Evidenced Based Practice Nursing

In treating patients with sudden onset of atrial fibrillation, is electric cardioversion more effective than pharmalogical cardioversion in returning patients heart rate and rhythm to sinus? Research was conducted through review of evidence based practice studies. Literature review was the means of research and included qualitative and quantitative studies. The review of these various studies concluded with the need to conduct further studies into practice guidelines and its coloration to proper and best treatment for sudden onset of atrial fibrillation.

Background:

Atrial Fibrillation (AF) is the most common cardiac dysrhythmia and has become more prevalent because of our aging population. Symptoms of Atrial fibrillation are palpitations, sensations of heart racing, uncomfortable, irregular heartbeat, decreased blood pressure, weakness, lightheadedness, confusion shortness of breath chest pain.

(http://wwww.mayoclinic.com/heatlh/atrial-fibrillation). AF is a potent risk factor for ischemic stroke and a cause of worsening heart failure and is a major public health problem. (Khoo & Lip, 2009, p. 1262). Many studies also indicate an increase in the number of hospitalizations for AF Over the last 25 years. This is attributed to aging population as well as the associated mortality

And morbidity of AF. More importantly, hospitalizations related to AF tend to be associated with greater health care costs and longer inpatient stays, with lower rate of discharge to home.(Khoo &Lip, 2009, p. 1262).

There is no consensus on the optimal management of recent onset of atrial fibrillation or flutter.(Stiell et al., 2010, p. 181). However most ED physicians typically proceed first with chemical cardioversion before electrical cardioversion, unless the stability of the patient is such

That immediate electrical conversion is required. (Stiell et al., 2010)

Objective:
The objective is to determine if electrical cardioversion has a higher rate of returning sudden onset of fibrillation back to sinus rhythm when compared to chemical cardioversion. The other component would be that use of cardioversion would not increase the percentage of adverse outcome as compared to chemical treatment. Search for Evidence:

In Journals@ Ovid Full Text a search for research based articles published in 2004 or later was completed. The first search was done for “atrial fibrillation” with results of 6, 2483 articles. The search was then narrowed down to “atrial fibrillation cardioversion” resulting in 194 articles. Many articles were helpful to this discussion. Further reading and review of references in these articles led to articles used in this summary. Summary of Research Evidence:

Electrical Cardioversion:
Xavier Scheuermeyer et al. ( 2010), Thirty-day Outcomes of Emergency Department Patients Undergoing Electrical Cardioversion for Atrial Fibrillation or Flutter. Academic Emergency Medicine. This was a two-center cohort study of consecutive ED patients who underwent cardioversion for AF or a flutter between January 1, 2000 and September 2007. The cohort was linked with a regional ED database to determine if patients and subsequent visits to the ED for stroke or thrombolytic events within thirty days of ED cardioversion. The results were quite revealing in that 1,233 made 1,820 visits to the ED for atrial fibrillation or flutter. Of those patients 400 were electrically cardioverted with no deaths or stroke or embolitic events within 30 days.

Burton et al., ( 2004) Electrical Cardioversion of Emergency department patients with atrial fibrillation. Annals of Emergency Medicine.

This was a retrospective study of health records survey of consecutive cohort ED patients with AF who underwent electrical cardioversion in 4 EDs during 42 month period. The study Population had 388 patients. The results were that 301 successfully electrically cardioverted.

Within those successfully cardioverted only 10% returned to the ED because of relapse. The Study concluded that electrical cardioversion success patients had infrequent hospital admissions and few immediate ad short term complications.Murray et al (2011) Atrial Fibrillation (AF) Care: Challenges in clinical Practice and Educational Needs Assessment.

This article examines the management of patients with sudden onset of atrial fibrillation and the different techniques used to determine treatment. The study uses both qualitative and quantitative methods of study. The data collection included interviews of family physicians, internists, cardiologist, neurologists, emergency physicians and patients. An online survey was completed for quantitative data collection. The data obtained was triangulated with the quantitative research to ensure reliability and trustworthiness. (Murray et al., 2011, p. 98) The study concluded there were gaps in decision-making, care and screening for atrial fibrillation. The authors further concluded that a solution would be form guidelines for study, education and practice in handling of atrial fibrillation patients.

