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deSouza IS, Shrestha P, Allen R, Koos J, Thode H. Safety and Effectiveness of Antidysrhythmic Drugs for Pharmacologic Cardioversion of Recent-Onset Atrial Fibrillation: a Systematic Review and Bayesian Network Meta-analysis. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07552-6. [PMID: 38324103 DOI: 10.1007/s10557-024-07552-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/08/2024]
Abstract
PURPOSE The available evidence to determine which antidysrhythmic drug is superior for pharmacologic cardioversion of recent-onset (onset within 48 h) atrial fibrillation (AF) is uncertain. We aimed to identify the safest and most effective agent for pharmacologic cardioversion of recent-onset AF in the emergency department. METHODS We searched MEDLINE, Embase, and Web of Science from inception to February 21, 2023 (PROSPERO: CRD42018083781). Eligible studies were randomized controlled trials that enrolled adult participants with AF ≤ 48 h, compared a guideline-recommended antidysrhythmic drug with another antidysrhythmic drug or a different formulation of the same drug or placebo and reported specific adverse events. The primary outcome was immediate, serious adverse event - cardiac arrest, sustained ventricular tachydysrhythmia, atrial flutter 1:1 atrioventricular conduction, hypotension, and bradycardia. Additional analyses included the outcomes of conversion to sinus rhythm within 4 h and 24 h. We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effect model and vague prior distribution to calculate odds ratios with 95% credible intervals. We assessed confidence using CINeMA. We used surface under the cumulative ranking curve (SUCRA) to rank agent(s). RESULTS The systematic review initially identified 5545 studies. Twenty-five studies met eligibility criteria, and 22 studies (n = 3082) provided data for NMA, which demonstrated that vernakalant (SUCRA = 70.9%) is most likely to be safest. Additional effectiveness NMA demonstrated that flecainide (SUCRA = 89.0%) is most likely to be superior for conversion within 4 h (27 studies; n = 2681), and ranolazine-amiodarone IV (SUCRA 93.7%) is most likely to be superior for conversion within 24 h (24 studies; n = 3213). Confidence in the NMA estimates is variable and limited mostly by within-study bias and imprecision. CONCLUSIONS Among guideline-recommended antidysrhythmic drugs, the combination of digoxin IV and amiodarone IV is definitely among the least safe for cardioversion of recent onset AF; flecainide, vernakalant, ibutilide, propafenone, and amiodarone IV are definitely among the most effective for cardioversion within 4 h; flecainide is definitely among the most effective for cardioversion within 24 h. Further, randomized controlled trials with predetermined and strictly defined, hemodynamic adverse event outcomes are recommended.
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Affiliation(s)
- Ian S deSouza
- Department of Emergency Medicine, SUNY Downstate Health Sciences University and Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY, 11203, USA.
| | - Pragati Shrestha
- Department of Family, Population and Preventive Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Robert Allen
- Department of Emergency Medicine, Los Angeles General Medical Center, Los Angeles, CA, USA
| | - Jessica Koos
- Health Sciences Library, Stony Brook University, Stony Brook, NY, USA
| | - Henry Thode
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA
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Tsioufis P, Tsiachris D, Doundoulakis I, Kordalis A, Antoniou CK, Vlachakis PK, Theofilis P, Manta E, Gatzoulis KA, Parissis J, Tsioufis K. Rationale and Design of a Randomized Controlled Clinical Trial on the Safety and Efficacy of Flecainide versus Amiodarone in the Cardioversion of Atrial Fibrillation at the Emergency Department in Patients with Coronary Artery Disease (FLECA-ED). J Clin Med 2023; 12:3961. [PMID: 37373655 PMCID: PMC10299428 DOI: 10.3390/jcm12123961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/04/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
Pharmacologic cardioversion is a well-established alternative to electric cardioversion for hemodynamically stable patients, as it skips the risks associated with anesthesia. A recent network meta-analysis identifies the most effective antiarrhythmics for pharmacologic cardioversion with flecainide exhibiting a more efficacious and safer profile towards faster cardioversion. Moreover, the meta-analysis of class Ic antiarrhythmics revealed an absence of adverse events when used for pharmacologic cardioversion of AF in the ED, including patients with structural heart disease. The primary goals of this clinical trial are to prove the superiority of flecainide over amiodarone in the successful cardioversion of paroxysmal atrial fibrillation in the Emergency Department and to prove that the safety of flecainide is non-inferior to amiodarone in patients with coronary artery disease without residual ischemia, and an ejection fraction over 35%. The secondary goals of this study are to prove the superiority of flecainide over amiodarone in the reduction in hospitalizations from the Emergency Department due to atrial fibrillation in the time taken to achieve cardioversion, and in the reduction in the need to conduct electrical cardioversion.
