Comparison of intravenous flecainide, propafenone, and amiodarone for conversion of acute atrial fibrillation to sinus rhythm

External electrical and pharmacological cardioversion for atrial fibrillation, atrial flutter or atrial tachycardias: a network meta-analysis

BACKGROUND

Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion).

OBJECTIVES

To assess the efficacy and safety of pharmacological and electrical cardioversion for atrial fibrillation (AF), atrial flutter and atrial tachycardias.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Conference Proceedings Citation Index-Science (CPCI-S) and three trials registers (ClinicalTrials.gov, WHO ICTRP and ISRCTN) on 14 February 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) at the individual patient level. Patient populations were aged ≥ 18 years with AF of any type and duration, atrial flutter or other sustained related atrial arrhythmias, not occurring as a result of reversible causes.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology to collect data and performed a network meta-analysis using the standard frequentist graph-theoretical approach using the netmeta package in R. We used GRADE to assess the quality of the evidence which we presented in our summary of findings with a judgement on certainty. We calculated differences using risk ratios (RR) and 95% confidence intervals (CI) as well as ranking treatments using a P value. We assessed clinical and statistical heterogeneity and split the networks for the primary outcome and acute procedural success, due to concerns about violating the transitivity assumption.

MAIN RESULTS

We included 112 RCTs (139 records), from which we pooled data from 15,968 patients. The average age ranged from 47 to 72 years and the proportion of male patients ranged from 38% to 92%. Seventy-nine trials were considered to be at high risk of bias for at least one domain, 32 had no high risk of bias domains, but had at least one domain classified as uncertain risk, and one study was considered at low risk for all domains. For paroxysmal AF (35 trials), when compared to placebo, anteroapical (AA)/anteroposterior (AP) biphasic truncated exponential waveform (BTE) cardioversion (RR: 2.42; 95% CI 1.65 to 3.56), quinidine (RR: 2.23; 95% CI 1.49 to 3.34), ibutilide (RR: 2.00; 95% CI 1.28 to 3.12), propafenone (RR: 1.98; 95% CI 1.67 to 2.34), amiodarone (RR: 1.69; 95% CI 1.42 to 2.02), sotalol (RR: 1.58; 95% CI 1.08 to 2.31) and procainamide (RR: 1.49; 95% CI 1.13 to 1.97) likely result in a large increase in maintenance of sinus rhythm until hospital discharge or end of study follow-up (certainty of evidence: moderate). The effect size was larger for AA/AP incremental and was progressively smaller for the subsequent interventions. Despite low certainty of evidence, antazoline may result in a large increase (RR: 28.60; 95% CI 1.77 to 461.30) in this outcome. Similarly, low-certainty evidence suggests a large increase in this outcome for flecainide (RR: 2.17; 95% CI 1.68 to 2.79), vernakalant (RR: 2.13; 95% CI 1.52 to 2.99), and magnesium (RR: 1.73; 95% CI 0.79 to 3.79). For persistent AF (26 trials), one network was created for electrical cardioversion and showed that, when compared to AP BTE incremental energy with patches, AP BTE maximum energy with patches (RR 1.35, 95% CI 1.17 to 1.55) likely results in a large increase, and active compression AP BTE incremental energy with patches (RR: 1.14, 95% CI 1.00 to 1.131) likely results in an increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: high). Use of AP BTE incremental with paddles (RR: 1.03, 95% CI 0.98 to 1.09; certainty of evidence: low) may lead to a slight increase, and AP MDS Incremental paddles (RR: 0.95, 95% CI 0.86 to 1.05; certainty of evidence: low) may lead to a slight decrease in efficacy. On the other hand, AP MDS incremental energy using patches (RR: 0.78, 95% CI 0.70 to 0.87), AA RBW incremental energy with patches (RR: 0.76, 95% CI 0.66 to 0.88), AP RBW incremental energy with patches (RR: 0.76, 95% CI 0.68 to 0.86), AA MDS incremental energy with patches (RR: 0.76, 95% CI 0.67 to 0.86) and AA MDS incremental energy with paddles (RR: 0.68, 95% CI 0.53 to 0.83) probably result in a decrease in this outcome when compared to AP BTE incremental energy with patches (certainty of evidence: moderate). The network for pharmacological cardioversion showed that bepridil (RR: 2.29, 95% CI 1.26 to 4.17) and quindine (RR: 1.53, (95% CI 1.01 to 2.32) probably result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up when compared to amiodarone (certainty of evidence: moderate). Dofetilide (RR: 0.79, 95% CI 0.56 to 1.44), sotalol (RR: 0.89, 95% CI 0.67 to 1.18), propafenone (RR: 0.79, 95% CI 0.50 to 1.25) and pilsicainide (RR: 0.39, 95% CI 0.02 to 7.01) may result in a reduction in this outcome when compared to amiodarone, but the certainty of evidence is low. For atrial flutter (14 trials), a network could be created only for antiarrhythmic drugs. Using placebo as the common comparator, ibutilide (RR: 21.45, 95% CI 4.41 to 104.37), propafenone (RR: 7.15, 95% CI 1.27 to 40.10), dofetilide (RR: 6.43, 95% CI 1.38 to 29.91), and sotalol (RR: 6.39, 95% CI 1.03 to 39.78) probably result in a large increase in the maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: moderate), and procainamide (RR: 4.29, 95% CI 0.63 to 29.03), flecainide (RR 3.57, 95% CI 0.24 to 52.30) and vernakalant (RR: 1.18, 95% CI 0.05 to 27.37) may result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up (certainty of evidence: low). All tested electrical cardioversion strategies for atrial flutter had very high efficacy (97.9% to 100%). The rate of mortality (14 deaths) and stroke or systemic embolism (3 events) at 30 days was extremely low. Data on quality of life were scarce and of uncertain clinical significance. No information was available regarding heart failure readmissions. Data on duration of hospitalisation was scarce, of low quality, and could not be pooled.

AUTHORS' CONCLUSIONS

Despite the low quality of evidence, this systematic review provides important information on electrical and pharmacological strategies to help patients and physicians deal with AF and atrial flutter. In the assessment of the patient comorbidity profile, antiarrhythmic drug onset of action and side effect profile versus the need for a physician with experience in sedation, or anaesthetics support for electrical cardioversion are key aspects when choosing the cardioversion method.

SEA 2024 Standards for Global Control of Vascular Risk

One of the objectives of the Spanish Society of Arteriosclerosis is to contribute to the knowledge, prevention and treatment of vascular diseases, which are the leading cause of death in Spain and entail a high degree of disability and health expenditure. Atherosclerosis is a multifactorial disease and its prevention requires a global approach that takes into account the associated risk factors. This document summarises the current evidence and includes recommendations for patients with established vascular disease or at high vascular risk: it reviews the symptoms and signs to evaluate, the laboratory and imaging procedures to request routinely or in special situations, and includes the estimation of vascular risk, diagnostic criteria for entities that are vascular risk factors, and general and specific recommendations for their treatment. Finally, it presents aspects that are not usually referenced in the literature, such as the organisation of a vascular risk consultation.

