CRP: does it stand for C oronary R estenosis P rediction?

fibrillation recedes very rapidly after the first few minutes following cardioversion as a result of the rapid early phase of reverse remodelling of atrial myocardial electrophysiology, to pace the atria rapidly during this period, such as the 300 ms intervals as in the study in this issue, may actually attenuate this reverse remodelling and perpetuate the profibrillatory state. This may explain the lack of incremental benefit of pacing if excessively rapid. What can be concluded about pacing in early recurrence of atrial fibrillation? Is the evidence so compelling that we should consider cardioverting all patients internally in order that they can all be paced for a period after initial success? From the study in this issue, in that only 12 patients fulfilled the inclusion criteria of having repeatable early recurrence of atrial fibrillation after two successive shocks, broad generalizations for clinical practice cannot be drawn. What also cannot be established from this study is whether post cardioversion right atrial pacing in all patients would actually provoke atrial fibrillation in a proportion of patients who would not otherwise have had early recurrence of atrial fibrillation. It would not take many of the remaining 33 non-ERAF patients to have atrial fibrillation reinitiated by routine use of pacing to annihilate the benefits. The tiered strategy of atrial pacing and then intravenous sotalol for early recurrence of atrial fibrillation adopted in this study resulted in a 96% success rate of a single session of internal cardioversion. It remains to be proven whether such an impressive outcome can be achieved in larger studies. N. S. PETERS Department of Cardiology Imperial College Medical School at St Mary’s Hospital, London, U.K.