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Um KJ, McIntyre WF, Mendoza PA, Ibrahim O, Nguyen ST, Lin SH, Duceppe E, Rochwerg B, Healey JS, Koziarz A, Lengyel AP, Bhatnagar A, Amit G, Chu VA, Whitlock RP, Belley-Côté EP. Pre-treatment with antiarrhythmic drugs for elective electrical cardioversion of atrial fibrillation: a systematic review and network meta-analysis. Europace 2022; 24:1548-1559. [PMID: 35654763 DOI: 10.1093/europace/euac063] [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: 07/29/2021] [Accepted: 04/09/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS Our objective was to compare the efficacy of pre-treatment with different classes of anti-arrhythmic drugs (AADs) in patients with atrial fibrillation (AF) undergoing electrical cardioversion. METHODS AND RESULTS We performed a systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing different AADs in patients with AF undergoing electrical cardioversion. We grouped AADs into five network nodes: no treatment or rate control, Class Ia, Class Ic, Class III, and amiodarone. Outcomes were (i) acute restoration and (ii) maintenance of sinus rhythm. We searched MEDLINE and EMBASE from inception until June 2020. We used Python 3.8.3 and R 3.6.2 for data analysis. We evaluated the overall certainty of evidence with the GRADE framework. We included 28 RCTs. Compared with no treatment or rate control, Class III AADs [odds ratio (OR): 2.41; 95% credible interval (CrI): 1.37 to 4.62, high certainty] and amiodarone (OR: 2.58; 95% CrI: 1.54 to 4.37, high certainty) improved restoration of sinus rhythm. Amiodarone improved long-term maintenance of sinus rhythm when compared with no treatment or rate control (OR: 5.37; 95% CrI: 4.00-7.39, high certainty), Class Ic (OR: 1.89; 95% CrI: 1.05-3.45, moderate certainty) and Class III AADs (OR: 2.19; 95% CrI: 1.39-3.26, high certainty). CONCLUSION Before electrical cardioversion of AF, treatment with Class III AADs or amiodarone improves the acute restoration of sinus rhythm. Amiodarone is most likely to improve the maintenance of sinus rhythm after electrical cardioversion, but Class Ic and Class III AADs are also effective.
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Affiliation(s)
- Kevin J Um
- McMaster University, David Braley Cardiac, Vascular, and Stroke Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada.,Population Health Research Institute, Hamilton, ON L8L 2X2, Canada
| | - William F McIntyre
- McMaster University, David Braley Cardiac, Vascular, and Stroke Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada.,Population Health Research Institute, Hamilton, ON L8L 2X2, Canada
| | - Pablo A Mendoza
- McMaster University, David Braley Cardiac, Vascular, and Stroke Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Omar Ibrahim
- McMaster University, David Braley Cardiac, Vascular, and Stroke Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada.,Population Health Research Institute, Hamilton, ON L8L 2X2, Canada
| | - Stephanie T Nguyen
- McMaster University, David Braley Cardiac, Vascular, and Stroke Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Sabrina H Lin
- McMaster University, David Braley Cardiac, Vascular, and Stroke Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Emmanuelle Duceppe
- McMaster University, David Braley Cardiac, Vascular, and Stroke Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada.,Population Health Research Institute, Hamilton, ON L8L 2X2, Canada
| | - Bram Rochwerg
- McMaster University, David Braley Cardiac, Vascular, and Stroke Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Jeff S Healey
- McMaster University, David Braley Cardiac, Vascular, and Stroke Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada.,Population Health Research Institute, Hamilton, ON L8L 2X2, Canada
| | - Alex Koziarz
- McMaster University, David Braley Cardiac, Vascular, and Stroke Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Alexandra P Lengyel
- McMaster University, David Braley Cardiac, Vascular, and Stroke Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Akash Bhatnagar
- McMaster University, David Braley Cardiac, Vascular, and Stroke Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Guy Amit
- McMaster University, David Braley Cardiac, Vascular, and Stroke Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Victor A Chu
- University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Richard P Whitlock
- McMaster University, David Braley Cardiac, Vascular, and Stroke Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada.,Population Health Research Institute, Hamilton, ON L8L 2X2, Canada
