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American Journal of Cardiovascular Drugs

Published in:

26-05-2023 | Antiarrhythmic Drugs | Systematic Review

Bayesian Network Meta-analysis of Randomized Controlled Trials on the Efficacy of Antiarrhythmics in the Pharmacological Cardioversion of Paroxysmal Atrial Fibrillation

Authors: Daniele Orso, Sara Santangelo, Nicola Guglielmo, Tiziana Bove, Francesco Cilenti, Lorenzo Cristiani, Roberto Copetti

Published in: American Journal of Cardiovascular Drugs | Issue 4/2023

Abstract

Purpose

Since atrial fibrillation (AF) is one of the major arrhythmias managed in hospitals worldwide, it has a major impact on public health. The guidelines agree on the desirability of cardioverting paroxysmal AF episodes. This meta-analysis aims to answer the question of which antiarrhythmic agent is most effective in cardioverting a paroxysmal AF.

Materials and Methods

A systematic review and Bayesian network meta-analysis, searching MEDLINE, Embase, and CINAHL, were performed, including randomized controlled trials (RCTs) enrolling a population of unselected adult patients with a paroxysmal AF that compared at least two pharmacological regimes to restore the sinus rhythm or a cardioversion agent against a placebo. The main outcome was efficacy in restoring sinus rhythm.

Results

Sixty-one RCTs (7988 patients) were included in the quantitative analysis [deviance information criterion (DIC) 272.57; I² = 3%]. Compared with the placebo, the association verapamil–quinidine shows the highest SUCRA rank score (87%), followed by antazoline (86%), vernakalant (85%), tedisamil at high dose (i.e., 0.6 mg/kg; 80%), amiodarone–ranolazine (80%), lidocaine (78%), dofetilide (77%), and intravenous flecainide (71%). Taking into account the degree of evidence of each individual comparison between pharmacological agents, we have drawn up a ranking of pharmacological agents from the most effective to the least effective.

Conclusions

In comparing the antiarrhythmic agents used to restore sinus rhythm in the case of paroxysmal AF, vernakalant, amiodarone–ranolazine, flecainide, and ibutilide are the most effective medications. The verapamil–quinidine combination seems promising, though few RCTs have studied it. The incidence of side effects must be taken into account in the choice of antiarrhythmic in clinical practice.

Clinical Trial Registration

PROSPERO: International prospective register of systematic reviews, 2022, CRD42022369433 (Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022369433).

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Title: Bayesian Network Meta-analysis of Randomized Controlled Trials on the Efficacy of Antiarrhythmics in the Pharmacological Cardioversion of Paroxysmal Atrial Fibrillation
Authors: Daniele Orso
Sara Santangelo
Nicola Guglielmo
Tiziana Bove
Francesco Cilenti
Lorenzo Cristiani
Roberto Copetti
Publication date: 26-05-2023
Publisher: Springer International Publishing
Keywords: Antiarrhythmic Drugs
Digoxin
Verapamil
Atrial Fibrillation
Ranolazine
Published in: American Journal of Cardiovascular Drugs / Issue 4/2023
Print ISSN: 1175-3277
Electronic ISSN: 1179-187X
DOI: https://doi.org/10.1007/s40256-023-00586-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Bayesian Network Meta-analysis of Randomized Controlled Trials on the Efficacy of Antiarrhythmics in the Pharmacological Cardioversion of Paroxysmal Atrial Fibrillation

Abstract

Purpose

Materials and Methods

Results

Conclusions

Clinical Trial Registration

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Materials and Methods

Results

Conclusions

Clinical Trial Registration

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