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Affiliation(s)
- Panagiotis Tsioufis
- First Department of Cardiology, Hippocration General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (I.D.); (A.K.); (E.M.); (K.A.G.); (K.T.)
| | - Dimitris Tsiachris
- First Department of Cardiology, Hippocration General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (I.D.); (A.K.); (E.M.); (K.A.G.); (K.T.)
- Athens Heart Center, Athens Medical Center, 11526 Athens, Greece
| | - Ioannis Doundoulakis
- First Department of Cardiology, Hippocration General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (I.D.); (A.K.); (E.M.); (K.A.G.); (K.T.)
- Athens Heart Center, Athens Medical Center, 11526 Athens, Greece
| | - Athanasios Kordalis
- First Department of Cardiology, Hippocration General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (I.D.); (A.K.); (E.M.); (K.A.G.); (K.T.)
| | - Christos-Konstantinos Antoniou
- First Department of Cardiology, Hippocration General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (I.D.); (A.K.); (E.M.); (K.A.G.); (K.T.)
- Athens Heart Center, Athens Medical Center, 11526 Athens, Greece
| | - Panayotis K. Vlachakis
- First Department of Cardiology, Hippocration General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (I.D.); (A.K.); (E.M.); (K.A.G.); (K.T.)
| | - Panagiotis Theofilis
- First Department of Cardiology, Hippocration General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (I.D.); (A.K.); (E.M.); (K.A.G.); (K.T.)
| | - Eleni Manta
- First Department of Cardiology, Hippocration General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (I.D.); (A.K.); (E.M.); (K.A.G.); (K.T.)
| | - Konstantinos A. Gatzoulis
- First Department of Cardiology, Hippocration General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (I.D.); (A.K.); (E.M.); (K.A.G.); (K.T.)
| | - John Parissis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Konstantinos Tsioufis
- First Department of Cardiology, Hippocration General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.T.); (I.D.); (A.K.); (E.M.); (K.A.G.); (K.T.)
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3
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Niforatos JD, Ehmann MR, Balhara KS, Hinson JS, Ramcharran L, Lobner K, Weygandt PL. Management of atrial flutter and atrial fibrillation with rapid ventricular response in patients with acute decompensated heart failure: A systematic review. Acad Emerg Med 2023; 30:124-132. [PMID: 36326565 DOI: 10.1111/acem.14618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/15/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective was to evaluate the comparative effectiveness and safety of pharmacological and nonpharmacological management options for atrial fibrillation/atrial flutter with rapid ventricular response (AFRVR) in patients with acute decompensated heart failure (ADHF) in the acute care setting. METHODS This study was a systematic review of observational studies or randomized clinical trials (RCT) of adult patients with AFRVR and concomitant ADHF in the emergency department (ED), intensive care unit, or step-down unit. The primary effectiveness outcome was successful rate or rhythm control. Safety outcomes were adverse events, such as symptomatic hypotension and venous thromboembolism. RESULTS A total of 6577 unique articles were identified. Five studies met inclusion criteria: one RCT in the inpatient setting and four retrospective studies, two in the ED and the other three in the inpatient setting. In the RCT of diltiazem versus placebo, 22 patients (100%) in the treatment group had a therapeutic response compared to 0/15 (0%) in the placebo group, with no significant safety differences between the two groups. For three of the observational studies, data were limited. One observation study showed no difference between metoprolol and diltiazem for successful rate control, but worsening heart failure symptoms occurred more frequently in those receiving diltiazem compared to metoprolol (19 patients [33%] vs. 10 patients [15%], p = 0.019). A single study included electrical cardioversion (one patient exposed with failure to convert to sinus rhythm) as nonpharmacological management. The overall risk of bias for included studies ranged from serious to critical. Missing data and heterogeneity of definitions for effectiveness and safety outcomes precluded the combination of results for quantitative meta-analysis. CONCLUSIONS High-level evidence to inform clinical decision making regarding effective and safe management of AFRVR in patients with ADHF in the acute care setting is lacking.
