Pharmacologic Cardioversion of Recent-Onset Atrial Fibrillation and Flutter in the Emergency Department: A Systematic Review and Network Meta-analysis.
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Journal title
Annals of emergency medicineDate Published
2020-03-12Publication Volume
76Publication Issue
1Publication Begin page
14Publication End page
30
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Show full item recordAbstract
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).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 We also searched for unpublished data.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.
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.
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.
Citation
deSouza IS, Tadrous M, Sexton T, Benabbas R, Carmelli G, Sinert R. Pharmacologic Cardioversion of Recent-Onset Atrial Fibrillation and Flutter in the Emergency Department: A Systematic Review and Network Meta-analysis. Ann Emerg Med. 2020 Jul;76(1):14-30. doi: 10.1016/j.annemergmed.2020.01.013. Epub 2020 Mar 12. PMID: 32173135.DOI
10.1016/j.annemergmed.2020.01.013ae974a485f413a2113503eed53cd6c53
10.1016/j.annemergmed.2020.01.013
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Except where otherwise noted, this item's license is described as Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.