Intravenous propafenone for converting recent onset atrial fibrillation in emergency departments: a randomized placebo-controlled multicenter trial. FAPS Investigators Study Group. Ranolazine enhances the efficacy of amiodarone for conversion of recent-onset atrial fibrillation. Cardioversion of acute atrial fibrillation in the short observation unit: comparison of a protocol focused on electrical cardioversion with simple antiarrhythmic treatment Impact of Emergency Department Management of Atrial Fibrillation on Hospital Charges Ibutilide to expedite ED therapy for recent-onset atrial fibrillation flutter. Rapid loading of sotalol or amiodarone for management of recent onset symptomatic atrial fibrillation: a randomized, digoxin-controlled trial. Comparison of pharmacological and electrical cardioversion in permanent atrial fibrillation after prosthetic cardiac valve replacement: A prospective randomized trial Early or Delayed Cardioversion in Recent‐Onset Atrial Fibrillation A randomized active-controlled study comparing the efficacy and safety of vernakalant to amiodarone in recent-onset atrial fibrillation. Comparison of effectiveness of ranolazine plus amiodarone versus amiodarone alone for conversion of recent-onset atrial fibrillation. Intravenous propafenone in paroxysmal atrial fibrillation: A randomized, placebo‐controlled, double‐blind, multicenter clinical trial Dronedarone for prevention of atrial fibrillation: a dose-ranging study. Ranolazine Added to Amiodarone Facilitates Earlier Conversion of Atrial Fibrillation Compared to Amiodarone‐Only Therapy Efficacy of propafenone for maintaining sinus rhythm in patients with recent onset or persistent atrial fibrillation after conversion: a randomized, placebo-controlled study A Randomized Comparison of External and Internal Cardioversion of Chronic Atrial Fibrillation Efficacy and Safety of Oral Dofetilide in Converting to and Maintaining Sinus Rhythm in Patients With Chronic Atrial Fibrillation or Atrial Flutter: The Symptomatic Atrial Fibrillation Investigative Research on Dofetilide (SAFIRE-D) Study Performance of an expedited rhythm control method for recent onset atrial fibrillation in a community hospital. Treatment of Stable Atrial Fibrillation in the Emergency Department: A Population-Based Comparison of Electrical Direct-Current versus Pharmacological Cardioversion or Conservative Management Conversion efficacy of intravenous ibutilide compared with intravenous amiodarone in patients with recent-onset atrial fibrillation and atrial flutter. Propafenone added to ibutilide increases conversion rates of persistent atrial fibrillation Managing emergency department patients with recent-onset atrial fibrillation. Transesophageal echocardiographically facilitated early cardioversion from atrial fibrillation using short-term anticoagulation: final results of a prospective 4.5-year study. Impact of biphasic electrical cardioversion of atrial fibrillation on early recurrent atrial fibrillation and shock efficacy.
Atrial fibrillation ( AF ) is one of the most frequent dysrhythmias in patients coming to emergency departments ( EDs ) , and pharmacological treatment is frequently performed . The aim of this r and omized placebo-controlled multicenter trial was to compare propafenone ( a class 1C antidysrhythmic agent ) , administered i.v . in the ED , with placebo in the treatment of recent-onset AF ( < 72 h ) . We r and omly allocated 156 patients ( 88 males ; 68 females ) from 18 to 80 years old , with recent-onset AF , to receive i.v . propafenone ( 2 mg/kg for 10 min ) or the matching placebo . The patients were followed for 2 h. Exclusion criteria were the presence of one of the following : lack of informed consent , clinical evidence of heart failure , clinical hyperthyroidism , recent acute myocardial infa rct ion , atrioventricular block , cardiac valve dysfunction , a history of bronchial asthma , and current treatment with antidysrhythmic agents including digitalis . The two groups did not differ significantly in terms of sex , age , body weight , or estimated time elapsed since the beginning of atrial fibrillation . Conversion to sinus rhythm occurred in 13 of the 75 patients who received the placebo ( 17.3 % ) and in 57 of the 81 patients who were given propafenone ( 70.3 % ) . In conclusion , intravenous propafenone administration in the ED can be considered a safe and effective approach for converting AF to sinus rhythm AIMS Amiodarone is used commonly for pharmacological cardioversion of atrial fibrillation ( AF ) , but it is limited by moderate efficacy and delayed action . Ranolazine and amiodarone are markedly synergistic in suppressing experimental AF in vitro , yet the clinical efficacy of ranolazine combined with amiodarone for AF conversion has only undergone minimal investigation . This prospect i ve , single-blinded , r and omized study compared the safety and efficacy of ranolazine added to amiodarone vs. amiodarone alone for conversion of recent-onset AF . METHODS AND RESULTS We enroled 121 patients ( 64 ± 10 years , 45 % male ) with recent-onset ( < 48 h duration ) AF who were eligible for pharmacological cardioversion . Patients received either 24 h amiodarone infusion ( loading dose 5 mg/kg followed by maintenance dose of 50 mg/h ; n = 60 ) , or amiodarone infusion at the same dosage plus a single oral dose of ranolazine 1500 mg ( n = 61 ) . Patients in the amiodarone