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Affiliation(s)
- Joshua D Niforatos
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael R Ehmann
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kamna S Balhara
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lukas Ramcharran
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Katie Lobner
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - P Logan Weygandt
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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4
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Tang Y, Wang Y, Sun X, Shi Y, Liu S, Jiang W, Yuan H, Lu Y, Cai J, Wu J. Effect of Early Pharmacologic Cardioversion vs. Non-early Cardioversion in the Patients With Recent-Onset Atrial Fibrillation Within 4-Week Follow-Up Period: A Systematic Review and Network Meta-Analysis. Front Cardiovasc Med 2022; 9:843939. [PMID: 35479281 PMCID: PMC9036487 DOI: 10.3389/fcvm.2022.843939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 03/14/2022] [Indexed: 12/02/2022] Open
Abstract
Background Whether early pharmacologic cardioversion is necessary for recent-onset atrial fibrillation is still controversial. Current meta-analyses were limited to evaluating the effects within 24 h without sufficient considering longer follow-up outcomes. We aimed to compare the effect of early pharmacologic cardioversion and non-early cardioversion in patients with recent-onset atrial fibrillation within 4-weeks of follow-up. Methods We searched the Cochrane Library, EMBASE, MEDLINE, PubMed, Web of Science, ClinicalTrials.gov, and Clinicaltrialsregister. eu for randomized controlled trials (RCTs) published before November 2021 comparing early pharmacologic cardioversion and non-early cardioversion in recent-onset atrial fibrillation and synthesized data in accordance with PRISMA-Systematic Reviews and Network Meta-Analysis (NMA). Early pharmacological cardioversion referred to immediate cardioversion with antiarrhythmic drugs (i.e., amiodarone, propafenone, flecainide, tedisamil, vernakalant, vanoxerine, and sotalol) upon admission, while non-early cardioversion involved the administration of rate-control or placebo medication without immediate cardioversion. Results 16 RCTs with 2,395 patients were included. Compared to non-early cardioversion, a systematic review showed that early pharmacologic cardioversion resulted in a higher probability of sinus rhythm maintenance within 24 h (odds ratios [OR] 2.50, 95% credible interval [CrI] 1.76 to 3.54) and 1-week (2.50, 1.76 to 3.54), however, there was no significant difference in sinus rhythm maintenance within 4-weeks (1.37, 0.90 to 2.09). In subgroup analysis, the Bayesian NMA revealed that vernakalant may be successful in sinus rhythm maintenance within both 24 h (3.55, 2.28 to 5.55) and 1-week (2.72, 1.72 to 4.31). The results were consistent with the frequentist NMA. Conclusions Non-early pharmacologic cardioversion may not be inferior to early cardioversion within a 4-week follow-up period in patients with recent-onset atrial fibrillation. The evidence remains insufficient to determine which antiarrhythmic agent is optimal in the longer run. Further high-quality relevant RCTs are necessary. Clinical Trial Registration PROSPERO CRD42020166862.
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Affiliation(s)
- Yan Tang
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Yujie Wang
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Xuejing Sun
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Yunmin Shi
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Suzhen Liu
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Weihong Jiang
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Hong Yuan
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Yao Lu
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Jingjing Cai
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Jingjing Cai
| | - Junru Wu
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, China
- Junru Wu
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5
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Tsiachris D, Doundoulakis I, Tsioufis K. Pharmacologic Cardioversion of Paroxysmal Atrial Fibrillation in the Emergency Department in the Novel Anticoagulants' Era. Cardiovasc Drugs Ther 2022; 36:1253-1254. [PMID: 35218470 DOI: 10.1007/s10557-022-07330-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Dimitris Tsiachris
- Athens Heart Center, Athens Medical Center, Distomou 5-7, 15125, Athens, Greece.
