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 ) .
Early or Delayed Cardioversion in Recent‐Onset Atrial Fibrillation
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 .
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 ) .