Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, NY 11203, USA.
Department of Emergency Medicine, Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY 11203, USA.
Europace. 2020 Jun 1;22(6):854-869. doi: 10.1093/europace/euaa024.
We sought to identify the most effective antidysrhythmic drug for pharmacologic cardioversion of recent-onset atrial fibrillation (AF).
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 We also searched for unpublished data.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 AF ≤ 48 h and compared antidysrhythmic agents, placebo, or control. We determined these outcomes prior to data extraction: (i) rate of conversion to sinus rhythm within 24 h, (ii) time to cardioversion to sinus rhythm, (iii) rate of significant adverse events, and (iv) rate of thromboembolism within 30 days. We extracted data according to PRISMA-NMA and appraised selected trials using the Cochrane review handbook. The systematic review initially identified 640 studies; 30 met inclusion criteria. Twenty-one trials that randomized 2785 patients provided efficacy data for the conversion rate outcome. Bayesian network meta-analysis using a random-effects model demonstrated that ranolazine + amiodarone intravenous (IV) [odds ratio (OR) 39.8, 95% credible interval (CrI) 8.3-203.1], vernakalant (OR 22.9, 95% CrI 3.7-146.3), flecainide (OR 16.9, 95% CrI 4.1-73.3), amiodarone oral (OR 10.2, 95% CrI 3.1-36.0), ibutilide (OR 7.9, 95% CrI 1.2-52.5), amiodarone IV (OR 5.4, 95% CrI 2.1-14.6), and propafenone (OR 4.1, 95% CrI 1.7-10.5) were associated with significantly increased likelihood of conversion within 24 h when compared to placebo/control. Overall quality was low, and the network exhibited inconsistency. Probabilistic analysis ranked vernakalant and flecainide high and propafenone and amiodarone IV low.
For pharmacologic cardioversion of recent-onset AF within 24 h, there is insufficient evidence to determine which treatment is superior. Vernakalant and flecainide may be relatively more efficacious agents. Propafenone and IV amiodarone may be relatively less efficacious. Further high-quality study is necessary.
我们旨在确定最近发作的心房颤动（房颤）患者药物复律时最有效的抗心律失常药物。
我们检索了 MEDLINE、Embase 和 Web of Science 从开始到 2019 年 3 月的文献，仅限于人类受试者和英文文献。我们还搜索了未发表的数据。我们将研究仅限于随机对照试验，纳入了房颤发作时间不超过 48 小时的成年患者，并比较了抗心律失常药物、安慰剂或对照药物。在提取数据之前，我们确定了以下结局：（i）24 小时内窦性心律的转换率，（ii）复律至窦性心律的时间，（iii）严重不良事件的发生率，以及（iv）30 天内血栓栓塞的发生率。我们根据 PRISMA-NMA 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，其中 30 项符合纳入标准。21 项随机分配 2785 例患者的试验提供了转换率结局的疗效数据。采用随机效应模型的贝叶斯网络荟萃分析表明，雷诺嗪+胺碘酮静脉（IV）[比值比（OR）39.8，95%可信区间（CrI）8.3-203.1]、维纳卡兰（OR 22.9，95% CrI 3.7-146.3）、氟卡尼（OR 16.9，95% CrI 4.1-73.3）、胺碘酮口服（OR 10.2，95% CrI 3.1-36.0）、伊布利特（OR 7.9，95% CrI 1.2-52.5）、胺碘酮 IV（OR 5.4，95% CrI 2.1-14.6）和普罗帕酮（OR 4.1，95% CrI 1.7-10.5）与 24 小时内窦性心律的转换率显著增加相关。整体质量较低，网络存在不一致性。概率分析将维纳卡兰和氟卡尼排在前列，而普罗帕酮和胺碘酮 IV 排在后面。
对于最近发作的房颤在 24 小时内的药物复律，没有足够的证据来确定哪种治疗方法更有效。维纳卡兰和氟卡尼可能是相对更有效的药物。普罗帕酮和胺碘酮 IV 可能相对效果较差。需要进一步进行高质量的研究。
