Background and importance Acute atrial fibrillation (AF) is the most common arrythmia managed in the emergency department (ED). Conversion to normal sinus rhythm can be performed by electrical (ECV) or pharmacological cardioversion. ECV is more effective and it is the method of choice for haemodynamically unstable patients or new onset AF; however, pharmacological cardioversion does not require anaesthesia and it is easier to attempt.

The choice to pursue rhythm control is an individualised one according to the clinical profile of the patient and the therapeutic options available.

Aim and objectives To analyse the strategies to restore sinus rhythm for ED patients with acute AF and the results obtained.

To analyse the time from AF onset to restoration of sinus rhythm.

Material and methods Observational, retrospective, multidisciplinary study. Inclusion criteria: patients >18 years treated at the ED (June 2020−February 2021) with diagnosis of AF in which it was decided to restore sinus rhythm.

Variables demographic, comorbidities (chronic renal failure, diabetes, obesity), haemodynamic stability (yes/no), structural heart disease, type of cardioversion (ECV or pharmacological), drug used in pharmacological cardioversion, conversion to normal sinus rhythm (yes/no), time to restoration of rhythm, rescue cardioversion if failure.

Results For a total of 186 patients with a diagnosis of acute AF in the ED, 83 (45%) patients were eligible to pursue rhythm control. Mean age 66±13 years, 58% women, 47% with comorbidities. Haemodynamically unstable patients 11%, 34% had structural heart disease.

Seven patients underwent ECV. Pharmacological cardioversion (92%): 55% amiodarone, 41% flecainide, 3% vernakalant, 1% propafenone.

Time from AF onset to restoration of sinus rhythm: <2 hours in 100% of ECV; amiodarone 45% of patients <2 hours, 17% 2–6 hours, 21% 6–12 hours, 17% >12 hours; flecainide 52% <2 hours, 44% 2–6 hours; vernakalant 100% <2 hours.

Cardioversion failed in 25% of patients. Rescue therapy: 67% alternative cardioversion strategy and 33% rate control approach.

Conclusion and relevance Although the gold standard therapy is ECV, it was underused in our sample of patients.

In addition, amiodarone was the most widely prescribed drug, although the time to restore sinus rhythm was shorter with other therapies (excluding flecainide).

More trials comparing different strategies are needed to better understand the optimal management of acute AF.

Conflict of interest No conflict of interest