plus ranolazine group compared with the amiodarone-only group showed significantly higher conversion rates at 24 h ( 87 vs. 70 % , respectively ; P = 0.024 ) and at 12 h ( 52 vs. 32 % ; P = 0.021 ) , and shorter time to conversion ( 10.2 ± 3.3 vs. 13.3 ± 4.1 h ; P = 0.001 ) . Subgroup analysis identified higher 24 h conversion in patients with left atrial ( LA ) diameter > 46 mm who received the combination treatment vs. amiodarone alone ( 81 vs. 54 % ; P = 0.02 ) , whereas the efficacy of the two interventions did not differ among patients with LA diameter ≤46 mm ( P = 0.77 ) . There was modest QT prolongation in both the groups , no serious adverse reactions , and no pro-arrhythmic events . CONCLUSION Addition of ranolazine to amiodarone was safe and well tolerated in this study , and it demonstrated efficacy superior to amiodarone alone for conversion of recent-onset AF . These findings may have clinical implication s by offering a simple therapeutic manoeuvre to enhance amiodarone 's effectiveness for conversion of AF Background Direct current cardioversion ( DCC ) has been shown to be effective for the management of  atrial fibrillation ( AF )  in the emergency department ( ED ) . Pharmacological cardioversion was compared with a strategy including DCC on patients with uncomplicated , recent-onset ( < 48 h ) AF managed in a short observation unit ( SOU ) . Methods A prospect i ve observational study was undertaken over a period of 13 months in two institutions . A DCC-centred protocol was applied to 171 AF cases in a hospital ( DCC-cohort ) and pharmacological cardioversion to 151 AF cases in another hospital ( P-cohort ) . Patients remaining in AF after 24 h were admitted . The outcomes were rate of discharge in sinus rhythm , length of stay in the ED-SOU , rate of hospitalisation and complications of treatment . Data collected were analysed according to Student t test and χ2 statistics . Results Discharge in sinus rhythm was achieved in 159/171 cases in the DCC-cohort and 77/151 cases in the P-cohort ( 93 % vs 51 % ; number needed to treat ( NNT ) 2.4 ; 95 % CI 2.0 to 3.1 , p<0.001 ) , whereas mean length of stay was 7 + 7 h in the DCC-cohort and 9 + 6 h in the P-cohort ( p=0.43 ) . Eleven cases from the DCC-cohort and 67 from the P-cohort were admitted ( admission rate 6 % vs 44 % ; NNT 2.6 ; 95 % CI 2.2 to 3.5 , p<0.001 ) . Three short-term complications occurred in the DCC-cohort and five in the P-cohort ( 2 % vs 3 % , p=0.59 ) . Two strokes were registered in the DCC-cohort during 6-month follow-up ( p undefined ) . Conclusions Electrical cardioversion of recent-onset AF in the SOU is safe , effective and reduces hospitalisations . Further studies are needed to identify the most cost-effective strategy for the management of AF patients in emergency setting Introduction Emergency department ( ED ) cardioversion ( EDCV ) and discharge of patients with recent onset atrial fibrillation or atrial flutter ( AF ) has been shown to be a safe and effective management strategy . This study examines the impact of such aggressive ED management on hospital charges . Methods : A r and om sample of 300 AF patients were identified from an ED electronic data base and screened for timing of onset of their symptoms . Patients were considered eligible for EDCV if either nursing or physician notes documented an onset of symptoms less than 48 hours prior to ED presentation and the patient was less than 85 years of age . An explicit chart review was then performed to determine patient management and disposition . Cardioversion attempts were defined as ED administration of procainamide , flecainide , propafenone , ibutilide , amiodarone or direct current cardioversion ( DCCV ) .  Total hospital charges for each patient were obtained from the hospital billing office . Differences across medians were analyzed utilizing through Wilcoxon rank sum tests and chi square . Results : A total of 51 patients were included in the study .  EDCV  was attempted on 24 ( 47 % ) patients , 22 ( 92 % ) were successfully cardioverted to normal sinus rhythm ( NSR ) . An additional 12 ( 23 % ) spontaneously converted to NSR . Twenty ( 91 % ) of those successfully cardioverted were discharged from the ED along with 4 ( 33 % ) of those spontaneously converting . Pharmacologic cardioverson was attempted in six patients and was successful in three ( 50 % ) , one after failed DCCV attempt .  Direct current cardioversion  was attempted in 21 ( 88 % ) and was successful in 19 ( 90 % ) , two after failed pharmacologic attempts . Median charges for patients cardioverted and discharged from the ED were $ 5,460 ( IQR $ 4,677–$6,190 ) . Median charges for admitted patients with no attempt at cardioversion were $ 23,202 ( IQR $ 19,663–$46,877 ) . Median charges for patients whose final ED rhythm was NSR were $ 5,641 ( IQR $ 4,638–$12,339 ) while for those remaining inAF median charges were $ 30,299 ( IQR $ 20,655 – $ 69,759 ) . Conclusion : ED cardioversion of recent onset AF patients results in significant hospital savings OBJECTIVE Ibutilide is a type III antiarrhythmic agent approved for the pharmacologic conversion of atrial fibrillation ( AF ) and atrial flutter ( AFl ) . Previous studies conducted outside the ED setting have demonstrated conversion rates of 60 % to 80 % . This response has been highest in patients with recent-onset AF-AFl . These observations and the 4-hour half-life of ibutilide suggest that it may be an excellent drug with which to treat AF-AFl in the ED . The purpose of the study was to examine the efficacy and safety of ibutilide in terminating AF-AFl in patients who present to the ED with symptoms of less than 3 days ' duration , neither angina nor heart failure , and no comorbid conditions that require admission . METHODS Among 36 enrolled patients , the admission electrocardiogram demonstrated AF in 26 and AFl in 10 .  