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Reappraising the role of class Ic antiarrhythmics in atrial fibrillation

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Abstract

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

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Data availability

The data underlying this article are available in the article and in its online supplementary material.

Abbreviations

ED:

Emergency department

AF:

Atrial fibrillation

SHD:

Structural heart disease

RCTs:

Randomized clinical trials

CER:

Control event rate

NNT:

Number needed to treat

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Authors and Affiliations

  1. Athens Medical Center, Athens Heart Center, Distomou 5-7, 15125, Athens, Greece

    Dimitris Tsiachris, Ioannis Doundoulakis, Christos-Konstantinos Antoniou & Christodoulos Stefanadis

  2. First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, Athens, Greece

    Dimitris Tsiachris, Ioannis Doundoulakis, Panagiotis Tsioufis, Konstantinos A. Gatzoulis & Konstantinos Tsioufis

  3. Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece

    Eirini Pagkalidou

  4. Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, NY, USA

    Stefanos M. Zafeiropoulos

  5. Feinstein Institutes for Medical Research at Northwell Health, Manhasset, NY, USA

    Stefanos M. Zafeiropoulos

  6. Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA

    Christodoulos Stefanadis

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  1. Dimitris Tsiachris
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  2. Ioannis Doundoulakis
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  4. Eirini Pagkalidou
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  6. Stefanos M. Zafeiropoulos
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  7. Konstantinos A. Gatzoulis
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  8. Konstantinos Tsioufis
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  9. Christodoulos Stefanadis
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Contributions

DT and ID proposed the structure of the paper, critically appraised the paper, and were the major contributors in writing the manuscript. EP proposed the statistical analysis. PT, CKA, and SZ screened all titles and abstracts, perused full texts for eligible records, and independently extracted data from eligible studies. KAG, KT, and CS critically appraised the paper and made the final suggestions. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Dimitris Tsiachris.

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Key points

• In this systematic review, intravenous flecainide is the most effective option for pharmacologic cardioversion of AF.

• Most importantly, class Ic agents appear to be extremely safe in the context of pharmacologic cardioversion of AF irrespective of the presence of structural heart disease, pointing towards a possible reappraisal of their role in this setting.

• We suggest that class Ic agents should be used for pharmacologic cardioversion in stable AF patients with unknown medical history, after excluding severe cardiac disease through a bedside examination.

Supplementary Information

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Tsiachris, D., Doundoulakis, I., Tsioufis, P. et al. Reappraising the role of class Ic antiarrhythmics in atrial fibrillation. Eur J Clin Pharmacol 78, 1039–1045 (2022). https://doi.org/10.1007/s00228-022-03296-0

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