Efficacy of propafenone vs. amiodarone in pharmacological cardioversion of recent-onset atrial fibrillation to sinus rhythm: a pooled meta-analysis of 9 randomized controlled trials
Authors: Borovac J A , Bozic J , Glavas D 
Published: October 2021

Abstract

Background
Atrial fibrillation (AF) is the most common sustained cardiac dysrhythmia and is associated with substantial morbidity and mortality. It can be managed either through ventricular rate control or conversion to sinus rhythm while for the patients with recent onset of AF, the latter is the recommended choice of treatment.

Purpose
To determine crude rates and the likelihood of conversion to sinus rhythm from recent-onset AF and mean difference in time to do so with respect if pharmacological cardioversion with propafenone or amiodarone is utilized.

Methods
MEDLINE and EMBASE electronic databases were searched and after exclusion criteria were applied, a total of 94 potential studies were identified, while 9 randomized controlled trials (RCTs) were included in the meta-analysis. These RCTs were conducted from 1994 until 2019 and investigated the use of oral/intravenous propafenone vs. amiodarone to convert recent-onset AF to sinus rhythm. The main outcome measures were a) likelihood of sinus rhythm restoration and for this analysis, an odds ratio (OR) with 95% confidence interval (95% CI) was reported, and b) mean time to sinus rhythm conversion between two treatment groups and the outcome measure for this endpoint was a mean difference (MD, in minutes). In both instances, OpenMeta[Analyst] software was used to perform meta-analysis while random-effects model was used with a restricted maximum likelihood-REML correction factor. Heterogeneity between RCTs was examined by the I2 test.

Results
A total of 9 RCTs pooled 822 patients, 410 randomized to propafenone and 412 to amiodarone treatment. All trials reported conversion rates while 7 trials reported on the time needed to reach sinus rhythm. Of these, only trials measuring conversion time during 12 to 24 hours were considered. Seven trials monitored patients for conversion during the 24 hours, one trial up until 12 hours, and 1 trial up to 8 hours. In most trials, recent-onset AF was defined as lasting ≤48 hours, and most were designed to perform intravenous drug comparisons. On average, conversion to sinus rhythm was achieved in 76.1% cases treated with propafenone and 71.8% cases treated with amiodarone. Propafenone use was non-significantly associated with a higher likelihood of conversion to sinus rhythm compared to amiodarone (OR 1.26, 95% CI 0.825–1.912) and there was a low degree of heterogeneity observed between trials (I2=34.9%, P=0.139; Figure 1). On the other hand, treatment with propafenone was associated with a significantly shorter mean time to sinus rhythm conversion compared to amiodarone (MD −304 minutes, 95% CI −342 to −266) and there was no heterogeneity observed between included trials (I2=2.78%, P=0.440; Figure 2).

Conclusion
Propafenone and amiodarone are similarly efficacious in converting patients from recent-onset atrial fibrillation to sinus rhythm, however, propafenone acts significantly faster and cuts mean time to sinus rhythm for about 5 hours.

Funding Acknowledgement
Type of funding sources: None. Figure 1. Odds ratio for conversion to SRFigure 2. Mean difference in minutes to reach SR