Ibutilide 1 mg was administered intravenously for 10 minutes . If sinus rhythm was not present 10 minutes after the infusion concluded , a second infusion of 1 mg was given . Successful conversion was defined as restoration of sinus rhythm within 1 hour after the last dose of ibutilide . RESULTS Sixteen ( 61.5 % ) of 26 patients with AF and 9 ( 90 % ) of 10 patients with AFl converted to sinus rhythm ( overall conversion rate=69 % ) . The mean time to arrhythmia termination was 19+/-9 minutes . The mean stay in the ED was 16.2 hours . No significant complications occurred . CONCLUSION We conclude that ibutilide is an excellent therapy option for restoring sinus rhythm in the ED . Its use may obviate the need for admission , avoid the risks and inconveniences of general anesthesia to perform electrical cardioversion , and reduce the ED length of stay in selected patients with recent-onset atrial arrhythmias BACKGROUND Amiodarone and sotalol are commonly used for the maintenance of sinus rhythm , but the efficacy of these agents administered as high-dose infusions for rapid conversion of atrial fibrillation is unknown . Use in this context would facilitate drug initiation in patients in whom ongoing prophylactic therapy is indicated . METHODS We assessed the efficacy and safety of rapid high-dose intravenous infusions of amiodarone and sotalol for heart rate control and rapid reversion to sinus rhythm in patients who came to the emergency department with recent-onset symptomatic atrial fibrillation . Patients ( n = 140 ) were r and omized to receive 1.5mg/kg of sotalol infused in 10 minutes , 10mg/kg of amiodarone in 30 minutes , or 500 microg of digoxin in 20 minutes . Electrical cardioversion was attempted for patients not converting to sinus rhythm within 12 hours . RESULTS The rapid infusion of sotalol or amiodarone result ed in more rapid rate control than digoxin . Each of the 3 trial strategies result ed in similar rates of pharmacological conversion to sinus rhythm  ( amiodarone , 51 % ; sotalol , 44 % ; digoxin , 50 % ; P = not significant ) . The overall rates of cardioversion after trial drug infusion and defibrillation were high for all groups ( amiodarone , 94 % ; sotalol , 95 % , ; digoxin , 98 % ; P = not significant ) , but there was a trend toward a higher incidence of serious adverse reactions in the amiodarone group . CONCLUSION The rapid infusion of sotalol or amiodarone in patients with symptomatic recent-onset atrial fibrillation results in rapid control of ventricular rate . Even with high-dose rapid infusions , all 3 agents are associated with a poor overall reversion rate within 12 hours . Almost all patients were returned to sinus rhythm with a combination of pharmacological therapy and electrical cardioversion Objective To compare the efficacy of electrical versus pharmacological cardioversion following prosthetic cardiac valve replacement in patients with permanent atrial fibrillation ( AF ) . Methods Patients with permanent AF who had undergone prosthetic cardiac valve replacement , who had a cardiothoracic ratio ≤0.5 and a left atrial diameter ≤50 mm for ≥6 months after surgery were r and omly divided to receive either electrical or pharmacological cardioversion . Patients in the electrical cardioversion group were given direct-current synchronized electrical defibrillation under general anaesthesia . Patients in the pharmacological cardioversion group were given oral combination therapy with amiodarone , captopril and simvastatin for 3 months . Results A total of 115 patients received either electrical cardioversion ( n = 59 ) or pharmacological cardioversion ( n = 56 ) ; reversion to sinus rhythm occurred in 98.3 % and 26.8 % , respectively . Recurrence rates were similar in the two groups ( 3.4 % and 6.7 % for electrical and pharmacological cardioversion , respectively ) . No deaths or severe complications were reported . Conclusion Electrical cardioversion has a favourable safety profile and appears to be a more effective method than pharmacological cardioversion for the treatment of permanent AF after cardiac valve replacement , once the heart has returned close to its normal size BACKGROUND Patients with recent‐onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion . However , whether immediate restoration of sinus rhythm is necessary is not known , since atrial fibrillation often terminates spontaneously . METHODS In a multicenter , r and omized , open‐label , noninferiority trial , we r and omly assigned patients with hemodynamically stable , recent‐onset ( < 36 hours ) , symptomatic atrial fibrillation in the emergency department to be treated with a wait‐ and ‐see approach ( delayed‐cardioversion group ) or early cardioversion . The wait‐ and ‐see approach involved initial treatment with rate‐control medication only and delayed cardioversion if the atrial fibrillation did not resolve within 48 hours . The primary end point was the presence of sinus rhythm at 4 weeks . Noninferiority would be shown if the lower limit of the 95 % confidence interval for the between‐group difference in the primary end point in percentage points was more than ‐10 . RESULTS The presence of sinus rhythm at 4 weeks occurred in 193 of 212 patients ( 91 % ) in the delayed‐cardioversion group and in 202 of 215 ( 94 % ) in the early‐cardioversion group ( between‐group difference , ‐2.9 percentage points ; 95 % confidence interval [ CI ] , ‐8.2 to 2.2 ; P=0.005 for noninferiority ) . In the delayed‐cardioversion group , conversion to sinus rhythm within 48 hours occurred spontaneously in 150 of 218 patients ( 69 % ) and after delayed cardioversion in 61 patients ( 28 % ) . In the early‐cardioversion group , conversion to sinus rhythm occurred spontaneously before the initiation of cardioversion in 36 of 219 patients ( 16 % ) and after cardioversion in 171 patients ( 78 % ) . Among the patients who completed remote monitoring during 4 weeks of follow‐up , a recurrence of atrial fibrillation occurred in 49 of 164 patients ( 30 % ) in the delayed‐cardioversion group and in 50 of 171 ( 29 % ) in the early‐cardioversion group . Within 4 weeks after r and omization , cardiovascular complications occurred in 10 patients and 8 patients , respectively . CONCLUSIONS In patients presenting to the emergency department with recent‐onset , symptomatic atrial fibrillation , a wait‐ and ‐see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks . ( Funded by the Netherl and s Organization for Health Research and Development and others ; RACE 7 ACWAS Clinical Trials.gov number , NCT02248753 . OBJECTIVES This r and omized double-blind study compared the efficacy and safety of intravenous vernakalant and amiodarone for the acute conversion of  recent-onset atrial fibrillation ( AF ) .  BACKGROUND Intravenous vernakalant has effectively converted recent-onset AF and was well tolerated in placebo-controlled studies . METHODS A total of 254 adult patients with AF ( 3 to 48 h duration ) eligible for cardioversion were enrolled in the study . Patients received either a 10-min infusion of vernakalant ( 3 mg/kg ) followed by a 15-min observation period and a second 10-min infusion ( 2 mg/kg ) if still in AF , plus a sham amiodarone infusion , or a 60-min infusion of amiodarone ( 5 mg/kg ) followed by a maintenance infusion ( 50 mg ) over an additional 60 min , plus a sham vernakalant infusion . RESULTS Conversion from AF to sinus rhythm within the first 90 min ( primary end point ) was achieved in 60 of 116 ( 51.7 % ) vernakalant patients compared with 6 of 116 ( 5.2 % ) amiodarone patients ( p < 0.0001 ) . Vernakalant result ed in rapid conversion ( median time of 11 min in responders ) and was associated with a higher rate of symptom relief compared with amiodarone ( 53.4 % of vernakalant patients reported no AF symptoms at 90 min compared with 32.8 % of amiodarone patients ; p = 0.0012 ) . Serious adverse events or events leading to discontinuation of study drug were uncommon . There were no cases of torsades de pointes , ventricular fibrillation , or polymorphic or sustained ventricular tachycardia . CONCLUSIONS Vernakalant demonstrated efficacy superior to amiodarone for acute conversion of recent-onset AF . Both vernakalant and amiodarone were safe and well tolerated in this study . ( A Phase III Superiority Study of Vernakalant vs Amiodarone in Subjects With Recent Onset Atrial Fibrillation [ AVRO ] ; NCT00668759 ) Ranolazine , an antianginal agent with antiarrhythmic properties , prevents atrial fibrillation ( AF ) in patients with acute coronary syndrome . In experimental models , the combination of ranolazine and amiodarone has marked synergistic effects that potently suppress AF . Currently , the clinical effect of the ranolazine-amiodarone combination for the conversion of AF is unknown . This prospect i ve r and omized pilot study compared the safety and efficacy of ranolazine plus amiodarone versus amiodarone alone for the conversion of recent-onset AF . We enrolled 51 consecutive patients with AF ( < 48-hour duration ) eligible for pharmacologic cardioversion . Patients ( 33 men , 63 ± 8 years of age ) were r and omized to intravenous amiodarone for 24 hours ( group A , n = 26 ) or to intravenous amiodarone plus oral ranolazine 1,500 mg at time of r and omization ( group A + R , n = 25 ) . The 2 groups were well balanced with respect to clinical characteristics and left atrial diameter . Conversion within 24 hours ( primary end point ) was achieved in 22 patients ( 88 % ) in group A + R versus 17 patients ( 65 % ) in group A ( p = 0.056 ) . Time to conversion was shorter in group A + R than in group A ( 9.8 ± 4.1 vs 14.6 ± 5.3 hours , p = 0.002 ) . According to Cox regression analysis , left atrial diameter and A + R treatment were the only independent predictors of time to conversion ( hazard ratio 5.35 , 95 % confidence interval 2.37 to 12.11 , p < 0.001 ; hazard ratio 0.81 , 95 % confidence interval 0.74 to 0.88 , p < 0.001 , respectively ) . There were no proarrhythmic events in either group . In conclusion , addition of ranolazine to st and ard amiodarone therapy is equally safe and appears to be more effective compared to amiodarone alone for conversion of recent-onset AF Background : Pharmacological conversion of paroxysmal atrial fibrillation is frequently necessary . The aim of this study was to compare intravenous propafenone , a class Ic