Background: Atrial Fibrillation (AF) is the most common clinically significant dysrhythmia. Early cardioversion of recent-onset AF may also result in a lower rate of AF recurrence and progression to sustained AF. Current guidelines do not uniformly agree on selection of antidysrhythmic agents for pharmacologic cardioversion of recent-onset AF.
Methods: We conducted a systematic review and network meta-analysis of randomized controlled trials that examined the efficacy of various antidysrhythmic drugs for cardioversion of recent-onset AF. We searched PubMed, Embase, and Web of Science up to November 2018 and used the Cochrane review handbook tool for quality assessment of included studies. Subsequently, we conducted network meta-analyses to calculate the odds ratios (ORs) with 95% credible intervals (CrI) for the outcomes of AF conversion within 4 and 24 hours. We used surface under the cumulative ranking (SUCRA) curves to rank various antidysrhythmic drugs in terms of efficacy.
Results: Twenty-nine studies encompassing 3,478 patients were included. Propafenone (OR 34.5, 95% CrI 3.84 to 403.6), antazoline (OR 25.3, 95% CrI 1.27 to 529.6), vernakalant (OR 19.6, 95% CrI 1.33 to 396.8), and flecainide (OR 13.8, 95% CrI 1.75 to 136.0) were more effective than placebo/non-antidysrhythmic control for conversion of AF at 4 hours, and propafenone is most likely to be the superior drug (SUCRA 84.0%). Multiple agents were more effective than placebo/non-antidysrhythmic control for conversion of AF at 24 hours, with the highest ORs belonging to ranolazine plus amiodarone (OR 44.7, 95% CrI 21.08 to 100.3), antazoline (OR 24.1, 95% CrI 7.24 to 99.6), vernakalant (OR 23.8, 95% CrI 12.7 to 45.2), flecainide (OR 13.4, 95% CrI 7.48 to 24.5). Ranolazine plus amiodarone IV is most likely to be the superior therapy (SUCRA 91.9%).
Conclusion: Propafenone is most likely to be the superior agent for AF conversion within four hours, and ranolazine plus amiodarone IV is most likely to be the superior regimen for AF conversion within 24 hours.