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STUDY OBJECTIVE: We conduct a systematic review and Bayesian network meta-analysis to indirectly compare and rank antidysrhythmic drugs for pharmacologic cardioversion of recent-onset atrial fibrillation and atrial flutter in the emergency department (ED).
METHODS: We searched MEDLINE, EMBASE, and Web of Science from inception to March 2019, limited to human subjects and English language. We also searched for unpublished data. We limited studies to randomized controlled trials that enrolled adult patients with recent-onset atrial fibrillation or atrial flutter and compared antidysrhythmic agents, placebo, or control. We determined these outcomes before data extraction: rate of conversion to sinus rhythm within 4 hours, time to cardioversion, rate of significant adverse events, and rate of thromboembolism within 30 days. We extracted data according to Preferred Reporting Items for Systematic Reviews and Meta-analyses network meta-analysis and appraised selected trials with the Cochrane review handbook.
RESULTS: The systematic review initially identified 640 studies; 19 met inclusion criteria. Eighteen trials that randomized 2,069 atrial fibrillation patients provided data for atrial fibrillation conversion rate outcome. Bayesian network meta-analysis using a random-effects model demonstrated that antazoline (odds ratio [OR] 24.9; 95% credible interval [CrI] 7.4 to 107.8), tedisamil (OR 12.0; 95% CrI 4.3 to 43.8), vernakalant (OR 7.5; 95% CrI 3.1 to 18.6), propafenone (OR 6.8; 95% CrI 3.6 to 13.8), flecainide (OR 6.1; 95% CrI 2.9 to 13.2), and ibutilide (OR 4.1; 95% CrI 1.8 to 9.6) were associated with increased likelihood of conversion within 4 hours compared with placebo or control. Overall quality was low, and the network exhibited inconsistency.
CONCLUSION: For pharmacologic cardioversion of recent-onset atrial fibrillation within a 4-hour ED visit, there is insufficient evidence to determine which treatment is superior. Several agents are associated with increased likelihood of conversion within 4 hours compared with placebo or control. Limited data preclude any recommendation for cardioversion of recent-onset atrial flutter. Further high-quality study is necessary.
A useful meta-analysis but most cardiologists know this.
It is not known which drug is superior.
Several agents like antazoline (odds ratio [OR] 24.9; 95% credible interval [CrI] 7.4 to 107.8), tedisamil (OR 12.0; 95% CrI 4.3 to 43.8), vernakalant (OR 7.5; 95% CrI 3.1 to 18.6), propafenone (OR 6.8; 95% CrI 3.6 to 13.8), flecainide (OR 6.1; 95% CrI 2.9 to 13.2), and ibutilide (OR 4.1; 95% CrI 1.8 to 9.6) are associated with increased likelihood of conversion within 4 hours compared with placebo or control. Limited data preclude any recommendation for cardioversion of recent-onset atrial flutter. Further high-quality study is necessary.
This work introduces a great insight to relative new treatments (not in 2014 Guidelines AHA/ACC/HRS) like Antazoline with a OR of 24.9 and SUCRA 0.972 even with a small population and limited data in the clinical trial. The article reinforce the guidelines of approved pharmacological options like Vernakalant, Flecainide, Propafenone, Ibutilide and Procainamide and exposes no RCT with dofetilide approved by the AHA which I think is a nice find. We could establish a change in clinical practice in ED if we manage the limitations found in the randomized clinical trials analyzed and use them as endpoints, follow up and adverse reactions for future clinical trials in order to obtain better evidence this manner.
The efficacy of antiarrhythmic drugs in pharmacologic cardioversion of recent-onset atrial fibrillation is well known, and, although this paper is a good summary of antiarrhythmic therapy in patients with new onset AF/Flutter, the novelty of the study is poor. Furthermore, the authors analyzed the rate of thromboembolic events within 30 days from new onset AF and no found any thromboembolic event. However, this secondary analysis was performed on only 2 studies and may present bias because it was influenced by CHA2DS2-VASc score of patients and anticoagulant therapy. Therefore, the analysis of thromboembolism rate not improves the quality and the useful of findings in clinical practice and may be confounding.
This is a very good overview of pharmacologic cardioversion (within 4 hours of onset) of atrial fibrillation and flutter. Amidarone is not the first choice because of its delayed effect, however in the subgroup of patients with AF and systolic dysfunction IV amiodarone is preferred.