title: Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation.
abstract: BACKGROUND
  Atrial fibrillation (AF) is the most frequent sustained arrhythmia. AF recurs frequently after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence, but the effect of these drugs on mortality and other clinical outcomes is unclear.
  
  
  OBJECTIVE
  To determine, in patients who recovered sinus rhythm after AF, the effect of long-term treatment with antiarrhythmic drugs on death, stroke and embolism, adverse effects, pro-arrhythmia, and recurrence of AF.
  
  
  METHODS
  We updated the searches of CENTRAL on The Cochrane Libary (Issue 1 of 4, 2010), MEDLINE (1950 to February 2010) and EMBASE (1966 to February 2010). The reference lists of retrieved articles, recent reviews and meta-analyses were checked.
  
  
  METHODS
  Two independent reviewers selected randomised controlled trials comparing any antiarrhythmic with a control (no treatment, placebo or drugs for rate control) or with another antiarrhythmic, in adults who had AF and in whom sinus rhythm was restored. Post-operative AF was excluded.
  
  
  METHODS
  Two reviewers independently assessed quality and extracted data. Studies were pooled, if appropriate, using Peto odds ratio (OR). All results were calculated at one year of follow-up.
  
  
  RESULTS
  In this update, 11 new studies met inclusion criteria, making a total of 56 included studies, comprising 20,771 patients. Compared with controls, class IA drugs quinidine and disopyramide (OR 2.39, 95% confidence interval (95%CI) 1.03 to 5.59, number needed to harm (NNH) 109, 95%CI 34 to 4985) and sotalol (OR 2.47, 95%CI 1.2 to 5.05, NNH 166, 95%CI 61 to 1159) were associated with increased all-cause mortality. Other antiarrhythmics did not seem to modify mortality.Several class IA (disopyramide, quinidine), IC (flecainide, propafenone) and III (amiodarone, dofetilide, dronedarone, sotalol) drugs significantly reduced recurrence of AF (OR 0.19 to 0.70, number needed to treat (NNT) 3 to 16). Beta-blockers (metoprolol) also reduced significantly AF recurrence (OR 0.62, 95% CI 0.44 to 0.88, NNT 9).All analysed drugs increased withdrawals due to adverse affects and all but amiodarone, dronedarone and propafenone increased pro-arrhythmia. We could not analyse other outcomes because few original studies reported them.
  
  
  CONCLUSIONS
  Several class IA, IC and III drugs, as well as class II (beta-blockers), are moderately effective in maintaining sinus rhythm after conversion of atrial fibrillation. However, they increase adverse events, including pro-arrhythmia, and some of them (disopyramide, quinidine and sotalol) may increase mortality. Possible benefits on clinically relevant outcomes (stroke, embolisms, heart failure) remain to be established.
authors.affiliation: Service deGériatrie à orientation Cardiologique etNeurologique, Groupe hospitalier Pitié-Salpêtrière-Charles Foix, AP-HP,UniversitéPierre et Marie Curie (Paris 6), Ivry-sur-Seine, France. c.lafuente@nodo3.net
authors.forename: Carmelo
authors.initials: C
authors.lastname: Lafuente-Lafuente
authors.forename: Miguel Angel
authors.initials: MA
authors.lastname: Longas-Tejero
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Bergmann
authors.forename: Joël
authors.initials: J
authors.lastname: Belmin
mesh_terms: D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000401:mortality / Q000517:prevention & control / Q000628:therapy*; D004554:Electric Countershock; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D055502:Secondary Prevention
chemical_list: D000889:Anti-Arrhythmia Agents