Key result
Overall cardioversion success in emergency department patients with atrial fibrillation decreased significantly with rising serum lactate levels, dropping from 79% in patients with lactate <1.1 mmol/L to 61% in those with >2.3 mmol/L.
Why the study?
In critically ill patients with AF, standard treatment algorithms might not be applicable, and the effectiveness of ED cardioversion algorithms based on lactate levels needed evaluation.
Does the severity of critical illness, surrogated by serum lactate levels, affect the success rate of electrical and medical cardioversion in emergency department patients with atrial fibrillation?
Cohort (n=3,535)
No
Does the severity of critical illness, surrogated by serum lactate levels, affect the success rate of electrical and medical cardioversion in emergency department patients with atrial fibrillation?
In critically ill emergency department patients with atrial fibrillation, rising lactate levels are associated with decreased medical cardioversion success, suggesting electrical cardioversion or rate control may be preferable.
Lactate-based ED cardioversion algorithms for AF may support individualized care; leaves open efficacy and outcomes in critically ill patients.
Objective: In critically ill patients with atrial fibrillation (AF) standard treatment algorithms might not be applicable. Emergency departments (ED) play a crucial role in implementing individualized treatment approaches. The aim of this study was to evaluate the effectiveness of ED cardioversion algorithms based on lactate levels as a surrogate for severity of illness. Design, Setting and Patients: This retrospective study was conducted at the ED of the Medical University of Vienna, Austria, between 2012 and 2022. A consecutive series of 3,535 AF episodes were analyzed. Measurement and main results: The main outcome was cardioversion success depending on serum lactate levels [mmol/L]. Lactate levels were divided into quintiles (lac <1.1, 1.1 - 1.3, 1.4 - 1.7, 1.8 - 2.3 and > 2.3mmol/L) and into two groups using a cut-off of 4mmol/L. Overall CV success decreased with rising lactate levels (79% in lac < 1.1mmol/L vs. 61% in lac > 2.3mmol/L; p < 0.001). For electrical cardioversion [eCV] (n=1,119 cases; sinus rhythm [SR] achieved in 86%) success, no significant difference was seen in relation to lactate levels. However, for medical cardioversion [mCV] (n=759; 67% SR), conversion success decreased with increasing lactate levels (SR: lac < 1.1mmol/L 84% vs. lac > 2.3mmol/L 59%; p < 0.001). Conclusion: Overall cardioversion success was less likely with rising lactate levels; especially medical cardioversion success rates decreased. Therefore, AF in the critically ill may benefit from either electrical cardioversion, treatment of the underlying condition or primary rate control, rather than medical cardioversion attempts.
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Gupta et al. (2023) conducted a cohort in Atrial fibrillation (n=3,535). Elevated serum lactate levels vs. Low serum lactate levels was evaluated on Cardioversion success (restoration of sinus rhythm) (p=<0.001). Overall cardioversion success in emergency department patients with atrial fibrillation decreased significantly with rising serum lactate levels, dropping from 79% in patients with lactate <1.1 mmol/L to 61% in those with >2.3 mmol/L.
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