Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY; Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, NY.
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Women's College Research Institute, Women's College Hospital in Toronto, Toronto, Ontario, Canada.
Ann Emerg Med. 2020 Jul;76(1):14-30. doi: 10.1016/j.annemergmed.2020.01.013. Epub 2020 Mar 12.
We conduct a systematic review and Bayesian network meta-analysis to indirectly compare and rank antidysrhythmic drugs for pharmacologic cardioversion of recent-onset atrial fibrillation and atrial flutter in the emergency department (ED).
We searched MEDLINE, EMBASE, and Web of Science from inception to March 2019, limited to human subjects and English language. We also searched for unpublished data. We limited studies to randomized controlled trials that enrolled adult patients with recent-onset atrial fibrillation or atrial flutter and compared antidysrhythmic agents, placebo, or control. We determined these outcomes before data extraction: rate of conversion to sinus rhythm within 4 hours, time to cardioversion, rate of significant adverse events, and rate of thromboembolism within 30 days. We extracted data according to Preferred Reporting Items for Systematic Reviews and Meta-analyses network meta-analysis and appraised selected trials with the Cochrane review handbook.
The systematic review initially identified 640 studies; 19 met inclusion criteria. Eighteen trials that randomized 2,069 atrial fibrillation patients provided data for atrial fibrillation conversion rate outcome. Bayesian network meta-analysis using a random-effects model demonstrated that antazoline (odds ratio [OR] 24.9; 95% credible interval [CrI] 7.4 to 107.8), tedisamil (OR 12.0; 95% CrI 4.3 to 43.8), vernakalant (OR 7.5; 95% CrI 3.1 to 18.6), propafenone (OR 6.8; 95% CrI 3.6 to 13.8), flecainide (OR 6.1; 95% CrI 2.9 to 13.2), and ibutilide (OR 4.1; 95% CrI 1.8 to 9.6) were associated with increased likelihood of conversion within 4 hours compared with placebo or control. Overall quality was low, and the network exhibited inconsistency.
For pharmacologic cardioversion of recent-onset atrial fibrillation within a 4-hour ED visit, there is insufficient evidence to determine which treatment is superior. Several agents are associated with increased likelihood of conversion within 4 hours compared with placebo or control. Limited data preclude any recommendation for cardioversion of recent-onset atrial flutter. Further high-quality study is necessary.
我们进行了系统评价和贝叶斯网络荟萃分析，以间接比较和排列急诊室（ED）近期新发心房颤动和心房扑动患者的抗心律失常药物转复窦性心律的效果。
我们检索了 MEDLINE、EMBASE 和 Web of Science 从建库到 2019 年 3 月的文献，仅限于人类研究和英文文献。我们还检索了未发表的数据。我们将研究限定为随机对照试验，纳入了近期新发心房颤动或心房扑动的成年患者，并比较了抗心律失常药物、安慰剂或对照组。我们在提取数据之前确定了这些结局：4 小时内窦性心律转复率、转复时间、严重不良事件发生率和 30 天内血栓栓塞发生率。我们根据系统评价和荟萃分析网络荟萃分析的首选报告项目提取数据，并使用 Cochrane 评价手册评价入选试验。
系统评价最初确定了 640 项研究；19 项符合纳入标准。18 项随机分配 2069 例心房颤动患者的试验提供了心房颤动转复率结局的数据。采用随机效应模型的贝叶斯网络荟萃分析显示，安他唑啉（比值比[OR] 24.9；95%可信区间[CrI] 7.4 至 107.8）、替地沙米（OR 12.0；95% CrI 4.3 至 43.8）、维纳卡兰（OR 7.5；95% CrI 3.1 至 18.6）、普罗帕酮（OR 6.8；95% CrI 3.6 至 13.8）、氟卡尼（OR 6.1；95% CrI 2.9 至 13.2）和伊布利特（OR 4.1；95% CrI 1.8 至 9.6）与 4 小时内转复窦性心律的可能性增加相关，与安慰剂或对照组相比。整体质量较低，网络存在不一致性。
对于 4 小时 ED 就诊的近期新发心房颤动患者，尚无足够证据确定哪种治疗方法更优。与安慰剂或对照组相比，几种药物与 4 小时内转复窦性心律的可能性增加相关。有限的数据不支持任何关于近期新发心房扑动转复的建议。需要进一步进行高质量的研究。