antiar‐rhythmic agent , with placebo in paroxysmal atrial fibrillation ( AF ) of recent onset ( < 72 h ) AIMS Dronedarone , a benzofurane derivative without iodine substituents , shares the electrophysiologic properties of amiodarone . This study was design ed to determine the most appropriate dose of dronedarone for prevention of  atrial fibrillation ( AF )  after cardioversion . METHODS AND RESULTS Patients with persistent AF were r and omly allocated to 800 , 1200 , 1600 mg daily doses of dronedarone or placebo . The main analysis was conducted on 199/270 patients , who entered the maintenance phase following pharmacological cardioversion or , if unsuccessful , DC cardioversion . Within 6-month follow-up , the time to AF relapse increased on dronedarone 800 mg , with a median of 60 days vs 5.3 days in the placebo group ( relative risk reduction 55 % [ 95 % CI , 28 to 72 % ] P=0.001 ) . No significant effect was seen at higher doses . Spontaneous conversion to sinus rhythm on  dronedarone  occurred in 5.8 to 14.8 % of patients ( P=0.026 ) . There were no proarrhythmic reactions . Drug-induced QT prolongation was only noticed in the 1600 mg group . Premature drug discontinuations affected 22.6 % of subjects given 1600 mg dronedarone versus 3.9 % on 800 mg and were mainly due to gastrointestinal side effects . No evidence of thyroid , ocular or pulmonary toxicity was found . CONCLUSION Dronedarone , at a 800 mg daily dose , appears to be effective and safe for the prevention of AF relapses after cardioversion . The absence of thyroid side effects and of proarrhythmia are important features of the drug . Further studies are needed to better delineate the antiarrhythmic profile of the drug Background : Amiodarone ( AMIO ) is for many years effectively used to control ventricular rate during atrial fibrillation ( AF ) and to convert it into sinus rhythm . However , due to its delayed onset of action , ranolazine ( RAN ) , a new antianginal agent with atrial‐selective electrophysiologic properties , has recently been attempted as add‐on therapy with AMIO to facilitate AF conversion . Methods : To establish the role of this combination therapy , we enrolled 173 consecutive patients ( 68 ± 10 years , 54 % male ) with recent‐onset ( < 48‐hour duration ) AF who were eligible for pharmacologic cardioversion . Patients were r and omized to intravenous AMIO ( loading dose 5 mg/kg in 1 hour followed by 50 mg/h ; n = 81 ) , or AMIO plus a single oral dose of RAN 1 g ( n = 92 ) . Results : Mean left atrial diameter did not significantly differ between groups , AMIO and AMIO + RAN ( 4.2 ± 0.5 cm vs 4.1 ± 0.4 cm , P = 0.18 ) . The AMIO + RAN group compared with the AMIO‐only group showed significantly shorter time to conversion ( 8.6 ± 2.8 hours vs 19.4 ± 4.4 hours , P < 0.0001 ) and higher conversion rate at 24 hours ( 98 % vs 58 % , P < 0.001 ) . Left ventricular ejection fraction did not markedly vary between the two groups and ranged within moderately reduced values . No serious clinical ly evident adverse effects were observed in any of the patients receiving either AMIO or the combination treatment . Conclusions : Our data demonstrate faster sinus rhythm restoration and enhanced conversion rate of AF  after AMIO plus RAN in patients with preserved ejection fraction and left atrial size , implicating a synergistic effect of the two agents Objective — The aim of this study was to investigate the efficacy and safety of propafenone in the prevention of  atrial fibrillation ( AF ) relapse after restoration of sinus rhythm . Methods — This study consisted of 110 consecutive patients with recent onset and persistent AF . After restoration of sinus rhythm , patients were r and omized to propafenone ( n : 58 , age : 60 ± 12 years ) or placebo ( n : 52 , age : 62 ± 10 years).There were 11 withdrawals ( 7 in the propafenone and 4 in the placebo group ) during follow-up . Follow-up evalutations were conducted at the first , 3rd and then at an interval of three months during 15 months . The clinical characteristics in both groups were comparable . The AF relapse was analysed by the Kaplan-Meier method . Results — At 15-month follow-up , AF relapsed in 20 ( 39 % ) and 31 ( 65 % ) patients in the propafenone and placebo groups , respectively ( p = 0.015 ) . In subgroup analysis , AF recurrence was significantly lower in the propafenone group than in the placebo group only in the recent onset AF patients with spontaneous conversion ( 21 % vs. 61 % , p = 0.01 ) . However , the AF relapse rates were similar in patients with persistent AF and with recent AF who converted to sinus rhythm pharmacologically or electrically in the propafenone and placebo groups . Four patients on propafenone and one on placebo  had adverse effects necessitating discontinuation of the drug ( p = 0.36 ) . Conclusion — At 15 months , propafenone seems to be superior to placebo for maintaining sinus rhythm in patients with recent onset or peristent AF . This superiority originates mainly from patients with recent onset AF in whom sinus rhythm occurred spontaneously . Its adverse effects are similar to placebo . ( Acta Cardiol 2004 ; 59(3 ) : 255 - 261 Background Delivery of shocks within the right atrium has been reported to be more effective than conventional external shocks in converting atrial fibrillation ( AF ) , but these two cardioversion techniques have never been compared prospect ively . The purpose