Trends in the use of electrical cardioversion for atrial fibrillation: influence of major trials and guidelines on clinical practice

Alegret et al. BMC Cardiovascular Disorders 2012, 12:42 http://www.biomedcentral.com/1471-2261/12/42 RESEARCH ARTICLE Open Access Trends in the use of electrical cardioversion for atrial fibrillation: influence of major trials and guidelines on clinical practice Josep M Alegret1*, Xavier Viñolas2, César Romero-Menor3, Silvia Pons4, Roger Villuendas5, Naiara Calvo6, Jordi Pérez-Rodon7, Xavier Sabaté8 and REVERCAT study investigators Abstract Background: The purpose of the present study was to assess the trends in the use of ECV following published studies that had compared rhythm and rate control strategies on atrial fibrillation (AF), and the recommendations included in the current clinical practice guidelines. Methods: The REVERCAT is a population-based assessment of the use of electrical cardioversion (ECV) in treating persistent AF in Catalonia (Spain). The initial survey was conducted in 2003 and the follow-up in 2010. Results: We observed a decrease of 9% in the absolute numbers of ECV performed (436 in 2003 vs. 397 in 2010). This is equivalent to 27% when considering population increases over this period. The patients treated with ECV in 2010 were younger, had a lower prevalence of previous embolism, a higher prevalence of diabetes, and increased body weight. Underlying heart disease factors indicated, in 2010, a higher proportion of NYHA ≥ II and left ventricular ejection fraction <30%. We observed a reduction in the number of ECV performed in 16 of the 27 (67%) participating hospitals. However, there was an increase of 14% in the number of procedures performed in tertiary hospitals, and was related to the increasing use of ECV as a bridge to AF ablation. Considering the initial number of patients treated with ECV, the rate of sinus rhythm at 3 months was almost unchanged (58% in 2003 vs. 57% in 2010; p = 0.9) despite the greater use of biphasic energy in 2010 and a similar prescription of anti-arrhythmic drugs. Conclusions: Although we observed a decrease in the number of ECVs performed over the 7 year period between the two studies, this technique remains a common option for treating patients with persistent AF. The change in the characteristics of candidate patients did not translate into better outcomes. Keywords: Atrial fibrillation, Electrical cardioversion, Rhythm control, Rate control, Follow-up Background The REVERCAT study (REgistre sobre la cardioVERSió elèctrica a CATalunya; Registry of Electrical Cardioversion in Catalonia) is a multi-center study involving 27 participating hospitals. The recording of characteristics of electrical cardioversion (ECV) was intended to evaluate the use of the technique in patients with atrial fibrillation (AF) in current clinical practice in Catalonia (Spain). The initial study was conducted at the start of * Correspondence: 1 Secció de Cardiologia, Hospital Universitari de Sant Joan, Institut d’Investigacions Sanitàries Pere Virgili, Universitat Rovira i Virgili, C/Dr. Laporte, s/n, Reus 43205, Spain Full list of author information is available at the end of the article 2003. The current re-evaluation was conducted early in 2010 and, over these past 7 years, there have been a few studies published, and subsequent guidelines generated, which described the lack of a clear benefit of rhythm control vs. rate control strategies in patients with AF [1-3]. The purpose of the present study was to compare the frequency and characteristics of patients treated with ECV between the years 2003 and 2010; the objective being to assess the impact of major clinical trials and recommendations included in the current clinical practice guidelines. Methods The REVERCAT study was set-up to record, prospectively, all patients with persistent AF who were © 2012 Alegret et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Alegret et al. BMC Cardiovascular Disorders 2012, 12:42 http://www.biomedcentral.com/1471-2261/12/42 considered candidates for ECV. There were 27 participating hospitals which are representative of the whole of Catalonia (an Autonomous Community in NE Spain) (Table 1). The area of Catalonia is 31,930 km2 and the population was 6,506,000 inhabitants in 2003 and 7,512,000 inhabitants in 2010, all of whom have the right to health-care provision under the publicly-funded National Health Service. The hospitals participating in the present study attend to approximately 90% of this population. The initial registry was set-up between 1st February and 30th October 2003. The present study was conducted between 1st February and 30th October 2010, the purpose being to assess the changes in the use of ECV in clinical practice in Catalonia. The patients included in the study to have ECV applied were all those who met the criteria of being ≥18 years of age, with AF Table 1 List of investigators and centers participating in the REVERCAT study Clinical Investigatora Affiliation X Sabaté H.U. de Bellvitge, Hospitalet de Llobregat R Serrat H del Mar A Sualís H de Mataró F Planas H. de Badalona G Vazquez H. Comarcal de la Selva, Blanes J Escudero H Mútua de Terrassa X Abardia/C Barberà Clínica Ponent, Lleida L Guillamon H. Parc Taulí, Sabadell L Mont/N Calvo H. Clínic, Barcelona J Sadurní H. General de Vic S Pons H de Barcelona A Descalzi H. Comarcal Alt Penedés, Vilafranca del Penedés N Batalla H. Sagrat Cor, Barcelona E Sanz/S Serrano H.U. Joan XXIII, Tarragona J Pérez-Rodon H.G.U. Vall d’ Hebrón, Barcelona E Rodríguez-Font H. Sta Creu i Sant Pau, Barcelona F Freire H. de Palamós, Palamós M Vilaseca H de Calella, Calella C Romero H. Sant Boi de Llobregat I Duran H.U. Sant Joan de Reus J Tomàs H.U. Arnau de Vilanova, Lleida I Lechuga H. Verge de la Cinta, Tortosa R Villuendas H. Germans Trias i Pujol, Badalona A Jaber H. de Terrassa I Romeo H. d’Igualada R Canals H. Comarcal de Mollet M Paz H de Figueras a Collaborators in Pubmed. Page 2 of 6 duration >7 days, and with no precipitating conditions including hyperthyroidism, fever, cardiac surgery and pericarditis. Successful ECV was considered when sinus rhythm (SR) was achieved, and excluded patients with immediate relapse. A clinical and ECG follow-up was performed at 3 months post-ECV. Patients were considered to have maintained SR at 3 months if there had not been a relapse of persistent AF and, as well, the ECG at 3 months of follow-up showed SR. The information recorded included clinical data, treatment, echocardiography data, and procedure variables. We compared all these variables in the two surveys conducted 7 years apart. The principal investigator in each hospital was the same in both surveys in 21 of the 27 participating hospitals. The study received approval (...truncated)