Chemical Cardioversion:

Stiell, IG et al (2007). Emergency Department use of intravenous

Procainamide for patients with acute atrial fibrillation or flutter. Academic Emergency Medicine.

The study objective was to examine the efficacy and safety of intravenous procainamide for acute atrial fibrillation or flutter. This was a health records review of a cohort of ED patients with acute-onset of AF who received IV procainamide. Of the 341 patients studied the conversion rates were 52.2% the protocol involved IV infusion of 1g of procainamide over 60 minutes followed by electrical cardioversion if necessary.

Use of Electrical Cardioversion and or Chemical Cardioversion: Vinson, D. R et al (2012 ). Managing Emergency Department Patients with Recent-Onset Atrial

Fibrillation. The Journal of Emergency Medicine.

This study was a cohort study of three community hospitals with convenience sampling. The main results were that out of the 206 patients enrolled chemical cardioversion was attempted on 52 participants with 31(60%) successful conversions. Electrical cardioversion was attempted on 83 patients with 80 successful conversions (96%) This number includes patients who were unsuccessfully converted by IV medication as the initial form of treatment. The study does help to give a statistical outcome of the use of ED cardioversion and helps to answer the question of whether it is a safe and effective mode for treating sudden onset of atrial fibrillation. Because of the excellent analysis of data, the study also helps to answer questions regarding success of modes of treatment for onset of AF, specifically pharmalogical cardioversion verses electrical cardioversion.

Stiell, IG et al. (2010) Association of Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. Canadian Journal of Emergency Medicine. This study was a medical record review of cases seen at the Ottawa Hospital Civic Campus ED from January 1, 2000 to June 30 2005 inclusive. Cohort was of Ed patients with visits of primary diagnosis of recent-onset episode of atrial fibrillation where aggressive attempt at cardioversion was used. The study had a total of 660 patient visits. All patients were initial administered intravenous procainamide with a 58.3% conversion rate. With a total of 243 requiring subsequent electrical cardioversion with a 91% conversion rate. The strength of the study is that it is the largest to evaluate the effectiveness and safety of an aggressive protocol for cardioversion and quick discharge of patients from the ED. In the conclusion the researches sate that future clinical trials should compare the drug first to shock-first approaches to cardioversion.

Critical Analysis:
Overall most of the studies reviewed have tout the benefits of aggressive treatment of the sudden onset of AF. However, the studies which discuss the use of electrical cardioversion have also included the use of chemical cardioversion as the usual first choice by ED physicians. The studies which specifically examined use of electrical cardioversion admit that these sampling of patients were initially administered rate control medications as well as chemical cardioversion attempts before electrical cardioversion.

This makes it difficult to determine which method is clearly more successful electrical cardio version verses chemical. There are many unanswered variables. For instance, does the initial administration or attempt to chemically cardiovert “prime” or “set up” the success for electrical cardioversion? The second prong is that of efficacy and invasive intervention when pharmacological means are available. Electrical cardioversion can be quite painful and disruptful for patients even with the administration of analgesics, though the outcome of achieving sinus rhythm may be more immediate. Is it worth the trauma to the patient if chemical cardioversion will give the same result? Limitations of Current Evidence:

The limitation of the current evidence is that there is no pure statistical study of immediate purely electrical cardioversion verses chemical cardioversion success rates. Researchers admit there that future clinical trials should compare the drug first to shock-first approaches to cardioversion. (Stiell et al., 2010). Secondly our qualitative literature review revealed that there are no specific practice guidelines for practitioners when treating initial onset of cardioversion in the sense that when practitioners were interviewed, based on case scenarios provided practitioners had varying methodologies and steps in providing treatment chemical verses electrical shock treatment for cardioversion. Though all used the same tools, medications when to use which tool or which medication was not consistent. This in itself can change the outcome of any study.