Safety and Effectiveness of Antidysrhythmic Drugs for Pharmacologic Cardioversion of Recent-Onset Atrial Fibrillation: a Systematic Review and Bayesian Network Meta-analysis

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.

Medical cardioversion of atrial fibrillation and flutter with class IC antiarrhythmic drugs in young patients with and without congenital heart disease

INTRODUCTION

The use of flecainide and propafenone for medical cardioversion of atrial fibrillation (AF) and atrial flutter/intra-atrial reentrant tachycardia (IART) is well-described in adults without congenital heart disease (CHD). Data are sparse regarding their use for the same purpose in adults with CHD and in adolescent patients with anatomically normal hearts and we sought to describe the use of class IC drugs in this population and identify factors associated with decreased likelihood of success.

METHODS

Single center retrospective cohort study of patients who received oral flecainide or propafenone for medical cardioversion of AF or IART from 2000 to 2022. The unit of analysis was each episode of AF/IART. We performed a time-to-sinus rhythm analysis using a Cox proportional hazards model clustering on the patient to identify factors associated with increased likelihood of success.

RESULTS

We identified 45 episodes involving 41 patients. As only episodes of AF were successfully cardioverted with medical therapy, episodes of IART were excluded from our analyses. Use of flecainide was the only factor associated with increased likelihood of success. There was a statistically insignificant trend toward decreased likelihood of success in patients with CHD.

CONCLUSIONS

Flecainide was more effective than propafenone. We did not detect a difference in rate of conversion to sinus rhythm between patients with and without CHD and were likely underpowered to do so, however, there was a trend toward decreased likelihood of success in patients with CHD. That said, medical therapy was effective in >50% of patients with CHD with AF.

Bayesian Network Meta-analysis of Randomized Controlled Trials on the Efficacy of Antiarrhythmics in the Pharmacological Cardioversion of Paroxysmal Atrial Fibrillation

PURPOSE

Since atrial fibrillation (AF) is one of the major arrhythmias managed in hospitals worldwide, it has a major impact on public health. The guidelines agree on the desirability of cardioverting paroxysmal AF episodes. This meta-analysis aims to answer the question of which antiarrhythmic agent is most effective in cardioverting a paroxysmal AF.

MATERIALS AND METHODS

A systematic review and Bayesian network meta-analysis, searching MEDLINE, Embase, and CINAHL, were performed, including randomized controlled trials (RCTs) enrolling a population of unselected adult patients with a paroxysmal AF that compared at least two pharmacological regimes to restore the sinus rhythm or a cardioversion agent against a placebo. The main outcome was efficacy in restoring sinus rhythm.

RESULTS

Sixty-one RCTs (7988 patients) were included in the quantitative analysis [deviance information criterion (DIC) 272.57; I² = 3%]. Compared with the placebo, the association verapamil-quinidine shows the highest SUCRA rank score (87%), followed by antazoline (86%), vernakalant (85%), tedisamil at high dose (i.e., 0.6 mg/kg; 80%), amiodarone-ranolazine (80%), lidocaine (78%), dofetilide (77%), and intravenous flecainide (71%). Taking into account the degree of evidence of each individual comparison between pharmacological agents, we have drawn up a ranking of pharmacological agents from the most effective to the least effective.

CONCLUSIONS

In comparing the antiarrhythmic agents used to restore sinus rhythm in the case of paroxysmal AF, vernakalant, amiodarone-ranolazine, flecainide, and ibutilide are the most effective medications. The verapamil-quinidine combination seems promising, though few RCTs have studied it. The incidence of side effects must be taken into account in the choice of antiarrhythmic in clinical practice.

CLINICAL TRIAL REGISTRATION

PROSPERO: International prospective register of systematic reviews, 2022, CRD42022369433 (Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022369433 ).

Electric Cardioversion vs. Pharmacological with or without Electric Cardioversion for Stable New-Onset Atrial Fibrillation: A Systematic Review and Meta-Analysis

BACKGROUND

There is no clear consensus on the preference for pharmacological cardioversion (PC) in comparison to electric cardioversion (EC) for hemodynamically stable new-onset atrial fibrillation (NOAF) patients presenting to the emergency department (ED).

METHODS

A systematic review and meta-analysis was conducted to assess PC (whether being followed by EC or not) vs. EC in achieving cardioversion for hemodynamically stable NOAF patients. PubMed, PubMed Central, Embase, Scopus, and Cochrane databases were searched to include relevant studies until 7 March 2022. The primary outcome was the successful restoration of sinus rhythm, and secondary outcomes included emergency department (ED) revisits with atrial fibrillation (AF), hospital readmission rate, length of hospital stay, and cardioversion-associated adverse events.

RESULTS

A total of three randomized controlled trials (RCTs) and one observational study were included. There was no difference in the rates of successful restoration to sinus rhythm (88.66% vs. 85.25%; OR 1.14, 95% CI 0.35-3.71; n = 868). There was no statistical difference across the two groups for ED revisits with AF, readmission rates, length of hospital stay, and cardioversion-associated adverse effects, with the exception of hypotension, whose incidence was lower in the EC group (OR 0.11, 95% CI 0.04-0.27: n = 727).

CONCLUSION

This meta-analysis suggests that there is no difference in successful restoration of sinus rhythm with either modality among patients with hemodynamically stable NOAF.

[Atrial fibrillation on the intensive care unit : The special prognostic importance of the first manifestation]

Atrial fibrillation (AF) is the most common arrhythmia in the intensive care unit (ICU) and is associated with increased mortality. The AF is classified into five different forms, initially diagnosed AF, paroxysmal AF, persistent AF, long-standing persistent AF and permanent AF. Studies could confirm that the first manifestation of AF (new onset AF) is of particular importance in intensive care patients. The mortality and costs are much higher than for patients with chronic AF. This important clinical difference of the AF pattern should be taken into consideration in the treatment of intensive care patients. The treatment of comorbidities is essential in the treatment concept on the ICU. In patients with an increased risk of thromboembolic complications, therapeutic anticoagulation is indicated, although the greatly increased risk of bleeding during intensive care treatment should be considered in individual cases. In cases of hemodynamic instability electrical cardioversion should immediately be carried out. Otherwise, pharmacological cardioversion can also be carried out. Apart from a few exceptions, amiodarone is the antiarrhythmic drug of choice for rhythm control due to the contraindications for other drugs.

The many NOs to the use of Class IC antiarrhythmics: weren’t the guidelines too strict?