| | - Ioannis Doundoulakis
- Athens Heart Center, Athens Medical Center, Distomou 5-7, 15125, Athens, Greece
- First Department of Cardiology, National and Kapodistrian University, "Hippokration" Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, National and Kapodistrian University, "Hippokration" Hospital, Athens, Greece
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6
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deSouza IS, Allen R, Shrestha P. Reassessment of Confidence in a Network Meta-analysis of Antidysrhythmic Drugs for Atrial Fibrillation Cardioversion. Cardiovasc Drugs Ther 2022; 36:1249-1251. [DOI: 10.1007/s10557-022-07318-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2022] [Indexed: 11/03/2022]
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7
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Papathanasiou KA, Giotaki SG, Vrachatis DA, Siasos G, Lambadiari V, Iliodromitis KE, Kossyvakis C, Kaoukis A, Raisakis K, Deftereos G, Papaioannou TG, Giannopoulos G, Avramides D, Deftereos SG. Molecular Insights in Atrial Fibrillation Pathogenesis and Therapeutics: A Narrative Review. Diagnostics (Basel) 2021; 11:diagnostics11091584. [PMID: 34573926 PMCID: PMC8470040 DOI: 10.3390/diagnostics11091584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 12/15/2022] Open
Abstract
The prevalence of atrial fibrillation (AF) is bound to increase globally in the following years, affecting the quality of life of millions of people, increasing mortality and morbidity, and beleaguering health care systems. Increasingly effective therapeutic options against AF are the constantly evolving electroanatomic substrate mapping systems of the left atrium (LA) and ablation catheter technologies. Yet, a prerequisite for better long-term success rates is the understanding of AF pathogenesis and maintenance. LA electrical and anatomical remodeling remains in the epicenter of current research for novel diagnostic and treatment modalities. On a molecular level, electrical remodeling lies on impaired calcium handling, enhanced inwardly rectifying potassium currents, and gap junction perturbations. In addition, a wide array of profibrotic stimuli activates fibroblast to an increased extracellular matrix turnover via various intermediaries. Concomitant dysregulation of the autonomic nervous system and the humoral function of increased epicardial adipose tissue (EAT) are established mediators in the pathophysiology of AF. Local atrial lymphomononuclear cells infiltrate and increased inflammasome activity accelerate and perpetuate arrhythmia substrate. Finally, impaired intracellular protein metabolism, excessive oxidative stress, and mitochondrial dysfunction deplete atrial cardiomyocyte ATP and promote arrhythmogenesis. These overlapping cellular and molecular alterations hinder us from distinguishing the cause from the effect in AF pathogenesis. Yet, a plethora of therapeutic modalities target these molecular perturbations and hold promise in combating the AF burden. Namely, atrial selective ion channel inhibitors, AF gene therapy, anti-fibrotic agents, AF drug repurposing, immunomodulators, and indirect cardiac neuromodulation are discussed here.
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Affiliation(s)
- Konstantinos A. Papathanasiou
- Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (K.A.P.); (S.G.G.); (D.A.V.); (G.S.); (V.L.); (T.G.P.)
| | - Sotiria G. Giotaki
- Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (K.A.P.); (S.G.G.); (D.A.V.); (G.S.); (V.L.); (T.G.P.)
| | - Dimitrios A. Vrachatis
- Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (K.A.P.); (S.G.G.); (D.A.V.); (G.S.); (V.L.); (T.G.P.)
| | - Gerasimos Siasos
- Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (K.A.P.); (S.G.G.); (D.A.V.); (G.S.); (V.L.); (T.G.P.)
| | - Vaia Lambadiari
- Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (K.A.P.); (S.G.G.); (D.A.V.); (G.S.); (V.L.); (T.G.P.)
| | | | - Charalampos Kossyvakis
- Department of Cardiology, “G. Gennimatas” General Hospital of Athens, 11527 Athens, Greece; (C.K.); (A.K.); (K.R.); (G.D.); (D.A.)
| | - Andreas Kaoukis
- Department of Cardiology, “G. Gennimatas” General Hospital of Athens, 11527 Athens, Greece; (C.K.); (A.K.); (K.R.); (G.D.); (D.A.)
