversion, with similar adverse event rates.
Limitations: The major limitations include it being an open-label study, exclusion of 4 patients with incorrect diagnosis of afib as per intention-to-treat analysis, procainamide not commonly being used for afib in several other countries, and cost limitations of vernakalant.
Interpretation: Vernakalant can be considered as an alternative to procainamide for rapid pharmacologic cardioversion of acute afib in the ED, particularly in patients <70 years.
For the atrial fibrillation/flutter best practice checklist – click here.
Summary by: Dr. Anchaleena Mandal
JC supervisor: Dr. Christian Vaillancourt
