deSouza Ian S, Shrestha Pragati, Allen Robert, Koos Jessica, Thode Henry
Department of Emergency Medicine, SUNY Downstate Health Sciences University and Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY, 11203, USA.
Department of Family, Population and Preventive Medicine, Stony Brook University, Stony Brook, NY, USA.
Cardiovasc Drugs Ther. 2024 Feb 7. doi: 10.1007/s10557-024-07552-6.
The available evidence to determine which antidysrhythmic drug is superior for pharmacologic cardioversion of recent-onset (onset within 48 h) atrial fibrillation (AF) is uncertain. We aimed to identify the safest and most effective agent for pharmacologic cardioversion of recent-onset AF in the emergency department.
We searched MEDLINE, Embase, and Web of Science from inception to February 21, 2023 (PROSPERO: CRD42018083781). Eligible studies were randomized controlled trials that enrolled adult participants with AF ≤ 48 h, compared a guideline-recommended antidysrhythmic drug with another antidysrhythmic drug or a different formulation of the same drug or placebo and reported specific adverse events. The primary outcome was immediate, serious adverse event - cardiac arrest, sustained ventricular tachydysrhythmia, atrial flutter 1:1 atrioventricular conduction, hypotension, and bradycardia. Additional analyses included the outcomes of conversion to sinus rhythm within 4 h and 24 h. We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effect model and vague prior distribution to calculate odds ratios with 95% credible intervals. We assessed confidence using CINeMA. We used surface under the cumulative ranking curve (SUCRA) to rank agent(s).
The systematic review initially identified 5545 studies. Twenty-five studies met eligibility criteria, and 22 studies (n = 3082) provided data for NMA, which demonstrated that vernakalant (SUCRA = 70.9%) is most likely to be safest. Additional effectiveness NMA demonstrated that flecainide (SUCRA = 89.0%) is most likely to be superior for conversion within 4 h (27 studies; n = 2681), and ranolazine-amiodarone IV (SUCRA 93.7%) is most likely to be superior for conversion within 24 h (24 studies; n = 3213). Confidence in the NMA estimates is variable and limited mostly by within-study bias and imprecision.
Among guideline-recommended antidysrhythmic drugs, the combination of digoxin IV and amiodarone IV is definitely among the least safe for cardioversion of recent onset AF; flecainide, vernakalant, ibutilide, propafenone, and amiodarone IV are definitely among the most effective for cardioversion within 4 h; flecainide is definitely among the most effective for cardioversion within 24 h. Further, randomized controlled trials with predetermined and strictly defined, hemodynamic adverse event outcomes are recommended.
目前尚无确凿证据表明哪种抗心律失常药物在近期发作（发作时间在48小时内）的心房颤动（AF）药物复律方面更具优势。我们旨在确定急诊科中用于近期发作AF药物复律的最安全、最有效的药物。
我们检索了MEDLINE、Embase和Web of Science数据库，检索时间从建库至2023年2月21日（国际前瞻性系统评价注册库：CRD42018083781）。符合条件的研究为随机对照试验，纳入发作时间≤48小时的成年AF患者，比较一种指南推荐的抗心律失常药物与另一种抗心律失常药物、同一药物的不同剂型或安慰剂，并报告特定不良事件。主要结局为即刻严重不良事件——心脏骤停、持续性室性快速心律失常、心房扑动1:1房室传导、低血压和心动过缓。额外分析包括4小时和24小时内转为窦性心律的结局。我们根据PRISMA-NMA提取数据，并使用Cochrane RoB 2评估试验。我们采用马尔可夫链蒙特卡罗方法和随机效应模型及模糊先验分布进行贝叶斯网络荟萃分析（NMA），以计算95%可信区间的比值比。我们使用CINeMA评估可信度。我们使用累积排序曲线下面积（SUCRA）对药物进行排序。
系统评价最初识别出5545项研究。25项研究符合纳入标准，22项研究（n = 3082）为NMA提供了数据，结果表明维纳卡兰（SUCRA = 70.9%）最有可能是最安全的。额外的有效性NMA表明，氟卡尼（SUCRA = 89.0%）在4小时内复律（27项研究；n = 2681）最有可能更具优势，雷诺嗪-静脉注射胺碘酮（SUCRA 93.7%）在24小时内复律（24项研究；n = 3213）最有可能更具优势。对NMA估计值的可信度各不相同，且主要受研究内偏倚和不精确性的限制。
在指南推荐的抗心律失常药物中，静脉注射地高辛和静脉注射胺碘酮联合使用在近期发作AF复律方面肯定是最不安全的；氟卡尼、维纳卡兰、伊布利特、普罗帕酮和静脉注射胺碘酮在4小时内复律肯定是最有效的；氟卡尼在24小时内复律肯定是最有效的。此外，建议进行具有预先确定且严格定义的血流动力学不良事件结局的随机对照试验。