| | - Konstantinos Raisakis
- Department of Cardiology, “G. Gennimatas” General Hospital of Athens, 11527 Athens, Greece; (C.K.); (A.K.); (K.R.); (G.D.); (D.A.)
| | - Gerasimos Deftereos
- Department of Cardiology, “G. Gennimatas” General Hospital of Athens, 11527 Athens, Greece; (C.K.); (A.K.); (K.R.); (G.D.); (D.A.)
| | - Theodore G. Papaioannou
- Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (K.A.P.); (S.G.G.); (D.A.V.); (G.S.); (V.L.); (T.G.P.)
| | | | - Dimitrios Avramides
- Department of Cardiology, “G. Gennimatas” General Hospital of Athens, 11527 Athens, Greece; (C.K.); (A.K.); (K.R.); (G.D.); (D.A.)
| | - Spyridon G. Deftereos
- Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (K.A.P.); (S.G.G.); (D.A.V.); (G.S.); (V.L.); (T.G.P.)
- Correspondence: ; Tel.: +30-21-0583-2355
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8
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Stiell IG, Sivilotti MLA, Taljaard M, Birnie D, Vadeboncoeur A, Hohl CM, McRae AD, Morris J, Mercier E, Macle L, Brison RJ, Thiruganasambandamoorthy V, Rowe BH, Borgundvaag B, Clement CM, Brinkhurst J, Brown E, Nemnom MJ, Wells GA, Perry JJ. A randomized, controlled comparison of electrical versus pharmacological cardioversion for emergency department patients with acute atrial flutter. CAN J EMERG MED 2021; 23:314-324. [PMID: 33959925 DOI: 10.1007/s43678-020-00067-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/09/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute atrial flutter has one-tenth the prevalence of acute atrial fibrillation in the emergency department (ED) but shares many management strategies. Our aim was to compare conversion from acute atrial flutter to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (Drug-Shock), and electrical cardioversion alone (Shock-Only). METHODS We conducted a randomized, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with IV procainamide followed by electrical cardioversion if necessary, and placebo infusion followed by electrical cardioversion. We enrolled stable patients with a primary diagnosis of acute acute atrial flutter at 11 academic EDs. The primary outcome was conversion to normal sinus rhythm. FINDINGS From July 2013 to October 2018, we enrolled 76 patients, and none were lost to follow-up. Comparing the Drug-Shock to the Shock-Only group, conversion to sinus rhythm occurred in 33 (100%) versus 40 (93%) (absolute difference 7.0%; 95% CI - 0.6 to 14.6; P = 0.25). Median time to conversion from start of infusion in the Drug-Shock group was 24 min (IQR 21-82) but only 9 (27%) cases were converted with IV procainamide. Patients in both groups had similar outcomes at 14 days; there were no strokes or deaths. INTERPRETATION This trial found that the Drug-Shock strategy is potentially superior but that either approach to immediate rhythm control in the ED for patients with acute acute atrial flutter is highly effective, rapid, and safe in restoring sinus rhythm and allowing patients to go home and return to normal activities. Unlike the case of atrial fibrillation, we found that IV procainamide alone was infrequently effective.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | | | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - David Birnie
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada
| | - Alain Vadeboncoeur
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Andrew D McRae
- Department of Emergency Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Judy Morris
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Eric Mercier
- Department of Family Medicine and Emergency Medicine, Centre de Recherche du CHU de Québec, Université Laval, Québec, QC, Canada
| | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Robert J Brison
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Bjug Borgundvaag
- Division of Emergency Medicine, Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Catherine M Clement
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jennifer Brinkhurst
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Erica Brown
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - George A Wells
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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9
