title: Efficacy of agents for pharmacologic conversion of atrial fibrillation and subsequent maintenance of sinus rhythm: a meta-analysis of clinical trials.
abstract: BACKGROUND
  Physicians have little evidentiary guidance for pharmacologic agent selection for atrial fibrillation (AF).
  
  
  OBJECTIVE
  To assess antiarrhythmic agent efficacy for AF conversion and subsequent maintenance of sinus rhythm (MSR).
  
  
  METHODS
  We searched the clinical trial database of the Cochrane Collaboration and MEDLINE encompassing literature from 1948 to May 1998.
  
  
  METHODS
  We selected 36 (28%) articles eligible as randomized trials of nonpostoperative AF conversion or MSR in adults.
  
  
  METHODS
  Study quality; rates of conversion, MSR, and adverse events were extracted.
  
  
  RESULTS
  Compared with control treatment (placebo, verapamil, diltiazem, or digoxin), the odds ratio (OR) for conversion was greatest for ibutilide/dofetilide (OR=29.1; 95% confidence interval [CI], 9.8-86.1) and flecainide (OR=24.7; 95% CI, 9.0-68.3). Less strong but conclusive evidence existed for propafenone (OR=4.6; 95% CI, 2.6-8.2). Quinidine (OR=2.9; 95% CI, 1.2-7.0) had moderate evidence of efficacy for conversion. Disopyramide (OR=7.0; 95% CI, 0.3-153.0) and amiodarone (OR=5.7; 95% CI, 1.0-33.4) had suggestive evidence of efficacy. Sotalol (OR=0.4; 95% CI, 0.0-3.0) had suggestive evidence of negative efficacy. For MSR, strong evidence of efficacy existed for quinidine (OR=4.1; 95% CI, 2.5-6.7), disopyramide (OR=3.4; CI, 1.6-7.1), flecainide (OR=3.1; 95% CI, 1.5-6.2), propafenone (OR=3.7; 95% CI, 2.4-5.7), and sotalol (OR=7.1; 95% CI, 3.8-13.4). The only amiodarone data, from comparison with disopyramide, provided moderate evidence of efficacy for MSR. No trial evaluated procainamide. Direct agent comparisons and adverse event data were limited.
  
  
  CONCLUSIONS
  Although multiple antiarrhythmic agents had strong evidence of efficacy compared with control treatment for MSR, ibutilide/dofetilide and flecainide had particularly strong evidence of efficacy compared with control treatment for AF conversion. There is sparse and inconclusive evidence on direct agent comparisons and adverse event rates. Obtaining information regarding these relative efficacies should be a research priority.
authors.affiliation: Division of Pediatric Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. mmiller@ahrq.gov
authors.forename: M R
authors.initials: MR
authors.lastname: Miller
authors.forename: R L
authors.initials: RL
authors.lastname: McNamara
authors.forename: J B
authors.initials: JB
authors.lastname: Segal
authors.forename: N
authors.initials: N
authors.lastname: Kim
authors.forename: K A
authors.initials: KA
authors.lastname: Robinson
authors.forename: S N
authors.initials: SN
authors.lastname: Goodman
authors.forename: N R
authors.initials: NR
authors.lastname: Powe
authors.forename: E B
authors.initials: EB
authors.lastname: Bass
mesh_terms: D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy*; D019317:Evidence-Based Medicine; D006801:Humans; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic
chemical_list: D000889:Anti-Arrhythmia Agents