Strength of Current Evidence:
The strength of current evidence for successfulness of electrical cardioversion is that in most of the studies, patients who did not have successful chemical conversion had a 90% plus chance of converting with electrical cardioversion. This may lead to the deduction that immediate electrical cardioversion would lead could have a 90% plus success rate as opposed to the 50% plus success rate of chemical cardioversion which occurred in most of the studies.

CONCLUSION
Based on the evidence reviewed, we recommend the following:
A future study strictly with clinical trials comparing the drug first to shock-first approaches to cardioversion. A cohort study utilizing the same standard of protocols for determining which patient will be cardioverted or just monitored for possible spontaneous conversion Further evaluation of the efficacy of by passing chemical cardioversion to electrical cardioversion and the trauma related with electrical cardioversion. It seems very feasible to at least conduct a study to determine if immediate electrical cardioversion is the best practice treatment for patients with sudden onset of atrial fibrillation. Many providers fear aggressive treatment for fear of adverse outcomes. The adverse out comes for aggressive electrical cardioversion are at best negligible.

The data from varied sources shows that carefully selected patients, treated with a clear ED protocol (with electrical conversion more effective than chemical, though both potential options) can and should be offered followed by appropriate follow up. (Cohn, Keim, & Yealy, 2013, p. 124). There are multiple stake holders that can benefit from such a study. Patients with sudden onset of AF are at higher risk for stroke and embolism. Shortening the duration of AF could possibly result in better outcome for patients. Secondly the cost of managing AF through chemical means may be more costly and could require longer hospital stays. Though the primary concern is always to achieve the best outcome for our patients, with today’s national healthcare initiatives focus on health care costs is of high concern as well.

References

Burton, J. H., Vinson, D. R., Drummond, K., Strout, T. D., Thode, H. C., & McInturff, J. J. (2004). Electrical Cardioversion of Emergency department patients with atrial fibrillation. Annals of Emergency Medicine, 44(1), 20-30. Cohn, B. G., Keim, S. M., & Yealy, D. M. (2013, January 27). Is Emergency Department Cardioversion of Recent-Onset Atrial Fibrillation Safe and Effective? The Journal of Emergency Medicine, 45(1), 117-127. Khoo, C. W., & Lip, G. Y. (2009). Burden of Atrial Fibrillation. Current Medical Research and Opinion, 25 (5), 1261-1263. http://dx.doi.org/10.1185/0 Murray, S., Lazure, P., Pullen, C., Maltais, P., & Dorian, P. (2011). Atrial Fibrillation Care: Challenges of Clinical Practice and Educational Needs Assessment. Canadian Journal of Cardiology, 27(), 98-104. http://dx.doi.org/doi:10.1016/j.cjca.2010.12.006 Stiell, I., Clement, C., Perry, J., Vaillancourt, C., Symington, C., Dickinson, G., Green, M. (2010). Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. Canadian Journal of Emergency Medicine, 12(3), 181-191. Stiell, I., Clement, C., Symington, C., Perry, J., Vaillancourt, C., & Wells, G. (2007, December). Emergency Department Use of Intravenous Procainamide for Patients with Acute Atrial Fibrillation or Flutter. Academic Emergency Medicine, 14(12), 1158-1164. Vinson, D. R., Hoehn, T., Garber, D. J., & Williams, T. M. (2012). Managing Emergency Department Patients with Recent-Onset Atrial Fibrillation. The Journal of Emergency Medicine, 42(2), 139-148.

References Continued
Xavier Scheuermeyer, F., Grafstein, E., Stenstrom, R., Innes, G., Poureslami, I., & Sighary, M. (2010, April). Thirty-day Outcomes of Emergency Department Patients Undergoing Electrical Cardioversion for Atrial Fibrillation or
Flutter. Academic Emergency Medicine, 17(4), 408-415.