Flecainide Versus Amiodarone in the Cardioversion of Paroxysmal Atrial Fibrillation at the Emergency Department, in Patients With Coronary Artery Disease Without Residual Ischemia

Inclusion criteria

• Age: 18-85 years old
• Paroxysmal Atrial Fibrillation, documented by 12-lead ECG, with one of the following:

• Atrial Fibrillation onset less than 48 hours from the time of presentation to the Emergency Department
• Atrial Fibrillation onset between 48 hours and 7 days from the time of presentation to the Emergency Department, and patient has been on anticoagulation for at least 30 days
• History of Coronary Artery Disease without residual ischemia, defined by one of the following criteria:

• PCI <= 1 year, or
• CABG <= 3 years, or
• Negative imaging-based stress testing within 1 year, and:

• History of known coronary artery stenosis > 60% without revascularization, or
• PCI >= 1 year, or
• CABG >= 3 years
• Ejection Fraction > 35% (documented by cardiac ultrasound at the Emergency Department, or within 1 year)
• Signed informed consent from the patient or legal representative.

Exclusion criteria

• Based on ECG at the Emergency Department:

• Atrial Flutter
• Newly documented Left Bundle Branch Block (LBBB)
• Newly documented Right Bundle Branch Block (RBBB) with QRS duration > 150ms
• Previously documented 24-hour ECG holter monitoring with > 720 poly PVCs/24hours, or non sustained ventricular tachycardia
• No history of coronary artery disease
• ST-Segment Elevation Myocardial Infarction (STEMI)
• Non-ST-Segment Elevation Myocardial Infarction (NSTEMI), according to ESC 2020 guidelines on NSTEMI:

• If troponin at t0h is over the "low" criterion on table of the cutoff values
• If the change of troponin (Δtroponin) at t1h is over the respective cutoff value at the table for the cutoff values
• Unstable angina, defined as myocardial ischemia at rest or at minimum effort, in the absence of acute injury/necrosis of myocardial cells
• Known residual ischemia:

• Positive imaging-based stress testing
• Negative imaging-based stress testing >= 1 year, and:

• History of known coronary artery stenosis > 60% without revascularization, or
• PCI >= 1 year, or
• CABG >= 3 years
• History of acute coronary syndrome within 1 year
• Severe Aortic Valve Stenosis (mean pressure gradient > 40mmHg, AVA < 1cm/m^2)
• Severe Chronic Kidney Disease (stage >= 4)
• Severe systematic disease, including neoplasmatic disease under any antineoplasmatic treatment, liver failure, infection with fever
• Use of strategy "pill in the pocket", by taking flecainide (max 200mg) or propafenone (max 600mg) within 6 hours prior to Emergency Department visit
• Known dysanexia or allergy to flecainide or amiodarone
• Pregnancy or/and breastfeeding
• Participation in any other clinical trial
• Life expectancy less than 1 year
• Inappropriate, unfit, or unwilling to follow the desingated protocol procedures.