Class IC antiarrhythmic drugs (AADs) currently represent a cornerstone in the therapy of atrial fibrillation, both for the restoration of sinus rhythm and for the prophylaxis of long-term relapses. They also play an important role in the treatment of idiopathic ventricular arrhythmias. Following the results of the Cardiac Arrhythmia Suppression Trial study, flecainide and by extension the other Class IC AADs were contraindicated in patients with ischaemic and structural heart disease, due to their pro-arrhythmic effect and the consequent increase in mortality observed in the study. Recent studies carried out on patients with chronic coronary heart disease without previous heart attacks and/or residual ischaemia have shown a good safety profile for this class of drugs. In addition, other studies have shown excellent efficacy in the absence of pro-arrhythmic effects of Class IC AADs in patients with structural heart disease such as arrhythmogenic right ventricular cardiomyopathy (ARVC) and tachy-cardiomyopathy. The purpose of this review is to evaluate the appropriate use of Class IC AADs in the different patient subgroups, in the light of the evidence and new diagnostic and therapeutic tools available.

Intravenous Magnesium Sulfate Reduces the Need for Antiarrhythmics during Acute-Onset Atrial Fibrillation in Emergency and Critical Care

Several studies have suggested the potential role of Magnesium Sulfate (MgSO4) for the treatment of Atrial Fibrillation (AF) but, in clinical practice, the use of magnesium is not standardized although it is largely used for the treatment of supraventricular arrhythmias. Objectives. We evaluated the role of MgSO4 infusion in association with flecainide in cardioversion of patients presenting in ED with symptomatic AF started less than 48 h before. We retrospectively searched for all patients presented in ED from 1 January 2019 to 31 December 2019 requiring pharmacological cardioversion with flecainide 2 mg/kg. Ninety-seven patients met these criteria, 46 received the administration of intravenous MgSO4 2 gr (Group A), and 51 did not (Group B). Among the 97 patients, the overall cardioversion rate was 85.6%, 91.3% in Group A and 80.4% in Group B. In 27 patients out of 97, the Flecainide was not administered because of spontaneous restoration of sinus rhythm of 9 pts (Group B) and 18 pts (Group A). We also found a statistical significance in the HR at the time of cardioversion between Group A (77.8 ± 19.1 bpm) and Group B (87 ± 21.7 bpm). No complications emerged. The association between MgSO4 and Flecainide has not yielded statistically significant results. However, in consideration of its high safety profile, MgSO4 administration may play a role in ED cardioversion of acute onset AF, reducing the need for antiarrhythmic medications and electrical cardioversion procedures, relieving symptoms reducing heart rate, and reducing the length of stay in the ED.

An Integrative Comparative Study Between Digoxin and Amiodarone as an Emergency Treatment for Patients With Atrial Fibrillation With Evidence of Heart Failure: A Systematic Review and Meta-Analysis

The emergency treatment of atrial fibrillation (AF) involves utilizing two strategies. The first strategy normally involves permitting the atrial fibrillation to persevere as the ventricular rate is controlled. The other method involves utilizing anti-arrhythmic drugs in cardioversion and attempting to maintain sinus rhythm. Different pharmacological treatments, including digoxin and amiodarone, have been used to manage AF. A literature review on amiodarone and digoxin in the treatment of AF among patients with heart failure (HF) has shown that both drugs have potential risks. Therefore, we are conducting this systematic review and meta-analysis to compare the effectiveness of amiodarone and digoxin in the treatment of AF among patients with evidence of HF.

A literature search of relevant articles was conducted on six electronic databases (PubMed, Web of Science, Medline, ScienceDirect, Cochrane Library, and Google Scholar) from 2000 to 2022. The search yielded seven studies that had met the inclusion criteria. Our meta-analysis of four studies showed that there was no significant difference in the reduction of heart rate after treatment with either amiodarone or digoxin (mean difference (MD): -5.44; 95% confidence interval (CI): -9.53 to -1.34; I² = 25%; p = 0.26). On the other hand, the statistical analysis showed that amiodarone had a better effect on the conversion to sinus rhythm than digoxin (63% versus 35%, respectively).

Based on evidence from our meta-analysis, the clinical effect of amiodarone and digoxin in the emergency treatment of AF on heart rate control was unclear. However, amiodarone has a significant impact on the restoration of sinus rhythm compared with digoxin and can be considered the first-line drug regimen in conversion to sinus rhythm for AF patients with evidence of heart failure. However, the use of amiodarone and digoxin is complicated by adverse events and all-cause mortality.

Reappraising the role of class Ic antiarrhythmics in atrial fibrillation

PURPOSE

The objective of the present systematic review was to compare the effectiveness and safety of class Ic agents for cardioversion of paroxysmal atrial fibrillation (AF), in patients with and without structural heart disease (SHD).

METHODS

We focused on RCTs enrolling at least 50 adult patients with electrocardiogram-documented paroxysmal AF that compared either two pharmacological class Ic cardioversion agents (flecainide, propafenone), regardless of study design (parallel or crossover). We searched MEDLINE and the Cochrane Central Register of Controlled Trials. Initial search was performed from inception to 15 July 2021 with no language restrictions.

RESULTS

Intravenous flecainide is the most effective option for pharmacologic cardioversion of AF since only 2 patients need to be treated in order to cardiovert one more within 4 h. Most importantly, class Ic agents appear to be safe in the context of pharmacologic cardioversion of AF irrespective of the presence of SHD, pointing towards a possible reappraisal of the role in this setting.

CONCLUSION

We suggest that class Ic agents (with flecainide appearing to be more effective) should be used for pharmacologic cardioversion in stable AF patients presenting in emergency department with unknown medical history, after excluding severe cardiac disease through a bedside examination.

REGISTRATION NUMBER (DOI)

Available in https://osf.io/apwt7/ , https://doi.org/10.17605/OSF.IO/APWT7.

Cardioversion of recent-onset atrial fibrillation using intravenous antiarrhythmics: A European perspective

Pharmacological cardioversion using intravenous antiarrhythmic agents is commonly indicated in symptomatic patients with recent-onset atrial fibrillation (AF). Except in hemodynamically unstable patients who require emergency direct current electrical cardioversion, for the majority of hemodynamically stable patients, pharmacological cardioversion represents a valid option and requires the clinician to be familiar with the properties and use of antiarrhythmic agents. The main characteristics of selected intravenous antiarrhythmic agents for conversion of recent-onset AF, the reported success rates, and possible adverse events are discussed. Among intravenous antiarrhythmics, flecainide, propafenone, amiodarone, sotalol, dofetilide, ibutilide, and vernakalant are commonly used. Antazoline, an old antihistaminic agent with antiarrhythmic properties was also reported to give encouraging results in Poland. Intravenous flecainide and propafenone are the only Class I agents still recommended by recent guidelines. Intravenous new Class III agents as dofetilide and ibutilide have high and rapid efficacy in converting AF to sinus rhythm but require strict surveillance with electrocardiogram (ECG) monitoring during and after intravenous administration because of the potential risk of QT prolongation and Torsades de Pointes, which can be prevented and properly managed. Vernakalant, a partial atrial selective was shown to have a high success rate and to be safe in real-life use.