| | - Emilie P Belley-Côté
- McMaster University, David Braley Cardiac, Vascular, and Stroke Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada.,Population Health Research Institute, Hamilton, ON L8L 2X2, Canada
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Um KJ, McIntyre WF, Healey JS, Mendoza PA, Koziarz A, Amit G, Chu VA, Whitlock RP, Belley-Côté EP. Pre- and post-treatment with amiodarone for elective electrical cardioversion of atrial fibrillation: a systematic review and meta-analysis. Europace 2019; 21:856-863. [PMID: 30875422 DOI: 10.1093/europace/euy310] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 12/03/2018] [Indexed: 09/07/2023] Open
Abstract
AIMS Clinicians frequently pre-treat patients with amiodarone to increase the efficacy of electrical cardioversion for atrial fibrillation (AF). Our objective was to determine the precise effects of amiodarone pre- and post-treatment on conversion efficacy and sinus rhythm maintenance. METHODS AND RESULTS We conducted a systematic review and meta-analysis of trials comparing pre- and post-treatment for electrical cardioversion with amiodarone vs. no therapy on (i) acute restoration and (ii) maintenance of sinus rhythm after 1 year. We searched MEDLINE and EMBASE from inception to July 2018 for randomized controlled trials. We evaluated the risk of bias for individual studies with the Cochrane tool and overall quality of evidence with the GRADE framework. We identified eight eligible studies (n = 1012). Five studies were deemed to have unclear or high risk of selection bias. We found the evidence to be of high quality based on GRADE. Treatment with amiodarone (200-800 mg daily for 1-6 weeks pre-cardioversion; 0-200 mg daily post-cardioversion) was associated with higher rates of acute restoration [relative risk (RR) 1.22, 95% confidence interval (CI) 1.07-1.39, P = 0.004, n = 1012, I2 = 65%] and maintenance of sinus rhythm over 13 months (RR 4.39, 95% CI 2.99-6.45, P < 0.001, n = 695, I2 = 0%). The effects of amiodarone for acute restoration were maintained when considering only studies at low risk of bias (RR 1.22, 95% CI 1.10-1.36, P < 0.001, n = 572, I2 = 0%). Adverse effects were typically non-serious, occurring in 3.4% (6/174) of subjects receiving amiodarone. CONCLUSION High-quality evidence demonstrated that treatment with amiodarone improved the restoration and maintenance of sinus rhythm after electrical cardioversion of AF. Short-term amiodarone was well-tolerated.
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Affiliation(s)
- Kevin J Um
- McMaster University, Hamilton, ON, Canada
| | - William F McIntyre
- McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Jeff S Healey
- McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | - Guy Amit
- McMaster University, Hamilton, ON, Canada
| | | | - Richard P Whitlock
- McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Emilie P Belley-Côté
- McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
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Asghar O, Alam U, Hayat SA, Aghamohammadzadeh R, Heagerty AM, Malik RA. Diabetes, Obesity and Atrial Fibrillation: Epidemiology, Mechanisms and Interventions. J Atr Fibrillation 2013; 6:869. [PMID: 28496876 DOI: 10.4022/jafib.869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 05/21/2013] [Accepted: 05/26/2013] [Indexed: 01/19/2023]
Abstract
Body mass index (BMI) is a powerful predictor of death, type 2 diabetes (T2DM) and cardiovascular (CV) morbidity and mortality. Over the last few decades, we have witnessed a global rise in adult obesity of epidemic proportions. Similarly, there has been a parallel increase in the incidence of atrial fibrillation (AF), itself a significant cause of cardiovascular morbidity and mortality. This may be partly attributable to advances in the treatment of coronary heart disease (CHD) and heart failure (HF) improving life expectancy, however, epidemiological studies have demonstrated an independent association between obesity, diabetes and AF, suggesting possible common pathophysiological mechanisms and risk factors. Indeed, cardiac remodeling, haemodynamic alterations, autonomic dysfunction, and diastolic dysfunction have been reported in obese and diabetic cohorts. Moreover, diabetic cardiomyopathy is characterized by an adverse structural and functional cardiac phenotype, which may predispose to the development of AF. In this review, we discuss the pathophysiological and mechanistic relationships between obesity, diabetes and AF, and some of the challenges posed in the management of this high-risk group of individuals.