of this study was to compare the efficacies of external and internal cardioversion in patients with chronic AF unresponsive to prior attempts at electrical and /or pharmacological cardioversion . Low-dose amiodarone was used in all patients after cardioversion to suppress recurrences of AF . Methods and Results One hundred twelve patients with AF of at least 1 month in duration were r and omly assigned to undergo external cardioversion with 300–360-J shocks or internal cardioversion with 200–300-J shocks delivered through a st and ard electrode catheter within the right atrium . The patients were treated with amiodarone ( 200 mg/day 5–7 days/week ) for 1 month before electrical cardioversion and afterward if the cardioversion was successful . The patients were-evaluated at regular intervals during 1 year of follow-up . The efficacy of internal cardioversion was significantly greater than that of external cardioversion ( 91 % versus 67 % , p = 0.002 ) . The only variable that was associated with the outcome of cardioversion was body weight . Among patients in whom sinus rhythm was restored , AF recurred as often after internal and external cardioversion ; at 1 year of follow-up , 37 % of patients in whom external or internal cardioversion had been effective were still in sinus rhythm .  Patients who had undergone an attempt at electrical cardioversion before entry into this study were less likely to remain in sinus rhythm after cardioversion . The only complications of cardioversion were one instance of cerebral thromboembolism after external cardioversion and one instance of transient pulmonary edema after internal cardioversion . Therapy with amiodarone was discontinued because of an adverse drug effect in only three patients . Conclusions Internal cardioversion is more effective than external cardioversion in restoring sinus rhythm and is as safe as external cardioversion in patients with chronic AF . The recurrence rate of AF is the same after both types of cardioversion . If conventional electrical cardioversion is ineffective , internal cardioversion should be attempted . The combination of low-dose amiodarone and external or internal cardioversion may result in maintaining sinus rhythm long-term in patients with refractory AF Background This double-blind , multicenter , placebo-controlled study determined the efficacy and safety of dofetilide in converting  atrial fibrillation ( AF ) or atrial flutter ( AFl )  to  sinus rhythm ( SR ) and maintaining SR for 1 year . Methods and Results Patients with AF or AFl ( n=325 ) were r and omized to 125 , 250 , or 500 & mgr;g dofetilide or placebo twice daily . Dosages were adjusted for QTc response and , after 105 patients were enrolled , for calculated creatinine clearance ( ClCr ) . Pharmacological cardioversion rates for 125 , 250 , and 500 & mgr;g dofetilide were 6.1 % , 9.8 % , and 29.9 % , respectively , versus 1.2 % for placebo ( 250 and 500 & mgr;g versus placebo;P = 0.015 and P < 0.001 , respectively ) . Seventy percent of pharmacological cardioversions with dofetilide were achieved in 24 hours and 91 % in 36 hours . For the 250 patients who successfully cardioverted pharmacologically or electrically , the probability of remaining in SR at 1 year was 0.40 , 0.37 , 0.58 for 125 , 250 , and 500 & mgr;g dofetilide , respectively , and 0.25 for placebo ( 500 & mgr;g versus placebo , P = 0.001 ) . Two cases of torsade de pointes occurred , 1 on day 2 and the other on day 3 ( 0.8 % of all patients given active drug ) ; 1 sudden cardiac death , classified as proarrhythmic , occurred on day 8 ( 0.4 % of all patients given active drug ) . Conclusions Dofetilide , a new class III antiarrhythmic agent , is moderately effective in cardioverting AF or AFl to SR and significantly effective in maintaining SR for 1 year . In-hospital initiation and dosage adjustment based on QTc and ClCr are necessary to minimize a small but nonnegligible proarrhythmic risk BACKGROUND A st and ard approach to recent onset atrial fibrillation ( AF ) in the emergency department ( ED ) in the United States has not been established . PURPOSE The purpose of this prospect i ve clinical trial was to determine how an ED protocol emphasizing rhythm control for recent onset AF compared similar patients receiving  st and ard therapy  in the same facility . METHODS We enrolled consecutive patients presenting to our community hospital with recent onset AF into a protocol , which called for rhythm control with procainamide and if unsuccessful electrical cardioversion and discharge home . We compared this prospect i ve cohort with matched historical controls . Primary outcome was admission rate . We also compared ED conversion rates and lengths of stay ( LOS ) . We reported 30-day data on the study group including ED recidivism , recurrent AF , outpatient follow-up , and any important adverse events . RESULTS Fifty-four patients were enrolled in the study group with 4 being admitted compared with 30 of 50 in the historical control group . Ninety-four percent of the study group converted compared with 28 % in the historical control . Both hospital and ED LOS were significantly shorter for the study group . Six patients had recurrent AF , and 4 of those returned to the ED . CONCLUSION An ED protocol that uses rhythm control decreased hospital admission and LOS , and there were no adverse events at 30 days Objective : To compare the success rates and