Pharmacologic cardioversion of recent-onset atrial fibrillation: a systematic review and network meta-analysis

AIMS

We sought to identify the most effective antidysrhythmic drug for pharmacologic cardioversion of recent-onset atrial fibrillation (AF).

METHODS AND RESULTS

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 AF ≤ 48 h and compared antidysrhythmic agents, placebo, or control. We determined these outcomes prior to data extraction: (i) rate of conversion to sinus rhythm within 24 h, (ii) time to cardioversion to sinus rhythm, (iii) rate of significant adverse events, and (iv) rate of thromboembolism within 30 days. We extracted data according to PRISMA-NMA and appraised selected trials using the Cochrane review handbook. The systematic review initially identified 640 studies; 30 met inclusion criteria. Twenty-one trials that randomized 2785 patients provided efficacy data for the conversion rate outcome. Bayesian network meta-analysis using a random-effects model demonstrated that ranolazine + amiodarone intravenous (IV) [odds ratio (OR) 39.8, 95% credible interval (CrI) 8.3-203.1], vernakalant (OR 22.9, 95% CrI 3.7-146.3), flecainide (OR 16.9, 95% CrI 4.1-73.3), amiodarone oral (OR 10.2, 95% CrI 3.1-36.0), ibutilide (OR 7.9, 95% CrI 1.2-52.5), amiodarone IV (OR 5.4, 95% CrI 2.1-14.6), and propafenone (OR 4.1, 95% CrI 1.7-10.5) were associated with significantly increased likelihood of conversion within 24 h when compared to placebo/control. Overall quality was low, and the network exhibited inconsistency. Probabilistic analysis ranked vernakalant and flecainide high and propafenone and amiodarone IV low.

CONCLUSION

For pharmacologic cardioversion of recent-onset AF within 24 h, there is insufficient evidence to determine which treatment is superior. Vernakalant and flecainide may be relatively more efficacious agents. Propafenone and IV amiodarone may be relatively less efficacious. Further high-quality study is necessary.

World Heart Federation Roadmap on Atrial Fibrillation - A 2020 Update

The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world's population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them. Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow. This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great.

Flecainide How and When: A Practical Guide in Supraventricular Arrhythmias

Transcatheter ablation was increasingly and successfully used to treat symptomatic drug refractory patients affected by supraventricular arrhythmias. Antiarrhythmic drug treatment still plays a major role in patient management, alone or combined with non-pharmacological therapies. Flecainide is an IC antiarrhythmic drug approved in 1984 from the Food and Drug Administration for the suppression of sustained ventricular tachycardia and later for acute cardioversion of atrial fibrillation and for sinus rhythm maintenance. Currently, flecainide is mostly used for sinus rhythm maintenance in atrial fibrillation (AF) patients without structural cardiomyopathy although recent studies enrolling different patient populations have demonstrated a good effectiveness and safety profile. How should we interpret the results of the CAST after the latest evidence? Is it possible to expand the indications of flecainide, and therefore, its use? This review aims to highlight the main characteristics of flecainide, as well as its optimal clinical use, delineating drug indications and contraindications and appropriate monitoring, based on the most recent evidence.

Current Drug Treatment Strategies for Atrial Fibrillation and TASK-1 Inhibition as an Emerging Novel Therapy Option

Atrial fibrillation (AF) is the most common sustained arrhythmia with a prevalence of up to 4% and an upwards trend due to demographic changes. It is associated with an increase in mortality and stroke incidences. While stroke risk can be significantly reduced through anticoagulant therapy, adequate treatment of other AF related symptoms remains an unmet medical need in many cases. Two main treatment strategies are available: rate control that modulates ventricular heart rate and prevents tachymyopathy as well as rhythm control that aims to restore and sustain sinus rhythm. Rate control can be achieved through drugs or ablation of the atrioventricular node, rendering the patient pacemaker-dependent. For rhythm control electrical cardioversion and pharmacological cardioversion can be used. While electrical cardioversion requires fasting and sedation of the patient, antiarrhythmic drugs have other limitations. Most antiarrhythmic drugs carry a risk for pro-arrhythmic effects and are contraindicated in patients with structural heart diseases. Furthermore, catheter ablation of pulmonary veins can be performed with its risk of intraprocedural complications and varying success. In recent years TASK-1 has been introduced as a new target for AF therapy. Upregulation of TASK-1 in AF patients contributes to prolongation of the action potential duration. In a porcine model of AF, TASK-1 inhibition by gene therapy or pharmacological compounds induced cardioversion to sinus rhythm. The DOxapram Conversion TO Sinus rhythm (DOCTOS)-Trial will reveal whether doxapram, a potent TASK-1 inhibitor, can be used for acute cardioversion of persistent and paroxysmal AF in patients, potentially leading to a new treatment option for AF.

Pharmacologic Cardioversion in Patients with Paroxysmal Atrial Fibrillation: A Network Meta-Analysis

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.

Predictors of time to conversion of new-onset atrial fibrillation to sinus rhythm with amiodarone therapy

BACKGROUND

New-onset atrial fibrillation (AF) is a frequent cause of presentation to the emergency department (ED). Epicardial fat thickness (EFT) is associated with the presence and recurrence of AF. However, no study has investigated the predictors of the time to conversion of AF to sinus rhythm with amiodarone therapy. The aim of this study was to investigate predictors of time to conversion of AF to sinus rhythm in patients with new-onset AF.

METHODS

A total of 122 patients admitted to the ED with symptoms of hemodynamically stable new-onset AF (lasting <48 hours) were registered consecutively. These patients received intravenous amiodarone. EFT was measured using 2D echocardiography in parasternal long-axis views.

RESULTS

A significant positive correlation was determined between EFT and conversion time (rho = 0.267, P = .017) in all patients. The median time for conversion from the start of amiodarone infusion was 410 min (150-830 minutes). Based on the median conversion time, patients were classified as early conversion (time < 410 minutes; n = 41) and late conversion (time > 410 minutes; n = 40). Multivariate logistic regression analysis demonstrated that EFT (P = .033, odds ratio [OR]: 1.68, 95% confidence interval [CI]: 1.6-2.7), higher troponin I level > 0.04 (P = .034, OR: 5.3, 95% CI: 1.1-24.8), and lower age (P = .003, OR: 0.8, 95% CI: 0.8-0.9) were significantly associated with longer conversion time.

CONCLUSIONS

We determined that EFT and high troponin level affected the time to conversion to sinus rhythm in patients with new-onset AF.

