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

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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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Data Availability

All data relevant to the study has been included in the article or uploaded as supplementary information.

Abbreviations

AF:

Atrial fibrillation

ED:

Emergency department

NMA:

Network meta-analysis

RCTs:

Randomized clinical trials

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Acknowledgements

We thank Christos-Konstantinos Antoniou for English language editing.

Funding

This study received no funding.

Author information

Authors and Affiliations

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

    Dimitris Tsiachris, Ioannis Doundoulakis, Athanasios Kordalis & Christodoulos Stefanadis

  2. First Department of Cardiology, University of Athens Medical School, Athens, Greece

    Ioannis Doundoulakis, 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. Second Department of Cardiology, University of Athens Medical School, Athens, Greece

    Spyridon Deftereos

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

    Spyridon Deftereos & Christodoulos Stefanadis

Authors
  1. Dimitris Tsiachris
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  2. Ioannis Doundoulakis
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  3. Eirini Pagkalidou
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  4. Athanasios Kordalis
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  5. Spyridon Deftereos
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  6. Konstantinos A. Gatzoulis
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  7. Konstantinos Tsioufis
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  8. Christodoulos Stefanadis
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Contributions

DT: Proposed the idea, proposed the structure of the paper, first independent reviewer, proposed the statistical analysis, and formulated the paper, ID: Proposed the idea, proposed the structure of the paper, second independent reviewer, proposed the statistical analysis, and formulated the paper, EP: Performed the statistical analysis, AK: Critically appraised the paper, made final suggestions, SD: Critically appraised the paper, made the final suggestions, KAG: Critically appraised the paper, made final suggestions, KT: Critically appraised the paper, made final suggestions, CS: Critically appraised the paper, made final suggestions. All authors had full access to all data and share responsibility for the decision to submit the manuscript for publication. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Dimitris Tsiachris.

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Tsiachris, D., Doundoulakis, I., Pagkalidou, E. et al. Pharmacologic Cardioversion in Patients with Paroxysmal Atrial Fibrillation: A Network Meta-Analysis. Cardiovasc Drugs Ther 35, 293–308 (2021). https://doi.org/10.1007/s10557-020-07127-1

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