A Faster Way To Sinus Rhythm

"Remember vernakalant", said no one.

In the Great White North, chemical cardioversion of recent-onset atrial fibrillation is relatively popular. Credit for some of this practice goes to Ian Stiell and a series of trials in this space demonstrating chemical-first strategies are as effective as electrical-first.

The usual agent is procainamide, but some of this stems from convenience and necessity – various regulators approve drugs at different rates. The EU has had vernakalant available, while Canada, the U.S., and others have not. The new availability of vernakalant in Canada, however, has led to a new trial by Stiell et al: RAFF4.

Ta da:

Faster, more effective.

What’s the catch? Safety. Occurrences of cardiogenic shock have occurred with infusions of vernakalant, resulting in narrowed eligibility criteria. However, in RAFF4, procainamide arguably incited a greater number of adverse events, along with a greater number exposed to the risks of procedural sedation, but the trial is too small to fully encompass rare, serious outcomes.

Regardless, it is good to see additional options for chemical cardioversion diffusing throughout the world.