short-term complications of three treatment approaches , pharmacological and direct-current cardioversion ( DCC ) , or ‘ wait- and -watch ’ among stable atrial fibrillation ( AF ) patients in the emergency department ( ED ) . Methods : All AF-related ED admissions during a 1-year period were retrospectively review ed , and those meeting criteria of eligibility for immediate cardioversion , based on clinical stability , AF duration and adequacy of anticoagulation , were included . The propensity score approach generalized for the three groups was used to adjust for the observational non-r and omized study nature . Results : Among 374 eligible patients , the rate of successful cardioversion was higher in DCC than in pharmacological or wait- and -watch groups ( 78.2 , 59.2 and 37.9 % respectively , p < 0.001 ) , with corresponding percentages of patients discharged from ED ( 52.9 , 47.9 and 32.1 % , p < 0.01 ) and respective odds ratios of 6.00 , 2.47 and 1 , adjusting for seniority of the treating physician , age , gender and patient comorbidities . DCC was 2.43 times more effective than pharmacological treatment in achieving sinus rhythm ( 95 % confidence interval = 1.36–4.33 , p = 0.003 ) . Rehospitalization within 14 days due to probable AF-treatment-related complications of home-discharged patients was 3.4 % . Conclusions : DCC was found to be the most effective treatment , with few short-term complications following conversion of stable AF patients to sinus rhythm in the ED AIM The aim of our study was to compare the efficacy and safety of ibutilide and amiodarone ( intravenously ) in converting  recent-onset atrial fibrillation ( AF ) and atrial flutter ( Af )  to sinus rhythm ( SR ) . METHODS The study was prospect i ve , r and omized and included 152 ( 103 men and 49 women ) consecutive patients with AF or Af of 3 - 48 h duration .  Ibutilide is a selective class III antiarrhythmic agent which when administered intravenously can terminate AF and Af .  Amiodarone is also a class III antiarrhythmic agent that when given intravenously or orally has proved to be more effective than other agents in terminating AF and Af [ B.N. Singh , F.V. Mody , B. Lopez , J.S. Sarma . Antiarrhythmic agents for atrial fibrillation : focus on prolonging atrial repolarization . Am J Cardiol 1999 Nov 4 ; 84 : 161R-173R . ] . Seventy-nine patients ( 56 with AF and 23 with Af ) that consisted group A were treated with ibutilide .  Seventy-three ( 52 with AF and 21 with Af ) consisted group B and were treated with intravenous infusion of amiodarone . RESULTS The conversion rate of group A ( ibutilide ) was significantly higher than the conversion rate of group B ( amiodarone ) ( 80 % vs. 57 % , p=0.0054 ) . As regards the kind of arrhythmia separately , for AF there was n't significant difference ( 77 % vs. 69 % , p = ns ) whereas for Af ibutilide was superior to amiodarone ( 87 % vs. 29 % , p=0.003 ) . The conversion rates of ibutilide did n't differ for AF and Af ( 77 % vs. 87 % , p = ns ) . CONCLUSIONS Ibutilide is more effective than amiodarone in converting recent-onset Af to SR whereas both drugs are equally effective in converting recent-onset AF to SR Objective : To assess the effectiveness and safety of pharmacological conversion of persistent atrial fibrillation ( AF ) with a combined propafenone plus ibutilide regimen . Methods and results : 100 consecutive patients ( 66 men , mean ( SD ) age 65 ( 10 ) years ) with persistent AF ( mean ( SD ) duration 99 ( 92 ) days ) admitted for elective pharmacological cardioversion were r and omly assigned to treatment with either intravenous ibutilide ( 1 mg plus an additional 1 mg , if required ; n = 51 ) or oral propafenone ( 600 mg ) plus intravenous ibutilide at the same dose ( n = 49 ) . Success rates were 41.1 % ( 21 of 51 patients ) for ibutilide alone and 71.4 % ( 35 of 49 patients ) for propafenone plus ibutilide ( p = 0.0044 ) . However , cardioversion occurred earlier in the ibutilide alone group ( 55 ( 20 ) minutes ) compared with the combination group ( 81 ( 32 ) minutes , p = 0.0019 ) . A comparable increase in the QTc interval was observed in both groups but one case of sustained torsade de pointes , requiring electrical cardioversion , was observed in the propafenone plus ibutilide group . No other complications were noted during the hospitalisation period . Conclusion : Concurrent administration of propafenone plus ibutilide for pharmacological cardioversion of persistent AF is safe and more effective than ibutilide alone BACKGROUND The management of emergency department ( ED ) patients with presumed recent-onset atrial fibrillation or flutter≤48h in duration varies widely . OBJECTIVE AND METHOD We conducted a prospect i ve study across three affiliated community EDs within a large integrated health care delivery system to describe the management of patients with recent-onset atrial fibrillation or flutter , to determine the safety and effectiveness of  ED cardioversion  , and to measure the incidence of thromboembolism 30 days after discharge . RESULTS We enrolled 206 patients with convenience sampling between June 2005 and November 2007 . Mean age was 64.0±14.4 years ( range 21 - 96 years ) . Patients were grouped for analysis into four categories based on whether cardioversion was 1 ) spontaneous in the ED ( 59 ; 28.6 % ) ; 2 ) attempted with electrical or pharmacological means ( 115 ; 56.3 % ) , with