{
  "abstract": "Abstract Objective To conduct a randomised, open label comparison of the effectiveness and safety of intravenous vernakalant and intravenous procainamide for the management of acute atrial fibrillation in the emergency department.Design Randomised clinical trial (RAFF4 trial).Setting 12 tertiary care emergency departments in Canada.Participants Patients with acute atrial fibrillation for whom acute rhythm control was a safe option.Interventions Patients were randomised (1:1) to an intravenous infusion of vernakalant or procainamide; when rapid conversion did not occur, patients were offered electrical cardioversion.Main outcomes and measures The primary outcome was conversion to sinus rhythm within 30 minutes of drug infusion completion. Secondary outcomes included time to conversion to sinus rhythm and whether the patient required electrical cardioversion.Results Of the 350 enrolled eligible patients, baseline characteristics were similar in the procainamide (n=172) and vernakalant (n=178) groups. For the primary outcome of conversion success, vernakalant was more effective (62.4% v 48.3%; adjusted absolute difference 15.0%, 95% confidence interval 4.6% to 25.0%, P=0.005; adjusted odds ratio 1.87, 95% confidence interval 1.2 to 2.9, P=0.006). With vernakalant, time to conversion was faster (21.8 v 44.7 minutes; mean difference −22.9, 95% confidence interval −29.9 to −16.0, P<0.001), and fewer patients underwent attempted electrical cardioversion (33.7% v 44.2%; odds ratio 0.62, 95% confidence interval 0.39 to 0.96, P=0.033). Adverse events were similar in both groups, were generally mild and brief, and most patients were discharged home. Subgroup analysis strongly favoured vernakalant for conversion in patients younger than 70 years (73.3% v 47.2%; adjusted odds ratio 3.1, 95% confidence interval 1.7 to 5.5, P=0.001, interaction P=0.005).Conclusions In this head-to-head comparison, vernakalant was superior to procainamide for patients with higher conversion rates and faster times to conversion. Therefore, vernakalant is a safe and highly effective intravenous alternative for the rapid cardioversion and discharge home of patients with acute atrial fibrillation.Trial registration ClinicalTrials.gov NCT04485195",
  "authors": [
    {
      "affiliations": [
        "Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada"
      ],
      "name": "Ian G Stiell"
    },
    {
      "affiliations": [
        "Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada"
      ],
      "name": "Monica Taljaard"
    },
    {
      "affiliations": [
        "Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada"
      ],
      "name": "Debra Eagles"
    },
    {
      "affiliations": [
        "Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada"
      ],
      "name": "Krishan Yadav"
    },
    {
      "affiliations": [
        "Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada"
      ],
      "name": "Alain Vadeboncoeur"
    },
    {
      "affiliations": [
        "Department of Emergency Medicine, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada"
      ],
      "name": "Corinne M Hohl"
    },
    {
      "affiliations": [
        "Département de médecine familiale et de médicine d’urgence et Département d'anesthésiologie et de soins intensifs, Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Université Laval, Québec City, Québec, Canada"
      ],
      "name": "Patrick M Archambault"
    },
    {
      "affiliations": [
        "Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada"
      ],
      "name": "David Birnie"
    },
    {
      "affiliations": [
        "Ottawa Hospital Research Institute, Ottawa, Ontario, Canada"
      ],
      "name": "Erica Brown"
    },
    {
      "affiliations": [
        "Department of Emergency Medicine, Dalhousie University, Halifax, Canada"
      ],
      "name": "Samuel G Campbell"
    },
    {
      "affiliations": [
        "Ottawa Hospital Research Institute, Ottawa, Ontario, Canada"
      ],
      "name": "Yutong Chen"
    },
    {
      "affiliations": [
        "Ottawa Hospital Research Institute, Ottawa, Ontario, Canada"
      ],
      "name": "Catherine M Clement"
    },
    {
      "affiliations": [
        "Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Île de-Montréal, Sacré-Coeur Hospital, Département de médecine de famille et médecine d'urgence, Montréal, Québec, Canada"
      ],
      "name": "Alexis Cournoyer"
    },
    {
      "affiliations": [
        "Department of Emergency Medicine, Queen’s University, Kingston, Ontario, Canada"
      ],
      "name": "Kerstin de Wit"
    },
    {
      "affiliations": [
        "CHU de Québec, Hôpital de l'Enfant-Jésus, Division of Emergency Medicine, Université Laval, Québec City, Québec, Canada"
      ],
      "name": "Marcel Emond"
    },
    {
      "affiliations": [
        "Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada"
      ],
      "name": "Laurent Macle"
    },
    {
      "affiliations": [
        "Department of Emergency Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada"
      ],
      "name": "Andrew D McRae"
    },
    {
      "affiliations": [
        "Department of Family Medicine and Emergency Medicine, Centre de Recherche du CHU de Québec, Université Laval, Québec City, Québec, Canada"
      ],
      "name": "Eric Mercier"
    },
    {
      "affiliations": [
        "Department of Family Medicine and Emergency Medicine, Université de Montréal, Montréal, Québec, Canada"
      ],
      "name": "Judy Morris"
    },
    {
      "affiliations": [
        "Ottawa Hospital Research Institute, Ottawa, Ontario, Canada"
      ],
      "name": "Ghadeer Mohamad"
    },
    {
      "affiliations": [
        "Ottawa Hospital Research Institute, Ottawa, Ontario, Canada"
      ],
      "name": "Marie-Joe Nemnom"
    },
    {
      "affiliations": [
        "Methodological & Implementation Research (MIR), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada"
      ],
      "name": "Stuart G Nicholls"
    },
    {
      "affiliations": [
        "Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec City, Québec, Canada"
      ],
      "name": "David Pare"
    },
    {
      "affiliations": [
        "Division of Cardiology, Department of Medicine, Dalhousie University, Dartmouth, Nova Scotia, Canada"
      ],
      "name": "Ratika Parkash"
    },
    {
      "affiliations": [
        "Department of Emergency Medicine, Queen’s University, Kingston, Ontario, Canada"
      ],
      "name": "Marco LA Sivilotti"
    },
    {
      "affiliations": [
        "Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada"
      ],
      "name": "Kednapa Thavorn"
    },
    {
      "affiliations": [
        "Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada"
      ],
      "name": "Jeffrey J Perry"
    }
  ],
  "title": "Vernakalant versus procainamide for rapid cardioversion of patients with acute atrial fibrillation (RAFF4): randomised clinical trial",
  "uid": "1354ff08-2baf-5edf-a2e9-a724c8bf5519"
}