Flecainide is well-tolerated and effective in patient with atrial fibrillation at 12 months: a retrospective study

Introduction:

Current atrial fibrillation (AF) guidelines recommend flecainide as a first-line rhythm control option in patients without structural heart disease. While there is proven efficacy in clinical trials and guideline support, it is hypothesized that flecainide may be underutilized due to negative outcomes in the CAST trial and that adverse effects are less common than previously perceived.

Methods:

This retrospective chart review evaluated patients ⩾18 years initiated on flecainide for AF from August 2011 to October 2016 by a cardiology provider at the study site. Exclusion criteria included: <5 days of flecainide therapy, AF due to a reversible cause, and inadequate documentation. The primary outcome was efficacy of flecainide at maintaining symptomatic control at 6 and 12 months. Secondary outcomes included characterization of alterations in rhythm control strategies and documented normal sinus rhythm per electrocardiogram at 6 and 12 months.

Results:

Of the 326 patients identified, 144 patients were included. After 6 and 12 months, 102 patients (70.8%) and 89 patients (61.8%) of the 144 were symptomatically controlled. Atenolol use (p = 0.024), female sex (p = 0.006), hypertension (p = 0.040), and dronedarone failure (p = 0.012) were associated with flecainide discontinuation at 6 months. At 12 months, only previous propafenone failure (p = 0.032) was significant. Of the 144 patients, 16 (11.1%) reported adverse effects with dizziness, hot flashes, bradycardia, and headache (1.4% each) being the most common.

Conclusion:

Flecainide is a well-tolerated medication, even at 12 months, with very minor adverse effects. These results support the utility of flecainide in guideline recommended patient populations.

How to Manage Atrial Fibrillation in the Emergency Department: a Critical Appraisal

Atrial fibrillation is the most common cardiac arrhythmia in emergency departments. There is growing evidence that certain patients with acute atrial fibrillation can be safely managed in the emergency room without the need for hospitalization, minimizing costs and reducing unnecessary exposures. This review addresses the emergency management of atrial fibrillation based on the latest updates on the subject with a focus on the assessment and prevention of thromboembolic phenomena, control of frequency x control of rhythm and strategies for cardioversion and restoration of sinus rhythm or for heart rate control.

Impact of emergency department management of atrial fibrillation with amiodarone on length of stay. A propensity score analysis based on the URGFAICS registry

OBJECTIVE

Amiodarone is a widely used drug in the emergency department (ED) for control of atrial fibrillation, but it has a delayed onset of action and slow metabolism, leading to longer length of ED stay. The aim of this study was to compare the length of ED stay of atrial fibrillation patients who were treated with or without amiodarone.

METHODS

We undertook a multicenter, observational, cohort study of the URGFAICS registry of older adults with atrial fibrillation who presented to five Spanish EDs and compared patients who had received amiodarone with those who had not. Afterward, we performed a propensity score matched analysis of atrial fibrillation to determine the ED length of stay related to amiodarone.

RESULTS

Of the 1199 patients included in the registry, 225 patients (18.8%) were treated with amiodarone while 974 (81.2%) were not. We performed a univariate study depending on amiodarone administration followed by propensity score calculation according to the 14 statistically different features found previously and six significant variables, obtaining 150 patients (75 for each group) suitable for the analysis. The length of ED stay was analyzed using box plot, with a P <0.001 in the crude analysis and P = 0.012 after propensity score matching and using survival curves for the analysis of prolonged ED stay, with a log rank <0.001 in the crude analysis and log rank 0.021 after the propensity score-matched analysis.

CONCLUSION

Amiodarone is associated with longer length of ED stay until discharge independently of the baseline characteristics of the patients.

Use of Flecainide for the Treatment of Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with substantial morbidity and impairment of quality of life. Restoration and maintenance of normal sinus rhythm is a desirable goal for many patients with AF; however, this strategy is limited by the relatively small number of antiarrhythmic drugs (AADs) available for AF rhythm control. Although it is recommended in current medical guidelines as first-line therapy for patients without structural heart disease, the use of flecainide has been curtailed since the completion of the Cardiac Arrhythmia Suppression Trial. In clinical trials and real-world use, flecainide has proven to be more effective than other AADs for the acute termination of recent onset AF. Flecainide is also moderately effective and, with the exception of amiodarone, equivalent to other AADs for the chronic suppression of paroxysmal and persistent AF. In patients without structural heart disease, flecainide has been demonstrated to be safe and well tolerated relative to other AADs. Despite this favorable profile, flecainide is underutilized, likely due to a perceived risk of ventricular proarrhythmia, a concern that has not been borne out in patients without underlying structural heart disease. Guidelines for administration and use of flecainide are summarized in this review.

Pharmacologic Cardioversion of Recent-Onset Atrial Fibrillation and Flutter in the Emergency Department: A Systematic Review and Network Meta-analysis

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.

Arnebiae Radix prevents atrial fibrillation in rats by ameliorating atrial remodeling and cardiac function

ETHNOPHARMACOLOGICAL RELEVANCE

Arnebiae Radix, a common herbal medicine in China, is often utilized to treat blood-heat syndrome and has been reported to exert an effect on the heart.

AIM OF THE STUDY

The combination of acetylcholine (Ach) and CaCl₂ has been widely used to induce atrial fibrillation (AF) in animals. However, whether Arnebiae Radix displays any preventive action on Ach-CaCl₂ induced AF in rats remains uncertain. In our study, we attempted to investigate the protective effects of Arnebiae Radix on Ach-CaCl₂ induced AF compared to amiodarone, which was employed as the positive control.

MATERIALS AND METHODS

To establish the AF model, SD rats were treated with a mixture of 0.1 mL/100 g Ach-CaCl₂ (60 μg/mL Ach and 10 mg/mL CaCl₂) by tail vein injection for 7 days. Rats were also given a gavage of Arnebiae Radix (0.18 g/mL) one week before or concurrently with the establishment of the AF model. At the end of the experimental period, the induction, duration and timing of AF were monitored using electrocardiogram recordings. Left atrial tissues were stained to observe the level of fibrosis. Electrophysiological measurements were used to examine atrial size and function.

RESULTS

In Ach-CaCl₂-induced AF rats, Arnebiae Radix decreased AF induction, duration and susceptibility to AF. In addition, Arnebiae Radix significantly reduced atrial fibrosis and inhibited atrial enlargement induced by Ach-CaCl₂. Moreover, there was an apparent improvement in cardiac function in the Arnebiae Radix-treated group.

CONCLUSIONS

Our findings indicate that Arnebiae Radix treatment can attenuate Ach-CaCl₂-induced atrial injury and serve as an effective therapeutic strategy for the treatment of AF in the future.