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Tsiachris D, Doundoulakis I, Pagkalidou E, Kordalis A, Deftereos S, Gatzoulis KA, Tsioufis K, Stefanadis C. Pharmacologic Cardioversion in Patients with Paroxysmal Atrial Fibrillation: A Network Meta-Analysis. Cardiovasc Drugs Ther 2021; 35:293-308. [PMID: 33400054 DOI: 10.1007/s10557-020-07127-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE We sought to indirectly compare and rank antiarrhythmic agents focusing exclusively on adults with paroxysmal atrial fibrillation in order to identify the most effective for pharmacologic cardioversion over different time settings (4 h as primary, and 12, 24 h as secondary outcomes). METHODS We searched several databases from inception to March 2020 without language restrictions, ClinicalTrials.gov, references of reviews, and meeting abstract material. We included randomized controlled trials of patients with AF lasting ≤7 days comparing either two or more intravenous (i.v.) or oral (p.o.) pharmacologic cardioversion agents or an agent against placebo. For each outcome, we performed network meta-analysis based on the frequentist approach. RESULTS Forty-one trials (6013 patients) were included in our systematic review. Moderate confidence evidence suggests that i.v. vernakalant and flecainide have the highest conversion rate within 4 h, possibly allowing discharge from the emergency department and reducing hospital admissions. Intravenous and p.o. formulations of class IC antiarrhythmics (flecainide more so than propafenone) are superior regarding conversion rates within 12 h, while amiodarone efficacy is exhibited in a delayed fashion (within 24 h), especially if ranolazine is added. CONCLUSION Our network meta-analysis identified with sufficient power and consistency the most effective antiarrhythmics for pharmacologic cardioversion over different time settings, with vernakalant and flecainide exhibiting a safer and more efficacious profile toward faster cardioversion.
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Affiliation(s)
- Dimitris Tsiachris
- Athens Heart Center, Athens Medical Center, Distomou 5-7, 15125, Athens, Greece.
| | - Ioannis Doundoulakis
- Athens Heart Center, Athens Medical Center, Distomou 5-7, 15125, Athens, Greece.,First Department of Cardiology, University of Athens Medical School, Athens, Greece
| | - Eirini Pagkalidou
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athanasios Kordalis
- Athens Heart Center, Athens Medical Center, Distomou 5-7, 15125, Athens, Greece
| | - Spyridon Deftereos
- Second Department of Cardiology, University of Athens Medical School, Athens, Greece.,Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Christodoulos Stefanadis
- Athens Heart Center, Athens Medical Center, Distomou 5-7, 15125, Athens, Greece.,Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
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10
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Ritchie LA, Qin S, Penson PE, Henney NC, Lip GY. Vernakalant hydrochloride for the treatment of atrial fibrillation: evaluation of its place in clinical practice. Future Cardiol 2020; 16:585-595. [PMID: 32460637 DOI: 10.2217/fca-2020-0039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Vernakalant is an intravenous anti-arrhythmic drug available in Europe, Canada and some countries in Asia for the restoration of sinus rhythm in acute onset atrial fibrillation. Currently, it is not available in USA because the US FDA have ongoing concerns about its safety. Vernakalant has a unique pharmacological profile of multi-ion channel activity and atrial-specificity that distinguishes it from other anti-arrhythmic drugs. This is thought to enhance efficacy but there are concerns of adverse events stemming from its diverse pharmacology. This ambiguity has prompted a review of the available clinical evidence on efficacy and safety to help re-evaluate its place in clinical practice.
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Affiliation(s)
- Leona A Ritchie
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart & Chest Hospital, Liverpool, L7 8TX, UK
| | - Shuguang Qin
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart & Chest Hospital, Liverpool, L7 8TX, UK.,Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an Jiaotong University, Xi'an 710004, China
| | - Peter E Penson
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart & Chest Hospital, Liverpool, L7 8TX, UK.,School of Pharmacy & Biomolecular Sciences, Liverpool John Moores University, Liverpool, L3 3AF, UK
| | - Neil C Henney
- School of Pharmacy & Biomolecular Sciences, Liverpool John Moores University, Liverpool, L3 3AF, UK
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart & Chest Hospital, Liverpool, L7 8TX, UK
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11
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Westafer LM, Schriger DL. Deconstructing the Network Meta-analysis. Ann Emerg Med 2020; 76:31-33. [PMID: 32331841 DOI: 10.1016/j.annemergmed.2020.02.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Lauren M Westafer
- Institute for Healthcare Delivery and Population Science and Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA.
| | - David L Schriger
- Department of Emergency Medicine, University of California, Los Angeles, CA
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