success in 110 ( 95.7 % ) ; 3 ) hoped for during a short stint of home observation ( 16 ; 7.8 % , 11 of which spontaneously converted to sinus rhythm within 24h ) ; or 4 ) contraindicated ( 16 ; 7.8 % ) . Of the entire group , 183 ( 88.8 % ) patients were discharged home . Adverse events requiring ED interventions were reported in 6 ( 2.9 % ; 95 % confidence interval [ CI ] 1.1 - 6.2 % ) patients , all of whom recovered . Two ( 1.0 % ; 95 % CI 0.1 - 3.5 % ) patients were found to have an embolic event on 30-day follow-up . CONCLUSIONS Our approach to ED patients with presumed recent-onset atrial fibrillation or flutter seems to be safe and effective , with a high rate of cardioversion and discharge to home coupled with a low ED adverse event and 30-day thromboembolic event rate OBJECTIVES We sought to vali date the safety of transesophageal echocardiographically guided early cardioversion in conjunction with short-term anticoagulation as a strategy for guiding early cardioversion in hospitalized patients with atrial fibrillation . BACKGROUND Because atrial thrombi are poorly seen by conventional imaging techniques , several weeks of prophylactic anticoagulation is routinely prescribed before cardioversion . Transesophageal echocardiography is a superior test for identifying atrial thrombi ; preliminary feasibility studies have supported its use to guide early cardioversion for patients in whom no thrombus is observed , but safety has not been vali date d in any large series . METHODS All patients admitted to hospital with atrial fibrillation during a 4.5-year period were screened . The inclusion criterion was a clinical duration of atrial fibrillation > 2 days or of unknown duration . Patients received anticoagulation with heparin/warfarin and underwent conventional transthoracic echocardiography followed by transesophageal study . Patients in whom transesophageal echocardiography revealed no atrial thrombus underwent pharmacologic or electrical cardioversion followed by warfarin therapy for 1 month . Cardioversion was deferred in patients with evidence of atrial thrombi , and they received prolonged warfarin treatment . RESULTS Two hundred thirty-three patients ( 86 % of those eligible ) agreed to participate , and 230 underwent transesophageal echocardiography . Transesophageal echocardiography identified 40 atrial thrombi ( left atrium 34 , right atrium 6 ) in 34 patients ( 15 % ) . One hundred eighty-six ( 95 % ) of 196 patients without thrombi had successful cardioversion to sinus rhythm , all without prolonged anticoagulation , and none ( 0 % , 95 % confidence interval 0 % to 1.6 % ) experienced a clinical thromboembolic event . Eighteen patients with atrial thrombi underwent uneventful cardioversion after prolonged anticoagulation . CONCLUSIONS Compared with smaller series that have shown only feasibility , this large prospect i ve and consecutive study of patients undergoing transesophageal echocardiographically facilitated early cardioversion in conjunction with short-term anticoagulation vali date s the safety of this strategy . This treatment algorithm has a safety profile similar to conventional therapy and minimizes both the period of anticoagulation and the overall duration of atrial fibrillation INTRODUCTION  Early recurrent atrial fibrillation ( ERAF ) after external cardioversion of atrial fibrillation ( AF ) occurs in 12 % to 26 % of patients . Whether biphasic cardioversion has an impact on the incidence of ERAF after cardioversion of AF is unclear . METHODS AND RESULTS Consecutive patients ( n = 216 , mean age 66 years , 71 % male , 88 % with structural cardiovascular disease or hypertension ) underwent cardioversion with a biphasic ( Bi ) or monophasic ( Mo ) shock waveform in r and omized fashion . Energies used were 120 - 150 - 200 - 200 Ws ( Bi ) or 200 - 300 - 360 - 360 Ws ( Mo ) . The two study groups ( Bi vs Mo ) did not differ with regard to age , sex , body mass index , underlying cardiovascular disease , left atrial diameter , left ventricular ejection fraction , duration of AF fibrillation , and antiarrhythmic drug therapy . Mean delivered energy was significantly lower in the Bi group ( Bi : 186 + /- 143 Ws vs Mo : 324 + /- 227 Ws ; P < 0.001 ) . Overall incidence of ERAF ( AF relapse within 1 minute after successful cardioversion ) was 8.9 % and showed no difference between the two groups ( Bi : 8.1 % vs Mo : 9.7 % , P = NS ) . Cardioversion was successful in 95.4 % of patients . The success rate was comparable in both groups ( Bi : 94.3 % vs Mo 96.8 % ; P = NS ) . First shock efficacy did not differ between Bi and Mo ( 76.4 % vs 67.7 % ; P = NS ) . Mean number of shocks were 1.4 shocks per patient in both groups . CONCLUSION Biphasic cardioversion allows comparable success rates with significantly lower energies . However , the incidence of ERAF is not influenced by biphasic cardioversion . With the energies used , biphasic and monophasic shock waveforms are comparable with regard to first shock and cumulative shock efficacy
Bayesian network meta- analysis using a r and om-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 .
Probabilistic analysis ranked vernakalant and flecainide high and propafenone and amiodarone IV low .
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 .
AIMS We sought to identify the most effective antidysrhythmic drug for pharmacologic cardioversion of recent-onset atrial fibrillation ( AF ) .