Acute Atrial Fibrillation and Flutter Treated Electively

Official title

Acute Atrial Fibrillation and Flutter Treated Electively - A Randomized Controlled Clinical Trial on the Safety of Elective Management of Acute Atrial Fibrillation and Flutter

Overview

The AFFELECT -study compares two types of treatment modalities for acute atrial fibrillation or flutter for patients in whom rhythm control is desirable. The main purpose is to observe if these arrhythmias can be safely treated electively (within 5-9 days). All patients are recruited in the emergency department. Patients must be in good clinical condition so that they can be discharged regardless to which treatment modality is randomly selected to them. Patients randomized to conventional care are treated conventionally which means acute rhythm control is applied by electrical or medical cardioversion in the emergency department (within 48 hours of onset of the arrhythmia). Patients randomized to elective care are discharged immediately after adequate temporary rhythm control is assured. All patients will visit a cardiologist out-patient clinic at approximately one week after the emergency room visit. Patients randomized to elective treatment and still in atrial fibrillation or in atrial flutter will be restored to sinus rhythm by electrical or medical cardioversion at the out-patient clinic. Cardiovascular status and treatment options are evaluated for all patients. Anticoagulation is managed according existing guidelines for all patients. Due to possibility of delayed cardioversion in the interventional group (elective care group), all patients receive anticoagulation before the out-patient clinic despite their thromboembolic risk. All patients who have not received adequate anticoagulation for three weeks prior to the delayed cardioversion will undergo a transesophageal cardiac ultrasound to ensure they are not in excess risk for thromboembolic events. Patients randomized to elective treatment have the possibility to opt-out and undergo acute cardioversion if their symptoms are unmanageable during the first week before the out-patient clinical. All patients are monitored for their symptoms by a standardized quality-of-life questionnaire and for possibly required acute medical interventions during the first week and one month after the out-patient clinic. After one month, all patients undergo an electrocardiography (ECG) to ensure the maintenance of normal rhythm in both treatment groups. After the months follow-up all patients are subsequently monitored for a maximum of five years for need of medical interventions due to atrial fibrillation of atrial flutter. New antiarrhythmics such as flecainide are not prescribed during the first month.

Interventions

• Other Acute cardioversion
  Acute restoration of sinus rhythm by medical or electrical cardioversion in the emergency department
• Other Delayed cardioversion
  Delayed restoration of sinus rhythm by medical or electrical cardioversion in the out-patient clinic

Primary outcome measures

• Sinus Rhythm [Time frame: One month after preplanned out-patient clinic visit]

Secondary outcome measures (7)

• Number of cardioversions after emergency department [Time frame: First week after randomization and before the preplanned out-patient clinic]
• Number of cardioversions after out-patient clinic [Time frame: One month after out-patient clinic]
• Overall number of cardioversions [Time frame: From randomization to the end of first month follow-up after out-patient clinic visit]
• Drop-out from delayed cardioversion group [Time frame: Four days or earlier after randomization to elective (delayed) treatment group]
• Rehospitalization due to cardiovascular causes [Time frame: One week before and one month after out-patient clinic visit]
• Immediate quality of life [Time frame: First week after randomization and before the preplanned out-patient clinic]
• Quality of life after out-patient clinic [Time frame: One month after out-patient clinic]

Eligibility criteria

Inclusion criteria

• Patients presenting with acute (<48hours) atrial fibrillation or atrial flutter to ER
• Planned acute rhythm control for the arrhythmia by the attending physician in ER
• Good perceived health as assessed by attending physician in ER
• Resting heart rate 110bpm or lower before or after adequate rate control therapy

Exclusion criteria

• Haemodynamically stable (mean arterial pressure above 60mmHg)
• Need for acute restoration of sinus rhythm due to some other somatic cause
• No other major complicating acute illness (e.g. decompensated HF or acute MI)
• Anticoagulation not safe
• Mechanical heart valve or mitral stenosis
• The need for prolonged (>24h) hospitalization due to any cause
• Exceptionally high risk for thromboembolic events (e.g. history of thromboembolic stroke regardless of adequate anticoagulation)
• Transesophageal echocardiography contraindicated

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Single blind

Primary purpose

Treatment

Study locations

Finland · 4 centers

• Central Finland Central Hospital — Jyväskylä
• Kanta-Häme Central Hospital — Hämeenlinna
• Päijät-Häme Central Hospital — Lahti
• Tampere University Hospital — Tampere

Publications

• Rankinen J, Lyytikainen LP, Jarventie J, Hautamaki M, Numminen A, Hurskainen M, Rantanen M, Muuronen A, Tynkkynen J, Hernesniemi J. Acute atrial fibrillation and flutter treated electively: rationale and design of the randomized controlled AFFELECT trial. Eur Heart J Open. 2026 Apr 13;6(2):oeag060. doi: 10.1093/ehjopen/oeag060. eCollection 2026 Mar. PMID 42064618

Identifiers

NCT: NCT04267159 · ETL R19133

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