Single-dose oral anti-arrhythmic drugs for cardioversion of recent-onset atrial fibrillation: a systematic review and network meta-analysis of randomized controlled trials

Aims Single oral dose anti-arrhythmic drugs (AADs) are used to cardiovert recent-onset atrial fibrillation (AF); however, the optimal agent is uncertain. Methods We performed a systematic review and network meta-analysis of randomized trials testing single oral dose AADs vs. any comparator to cardiovert AF <7 days duration. We searched MEDLINE, Embase, and CENTRAL to April 2020. The primary outcome was successful cardioversion at timepoint nearest 8 h after administration. Results From 12712 citations, 22 trials (2320 patients) were included. Thirteen trials included patients with some degree of heart failure; 19 included patients with some degree of ischaemic heart disease vs. placebo or rate-control (32% success) at 8 h, flecainide [73%, network odds ratio (OR) 7.6, 95% credible interval (Crl) 4.4-14.0] propafenone (70%, OR 4.6, Crl 2.9-7.3), and pilsicainide (59%, OR 10.0, Cr1 1.8-69.0), but not amiodarone (28%, OR 1.0, Crl 0.4-2.8) were superior. Flecainide (OR 7.5, Cr1 2.6-24.0) and propafenone (OR 4.5, Crl 1.6-13.0) were superior to amiodarone; propafenone vs. flecainide did not statistically differ (OR 0.6, Crl 0.3-1.1). At Longest follow-up, amiodarone was superior to placebo (OR 11.0, Crl 3.2-41.0), flecainide vs. amiodarone (OR 0.79, Crl 0.19-3.1), and propafenone vs. amiodarone (OR 0.36, Crl 0.092-1.4) were not statistically different, and flecainide was superior to propafenone (OR 2.2, Crl 1.1-4.8). Atrial and ventricular tachyarrhythmias, bradyarrhythmias, and hypotension were rare with PO AADs. Conclusion Single oral dose Class 1C AADs are effective and safe for cardioversion of recent-onset AF. Flecainide may be superior to propafenone. Amiodarone is a slower acting alternative.

Automated summary

The study found that single oral dose Class 1C AADs are effective and safe for cardioversion of recent-onset atrial fibrillation. Flecainide and propafenone were more effective than amiodarone at the nearest 8-hour timepoint.