Revisiting an Underrecognized Strategy for Rhythm Management: Hybrid Therapy for Patients who Convert from Atrial Fibrillation to Flutter on Antiarrhythmic Drugs

Atrial fibrillation (AF) is often treated with antiarrhythmic drugs (AADs) or catheter ablation. In a unique subset of patients, AF can convert to atrial flutter (AFL) after the initiation of an AAD. It has previously been shown that, in this subset of patients, cavotricuspid isthmus (CTI) ablation followed by the continuation of the AAD regimen has an unusually high rate of successfully maintaining sinus rhythm. This is an underrecognized approach toward rhythm management in such patients. However, the reason(s) for such a high degree of efficacy with this hybrid therapeutic approach are unclear. We suggest that conversion from AF to AFL selects for a group of patients in whom AF is particularly responsive to the effects of the AAD. Since CTI ablation is essentially curative of AFL, the combination of both techniques results in a high efficacy of sinus rhythm maintenance. Further investigation is required to confirm these hypotheses.

Efficacy and safety in pharmacological cardioversion of recent-onset atrial fibrillation: a propensity score matching to compare amiodarone vs class IC antiarrhythmic drugs

The acute management of recent-onset (<48 h) atrial fibrillation (AF) is still debated. Aim of our study was to compare efficacy and safety of intravenously administered class IC antidysrhythmic agents vs amiodarone in a propensity score matched series of patients acutely treated for AF in the emergency department. During a 3-year period, we retrospectively evaluated all episodes of recent-onset (<48 h) AF pharmacologically treated for sinus rhythm restoration in the emergency department. By means of a propensity score matching considering the main statistically different covariates, we selected two accurately matched treatment groups. We analysed the differences between amiodarone and class IC group in terms of efficacy and safety that is conversion to sinus rhythm rates within 12 and 48 h after starting treatment, time to conversion, and adverse drug effects. An overall number of 817 episodes of recent-onset AF were collected (amiodarone group = 406, class IC group = 411). After matching, we obtained 358 episodes equally divided (amiodarone group = 179 and class IC group = 179). Conversion rates within 12 h were 139 (53.1 %) in amiodarone group and 95 (72.6 %) in class IC group (p < 0.05). Median time for cardioversion was 420 min (331.6-508.3 CI 95 %) in amiodarone and 55 min (44.9-65.1 CI 95 %) in class IC group (p < 0.05). The incidence of adverse events in both groups was very low and equally distributed (p = ns). Intravenously administration of class IC agents, when compared with amiodarone, proved to be more rapid and effective, and equally safe in the acute management of recent-onset AF.

Intravenous vernakalant in comparison with intravenous flecainide in the cardioversion of recent-onset atrial fibrillation

Background:

Pharmacological cardioversion of atrial fibrillation is a reasonable alternative for electrical cardioversion in acute atrial fibrillation. We compared the efficacy and safety of intravenous vernakalant and intravenous flecainide in patients with recent-onset (< 48 h) atrial fibrillation.

Methods:

A total of 200 consecutive patients, 100 patients undergoing cardioversion with intravenous vernakalant and 100 patients undergoing cardioversion with intravenous flecainide, were included in this single centre non-randomized retrospective study. The primary endpoint was conversion to sinus rhythm within 120 minutes from the drug administration.

Results:

Cardioversion was successful in 67% of patients treated with vernakalant and in 46% of patients treated with flecainide ( p=0.003). Vernakalant (odds ratio 1.99, 95% confidence interval 1.08–3.69, p=0.029) and female gender (odds ratio 2.48, 95% confidence interval 1.22–15.05, p=0.012) were significant predictors of successful cardioversion. The success rate of cardioversion was lowest among men treated with flecainide (36.9%). Patients treated with vernakalant were discharged earlier from the emergency department compared with those treated with flecainide (8.2 ± 4.7 h vs. 12.0 ± 6.0 h, p < 0.001). There was no difference in the complication rate between the groups. Vernakalant treated patients were older (59.3 ± 12.5 vs. 55.4 ± 13.0 years, p=0.03), had higher CHA2DS2-VASc score (1.4 ± 1.3 vs. 0.9 ± 1.2, p = 0.002) and were more often on beta-blocker medication (59% vs. 42%, p= 0.016) than flecainide treated patients.

Conclusion:

Vernakalant was safe, more effective and faster than flecainide in the cardioversion of recent-onset atrial fibrillation. The difference in efficacy was especially apparent among men.

Rhythm control in atrial fibrillation

Many patients with atrial fibrillation have substantial symptoms despite ventricular rate control and require restoration of sinus rhythm to improve their quality of life. Acute restoration (ie, cardioversion) and maintenance of sinus rhythm in patients with atrial fibrillation are referred to as rhythm control. The decision to pursue rhythm control is based on symptoms, the type of atrial fibrillation (paroxysmal, persistent, or long-standing persistent), patient comorbidities, general health status, and anticoagulation status. Many patients have recurrent atrial fibrillation and require further intervention to maintain long term sinus rhythm. Antiarrhythmic drug therapy is generally recommended as a first-line therapy and drug selection is on the basis of the presence or absence of structural heart disease or heart failure, electrocardiographical variables, renal function, and other comorbidities. In patients who continue to have recurrent atrial fibrillation despite medical therapy, catheter ablation has been shown to substantially reduce recurrent atrial fibrillation, decrease symptoms, and improve quality of life, although recurrence is common despite continued advancement in ablation techniques.

Amiodarone Versus Propafenone to Treat Atrial Fibrillation after Coronary Artery Bypass Grafting: A Randomized Double Blind Controlled Trial

Background

Atrial fibrillation (AF) is one of the most common complications after cardiac surgery. Several therapeutic and preventive strategies have been introduced for postoperative AF, but the treatment and prophylaxis of AF remain controversial. We aimed to compare the efficacy of intravenous amiodarone and oral propafenone in the treatment of AF after coronary artery bypass grafting (CABG).

Methods

This was a randomized controlled trial performed in two hospitals in Shiraz, Iran from 2009 to 2012. We included all patients who underwent elective CABG and developed AF postoperatively. The patients were randomly assigned to receive propafenone or amiodarone. The duration of AF, the success rate of the treatment, the need for cardioversion, the frequency of repeated AF, and the need for repeating the treatment were compared.

Results

The duration of the first (p=0.361), second (p=0.832), and third (p=0.298) episodes of AF, the need for cardioversion (p=0.998), and the need to repeat the first and second doses of drugs (p=0.557, 0.699) were comparable between the study groups. Repeated AF was observed in 17 patients (30.9%) in the propafenone group and 23 patients (34.3%) in the amiodarone group (p=0.704).

Conclusion

Oral propafenone and intravenous amiodarone are equally effective in the treatment and conversion of recent-onset AF after CABG.

Atrial Fibrillation

Atrial fibrillation (AF) is a supraventricular tachyarrhythmia that results from the chaotic depolarization of atrial tissue. AF is the most common sustained cardiac dysrhythmia and the most common dysrhythmia diagnosed in US emergency departments. All patients with AF must have their cardioembolic risk assessed, even if sinus rhythm is restored. Novel oral anticoagulants may be considered instead of vitamin K antagonists for anticoagulation in patients with nonvalvular AF.

Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter

Objective:

There is no consensus on the optimal management of recent-onset episodes of atrial fibrillation or flutter. The approach to these conditions is particularly relevant in the current era of emergency department (ED) overcrowding. We sought to examine the effectiveness and safety of the Ottawa Aggressive Protocol to perform rapid cardioversion and discharge patients with these arrhythmias.

Methods:

This cohort study enrolled consecutive patient visits to an adult university hospital ED for recent-onset atrial fibrillation or flutter managed with the Ottawa Aggressive Protocol. The protocol includes intravenous chemical cardioversion, electrical cardioversion if necessary and discharge home from the ED.

Results:

A total of 660 patient visits were included, 95.2% involving atrial fibrillation and 4.9% involving atrial flutter. The mean age of patients enrolled was 64.5 years. In total, 96.8% were discharged home and, of those, 93.3% were in sinus rhythm. All patients were initially administered intravenous procaïnamide, with a 58.3% conversion rate. A total of 243 patients underwent subsequent electrical cardioversion with a 91.7% success rate. Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3% and 7-day relapse 8.6%. There were no cases of torsades de pointes, stroke or death. The median lengths of stay in the ED were as follows: 4.9 hours overall, 3.9 hours for those undergoing conversion with procaïnamide and 6.5 hours for those requiring electrical conversion.

Conclusion:

This is the largest study to date to evaluate the Ottawa Aggressive Protocol, a unique approach to cardioversion for ED patients with recent-onset episodes of atrial fibrillation and flutter. Our data demonstrate that the Ottawa Aggressive Protocol is effective, safe and rapid, and has the potential to significantly reduce hospital admissions and expedite ED care.

Use of rate control medication before cardioversion of recent-onset atrial fibrillation or flutter in the emergency department is associated with reduced success rates

Objective:

It is believed that when patients present to the emergency department (ED) with recent-onset atrial fibrillation or flutter (RAFF), controlling the ventricular rate before cardioversion improves the success rate. We evaluated the influence of rate control medication and other variables on the success of cardioversion.

Methods:

This secondary analysis of a medical records review comprised 1,068 patients with RAFF who presented to eight Canadian EDs over 12 months. Univariate analysis was performed to find associations between predictors of conversion to sinus rhythm including use of rate control, rhythm control, and other variables. Predictive variables were incorporated into the multivariate model to calculate adjusted odds ratios (ORs) associated with successful cardioversion.

Results:

A total of 634 patients underwent attempted cardioversion: 428 electrical, 354 chemical, and 148 both. Adjusted ORs for factors associated with successful electrical cardioversion were use of rate control medication, 0.39 (95% confidence interval [CI] 0.21-0.74); rhythm control medication, 0.28 (95% CI 0.15-0.53); and CHADS2score &gt; 0, 0.43 (95% CI 0.15-0.83). ORs for factors associated with successful chemical cardioversion were use of rate control medication, 1.29 (95% CI 0.82-2.03); female sex, 2.37 (95% CI 1.50-3.72); and use of procainamide, 2.32 (95% CI 1.43-3.74).

Conclusion:

We demonstrated reduced successful electrical cardioversion of RAFF when patients were pretreated with either rate or rhythm control medication. Although rate control medication was not associated with increased success of chemical cardioversion, use of procainamide was. Slowing the ventricular rate prior to cardioversion should be avoided.

Flecainide: Current status and perspectives in arrhythmia management

Flecainide acetate is a class IC antiarrhythmic agent and its clinical efficacy has been confirmed by the results of several clinical trials. Nowadays, flecainide is recommended as one of the first line therapies for pharmacological conversion as well as maintenance of sinus rhythm in patients with atrial fibrillation and/or supraventricular tachycardias. Based on the Cardiac Arrhythmia Suppression Trial study results, flecainide is not recommended in patients with structural heart disease due to high proarrhythmic risk. Recent data support the role of flecainide in preventing ventricular tachyarrhythmias in patients with catecholaminergic polymorphic ventricular tachycardia associated both with ryanodine receptor and calsequestrin mutations. We herein review the current clinical data related to flecainide use in clinical practice and some concerns about its role in the management of patients with coronary artery disease.

[Rate and rhythm control in atrial fibrillation : pharmacological approaches]

Atrial fibrillation is the most common form of cardiac arrhythmia, occurring in 1-2 % of the population and due to an increased life expectancy the prevalence will increase further. Pharmacological treatment of atrial fibrillation is an important component of basic initial therapeutic options for patients with atrial fibrillation. Independent of an individually adjusted prevention of thromboembolism, rate and rhythm management can also be carried out. While rate control mainly applies to all patients, rhythm control is only indicated in patients who remain clinically symptomatic despite sufficient rate control. Profound knowledge about antiarrhythmic drugs including specific interactions is necessary due to the variable individual effects and sometimes severe side effects.

Efficacy of a new class III drug niferidil in cardioversion of persistent atrial fibrillation and flutter

AIMS

To study the efficacy and safety of the new class III antiarrhythmic agent niferidil for pharmacological cardioversion in patients with persistent atrial fibrillation (AF) and atrial flutter (AFl).

METHODS AND RESULTS

One hundred thirty-four adults (aged 57.8 ± 11 years, 90 males) were included with median AF duration of 3 (1.5-6) months. All patients received a total of 10-30 μg/kg, niferidil, intravenously, in 1-3 (if needed) consecutive boluses at 15-minute intervals. Holter electrocardiogram monitoring was started before infusion and was continued for 24 hours. The criterion for an antiarrhythmic effect was sinus rhythm restoration within 24 hours of the initial bolus. Niferidil converted AF to sinus rhythm in 47.7% of cases after bolus 1, in 62% of cases after bolus 2, and in 84.6% of cases bolus 3. Niferidil induced a 100% recovery rate in patients with AFl and a 91.8% recovery rate in patients with AF of duration from 8 days to 3 months. Nonsustained torsade de pointes occurred in 1 patient (0.7%), and nonsustained monomorphic ventricular tachycardia was observed in 5 patients (3.7%).

CONCLUSIONS

The new intravenous class III drug niferidil demonstrated high conversion rates of 84.6% in patients with persistent AF and 100% in patients with persistent AFl. Niferidil may be used as a possible alternative to electrical cardioversion for pharmacological cardioversion of persistent AF/AFl.

Tissue velocity imaging of the left atrium predicts response to flecainide in patients with acute atrial fibrillation

BACKGROUND

Acute atrial fibrillation (AF) is often treated with the administration of intravenous flecainide; however, this treatment may not always be successful and is potentially hazardous. Previous studies suggest that electro-echocardiographic tissue velocity imaging (TVI) of the atrial wall may reflect atrial remodeling.

OBJECTIVE

To study whether atrial TVI can be used to identify nonresponders of flecainide administered intravenously in patients with acute AF.

