Effectiveness of Immediate Pharmacological Versus Electrical Cardioversion on Hemodynamic Stability and Rhythm Restoration in Patients With Refractory Atrial Fibrillation: A Systematic Review.

Atrial fibrillation (AF) is the most frequently encountered arrhythmia in emergency departments (EDs), often requiring urgent rhythm control when rate control fails. This systematic review and meta-analysis compare electrical cardioversion (ECV) and pharmacological cardioversion (PCV) in adult patients with both new-onset AF (NOAF) and refractoryAF, defined in the included studies as AF unresponsive to initial rate control and necessitating immediate rhythm intervention due to ongoing symptoms or hemodynamic instability. A comprehensive literature search was conducted in PubMed, Google Scholar and Cochrane Library. Eligible studies included randomized or observational trials comparing ECV and PCV in emergency settings. Screening and selection were performed independently and in duplicate. Eight studies (n=1,561) were included. ECV generally showed higher rhythm restoration rates, especially in persistent AF (e.g., 59.1% vs 12.5%; p=0.002). However, the pooled odds ratio (OR) was 1.31 (95% confidence interval (CI): 0.55-3.13; p=0.55), indicating no significant difference. Wide CIs and high heterogeneity (I²=88%) reflect imprecision and possible underpowering. Findings in persistent AF were not from a predefined subgroup analysis and should be interpreted cautiously. Three studies assessed discharge rates; pooled analysis showed no significant difference (OR=0.66, 95% CI: 0.24-1.79; p=0.42; I²=77%), despite individual studies favoring ECV for earlier discharge. Both strategies were safe, with no deaths or major complications. Safety assessments included hypotension, bradyarrhythmias, and procedural complications. Minor adverse events were rare and transient. In conclusion, ECV and PCV are both effective and safe for managing refractory AF in emergency settings. Clinical choice should consider patient-specific factors and provider experience.