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Affiliation(s)
- O Asghar
- Division of Cardiovascular Sciences, The University of Manchester, UK
| | - U Alam
- Division of Cardiovascular Sciences, The University of Manchester, UK
| | - S A Hayat
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | | | - A M Heagerty
- Division of Cardiovascular Sciences, The University of Manchester, UK
| | - R A Malik
- Division of Cardiovascular Sciences, The University of Manchester, UK
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Asghar O, Alam U, Hayat SA, Aghamohammadzadeh R, Heagerty AM, Malik RA. Obesity, diabetes and atrial fibrillation; epidemiology, mechanisms and interventions. Curr Cardiol Rev 2013; 8:253-64. [PMID: 22920475 PMCID: PMC3492809 DOI: 10.2174/157340312803760749] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 04/28/2012] [Accepted: 05/11/2012] [Indexed: 02/08/2023] Open
Abstract
The last few decades have witnessed a global rise in adult obesity of epidemic proportions. The potential impact of this is emphasized when one considers that body mass index (BMI) is a powerful predictor of death, type 2 diabetes (T2DM) and cardiovascular (CV) morbidity and mortality [1, 2]. Similarly we have witnessed a parallel rise in the incidence of atrial fibrillation (AF), the commonest sustained cardiac arrhythmia, which is also a significant cause of cardiovascular morbidity and mortality. Part of this increase is attributable to advances in the treatment of coronary heart disease (CHD) and heart failure (HF) improving life expectancy and consequently the prevalence of AF. However, epidemiological studies have demonstrated an independent association between obesity and AF, possibly reflecting common pathophysiology and risk factors for both conditions. Indeed, weight gain and obesity are associated with structural and functional changes of the cardiovascular system including left atrial and ventricular remodeling, haemodynamic alterations, autonomic dysfunction, and diastolic dysfunction. Moreover, diabetic cardiomyopathy is characterized by an adverse structural and functional cardiac phenotype which may predispose to the development of AF [3]. In this review, we discuss the pathophysiological and mechanistic relationships between obesity, diabetes and AF, and the challenges posed in the management of this high-risk group of individuals.
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Affiliation(s)
- O Asghar
- Division of Cardiovascular Sciences, The University of Manchester, UK
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Alegret JM, Viñolas X, Grande A, Castellanos E, Asso A, Tercedor L, Carmona JR, Medina O, Alberola AG, Fidalgo ML, Pérez-Alvarez L, Sabaté X. Clinical effectiveness of antiarrhythmic treatment after electrical cardioversion in patients without structural heart disease. Rev Esp Cardiol 2009; 61:1274-9. [PMID: 19080966 DOI: 10.1016/s1885-5857(09)60055-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION AND OBJECTIVES The aim was to investigate the clinical effectiveness of using antiarrhythmic drugs after electrical cardioversion in patients without structural heart disease, including their effect on the maintenance of sinus rhythm. METHODS In total, 528 patients with persistent atrial fibrillation but without significant structural heart disease who underwent successful electrical cardioversion at 96 Spanish hospitals were followed up for 1 year. Patients were assessed at 1, 3, 6 and 12 months. The use and effectiveness of antiarrhythmic drugs for preventing the recurrence of persistent atrial fibrillation was evaluated. RESULTS Some 80% of patients were receiving antiarrhythmic drugs at discharge, most frequently amiodarone. No specific clinical factor was associated with greater use of antiarrhythmics. Overall, 37% of patients were in sinus rhythm at all follow-up assessments. At the 1-year assessment, 59% of patients who remained in sinus rhythm were still taking antiarrhythmic drugs. Multivariate Cox regression analysis identified weight (hazard ratio [HR]=1.01 per kg; P=.04) and no antiarrhythmic treatment (HR=1.59; P=.001) as being independently associated with the recurrence of persistent atrial fibrillation. Amiodarone tended to be better than other antiarrhythmic drugs. CONCLUSIONS In routine clinical practice, the large majority of patients without structural heart disease received antiarrhythmic drugs, most frequently amiodarone, after successful electrical cardioversion. Drug use was the principal factor associated with the maintenance of sinus rhythm at 1 year.
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Affiliation(s)
- Josep Maria Alegret
- Servicio de Cardiología, Hospital de Sant Joan de Reus, Reus, Tarragona, Spain.
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