METHODS

We used atrial TVI to measure atrial fibrillatory cycle length determined by using tissue velocity imaging (AFCL-TVI) and atrial fibrillatory wall motion velocity determined by using tissue velocity imaging (AFV-TVI) in the left atrium in 52 (55%) patients presenting with acute AF in the emergency department. These 2 parameters reflect electrical and structural remodeling, respectively. Standard baseline characteristics were recorded.

RESULTS

Patients were predominantly men (76%) and 64 ± 11 years old. Thirty-six (69%) patients had successful cardioversion after flecainide infusion. There were no significant differences in baseline characteristics between responders and nonresponders. Patients with a successful cardioversion had a longer mean AFCL-TVI and higher median (interquartile range) AFV-TVI compared with patients with failed cardioversion: 172 ± 29 ms vs 137 ± 35 ms (P < .001) and 4.2 (3.3-6.2) cm/s vs 2.3 (1.9-3.5) cm/s (P = .001).

CONCLUSIONS

Electro-echocardiographic atrial TVI measurement is a promising noninvasive tool for predicting outcome of pharmacological cardioversion. A short AFCL-TVI and a low AFV-TVI are related to failure of cardioversion of AF using flecainide.

Anti-Arrhythmic Agents in the Treatment of Atrial Fibrillation

Although atrial fibrillation (AF) is the most common sustained arrhythmia seen during daily cardiovascular physician practice, its management remained a challenge for cardiology physician as there was no single anti-arrhythmic agents proved to be effective in converting atrial fibrillation and kept its effectiveness in maintaining sinus rhythm over long term. Moreover all the anti-arrhythmic agents that are used in treatment of AF were potentially pro-arrhythmic especially in patients with coronary artery disease and structurally abnormal heart. Some of these drugs also have serious non cardiac side effects that limit its long term use in the management of atrial fibrillation. Several new and investigational anti-arrhythmic agents are emerging but data supporting their effectiveness and safety are still limited. In this systematic review we examine the efficacy and safety of these medications supported by the major published randomized trials, meta-analyses and review articles and conclude with a summary of guidelines recommendations.

Contemporary approach to electrical and pharmacological cardioversion of atrial fibrillation

In patients with atrial fibrillation (AF), a rhythm-control strategy may be adopted when there are unacceptable symptoms from AF, failure of rate control, and/or the presence of comorbidities, such as heart failure, that may improve with restoration of sinus rhythm. When a rhythm-control strategy is chosen and the patient is in persistent AF, cardioversion will be necessary to convert the rhythm to sinus. Patients with AF present for > 48 hours must be effectively anticoagulated both prior to and after cardioversion. With newer oral anticoagulants, achieving effective anticoagulation is faster and more reliable, with no requirement for blood test monitoring. Cardioversion can be accomplished either electrically or pharmacologically, and in some cases, electrical cardioversion may be facilitated pharmacologically. Electrical cardioversion has a higher success rate compared with pharmacological cardioversion in the short-term. Pharmacological cardioversion is usually accomplished with intravenous ibutilide, oral flecainide or propafenone, or intravenous amiodarone. Oral amiodarone and dofetilide also result in chemical cardioversion in some patients over a longer period of time. Long-term success in the maintenance of sinus rhythm post-cardioversion can be increased with the use of antiarrhythmic drugs. Alternatively, when AF is recurrent and symptomatic despite the use of antiarrhythmic drugs, catheter ablation is a reasonable option for many patients. Cardioversion may be incorporated into the management approach of persistent AF when the primary therapeutic option chosen is catheter ablation.

Advances in the management of atrial fibrillation

Atrial fibrillation (AF) is the most common arrhythmia worldwide, increasing in incidence with the aging population. Substantial morbidity and mortality accompany its diagnosis. Management should focus on rate and rhythm management, on reducing thromboembolic risk, and also potentially on targeting the mechanisms responsible for its perpetuation. Current antiarrhythmic therapy has only modest efficacy and substantial side effects, and anticoagulation regimes are cumbersome and require regular monitoring. Novel anticoagulants and antiarrhythmics hold the promise of improved efficacy and safety. This review covers current therapy for AF, major advances in pharmacological management and future directions for therapy.

[Therapy of atrial fibrillation in the critically ill]

Atrial fibrillation (AF) is the most common form of arrhythmia in the intensive care unit (ICU) and is associated with increased mortality. A total of five types of AF can be distinguished: initially diagnosed, paroxysmal, persistent, long-standing persistent and permanent AF. In addition to the initial treatment, antithrombotic therapy, rate and rhythm management can be used. The treatment of comorbidities is part of the patient management and for patients with increased risk of thromboembolic events anticoagulation is recommended. The simplest risk assessment scheme is the CHADS score. In the acute setting rate control is important. Direct current cardioversion is urgently recommended for patients with AF when hemodynamic instability is present even in patients with AF and pre-excitation in Wolff-Parkinson-White syndrome. Pharmacological cardioversion may be considered in patients with AF when hemodynamic stability is present. When choosing the antiarrhythmic agent for critically ill patients only amiodarone can be considered with some exceptions due to the specific contraindications.

Safety of flecainide

Flecainide is a class Ic antiarrhythmic agent that has an important role as part of rhythm control strategies in patients with atrial fibrillation (AF). Early clinical data on the use of flecainide showed an increase in arrhythmias and mortality compared with placebo in patients with a previous myocardial infarction and asymptomatic or mildly symptomatic ventricular arrhythmias. These findings only apply to a specific group of patients with left ventricular dysfunction and ischaemic heart disease, but had a negative impact on the use of class Ic antiarrhythmics across all indications and patient groups. The aim of this review was to evaluate the available safety data for flecainide in the literature and to assess its current use in patients with AF. Current European guidelines now recommend the use of flecainide in carefully selected groups of patients with AF who do not have structural heart disease. This includes for the cardioversion of recent-onset AF, pretreatment prior to direct current cardioversion, out-of-hospital acute oral therapy ('pill-in-the-pocket' approach) and for the ongoing maintenance of sinus rhythm. Potential cardiac adverse effects of flecainide include proarrhythmia, conduction abnormalities and negative inotropic effects. Dizziness is the most frequent non-cardiac side effect, followed by blurred vision and difficulty focusing; these are almost all mild, transient and tolerable. Data from recent clinical trials in patients with supraventricular arrhythmias suggest that flecainide has a good tolerability profile in groups of appropriately selected patients. Caution is required when using flecainide in patients with renal dysfunction, and there are a number of drug interactions, but these are well documented and manageable. Overall, flecainide is a good choice for the pharmacological management of AF. It has a good safety record and low incidence of adverse effects, rare end-organ toxicity and a low risk of ventricular proarrhythmia. To ensure that the benefits of treatment outweigh any potential risks, careful patient selection and monitoring is required.