Key result
Single-dose flecainide and propafenone achieve ~73% cardioversion of recent-onset AF at eight hours vs placebo.
Why the study?
Single oral dose anti-arrhythmic drugs are used to cardiovert recent-onset AF, but the optimal agent remains uncertain.
Do single oral dose anti-arrhythmic drugs improve successful cardioversion in patients with recent-onset atrial fibrillation?
Meta-Analysis (n=2,320)
Do single oral dose anti-arrhythmic drugs improve successful cardioversion in patients with recent-onset atrial fibrillation?
Effect estimate: OR 7.6 (95% CI 4.4-14.0)
Absolute Event Rate: 73% vs 32%
Single oral dose Class 1C anti-arrhythmic drugs (flecainide, propafenone) are effective and safe for rapid cardioversion of recent-onset atrial fibrillation, with flecainide potentially superior to propafenone.
Single-dose flecainide or propafenone merits use for recent-onset AF cardioversion; confirms superiority to placebo or rate control in network meta-analysis.
AIMS: Single oral dose anti-arrhythmic drugs (AADs) are used to cardiovert recent-onset atrial fibrillation (AF); however, the optimal agent is uncertain. METHODS: We performed a systematic review and network meta-analysis of randomized trials testing single oral dose AADs vs. any comparator to cardiovert AF <7 days duration. We searched MEDLINE, Embase, and CENTRAL to April 2020. The primary outcome was successful cardioversion at timepoint nearest 8 h after administration. RESULTS: From 12 712 citations, 22 trials (2320 patients) were included. Thirteen trials included patients with some degree of heart failure; 19 included patients with some degree of ischaemic heart disease vs. placebo or rate-control (32% success) at 8 h, flecainide [73%, network odds ratio (OR) 7.6, 95% credible interval (CrI) 4.4-14.0], propafenone (70%, OR 4.6, CrI 2.9-7.3), and pilsicainide (59%, OR 10.0, CrI 1.8-69.0), but not amiodarone (28%, OR 1.0, CrI 0.4-2.8) were superior. Flecainide (OR 7.5, CrI 2.6-24.0) and propafenone (OR 4.5, CrI 1.6-13.0) were superior to amiodarone; propafenone vs. flecainide did not statistically differ (OR 0.6, CrI 0.3-1.1). At longest follow-up, amiodarone was superior to placebo (OR 11.0, CrI 3.2-41.0), flecainide vs. amiodarone (OR 0.79, CrI 0.19-3.1), and propafenone vs. amiodarone (OR 0.36, CrI 0.092-1.4) were not statistically different, and flecainide was superior to propafenone (OR 2.2, CrI 1.1-4.8). Atrial and ventricular tachyarrhythmias, bradyarrhythmias, and hypotension were rare with PO AADs. CONCLUSION: Single oral dose Class 1C AADs are effective and safe for cardioversion of recent-onset AF. Flecainide may be superior to propafenone. Amiodarone is a slower acting alternative.
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Ibrahim et al. (2021) conducted a meta-analysis in recent-onset atrial fibrillation (n=2,320). Single oral dose anti-arrhythmic drugs (flecainide, propafenone, pilsicainide, amiodarone) vs. placebo or rate-control was evaluated on successful cardioversion at timepoint nearest 8 h after administration (OR 7.6, 95% CI 4.4-14.0). Single oral dose flecainide (73%, OR 7.6, 95% CrI 4.4-14.0) and propafenone (70%, OR 4.6) were superior to placebo or rate-control (32%) for cardioversion of recent-onset AF at 8 hours.
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