Combination Pharmacological Cardioversion of Permanent Atrial Fibrillation in Post-prosthetic Mitral Valve Replacement Outpatients: A Novel Approach for the Treatment of Atrial Fibrillation Comparison of pharmacological and electrical cardioversion in permanent atrial fibrillation after prosthetic cardiac valve replacement: A prospective randomized trial Effectiveness and costs of chemical versus electrical cardioversion of atrial fibrillation. Efficacy of transthoracic cardioversion of atrial fibrillation using a biphasic, truncated exponential shock waveform at variable initial shock energies. Atrial fibrillation: an observational study with outpatients. Treatment of Stable Atrial Fibrillation in the Emergency Department: A Population-Based Comparison of Electrical Direct-Current versus Pharmacological Cardioversion or Conservative Management Postapproval Observational Studies of Non-Vitamin K Antagonist Oral Anticoagulants in Atrial Fibrillation. Efficacy and proarrhythmic hazards of pharmacologic cardioversion of atrial fibrillation: prospective comparison of sotalol versus quinidine. Cardioversion of acute atrial fibrillation in the short observation unit: comparison of a protocol focused on electrical cardioversion with simple antiarrhythmic treatment Maintenance of sinus rhythm in patients with atrial fibrillation: an AFFIRM substudy of the first antiarrhythmic drug. Intravenous propafenone for converting recent onset atrial fibrillation in emergency departments: a randomized placebo-controlled multicenter trial. FAPS Investigators Study Group. Atrial fibrillation and heart failure in cardiology practice: reciprocal impact and combined management from the perspective of atrial fibrillation: results of the Euro Heart Survey on atrial fibrillation. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Optimal heart failure therapy and successful cardioversion in heart failure patients with atrial fibrillation. Impact of biphasic electrical cardioversion of atrial fibrillation on early recurrent atrial fibrillation and shock efficacy. A randomized, controlled trial of RSD1235, a novel anti-arrhythmic agent, in the treatment of recent onset atrial fibrillation. Antiarrhythmic drug therapy and cardiac mortality in atrial fibrillation. The Stroke Prevention in Atrial Fibrillation Investigators.
This study explored the efficacy and safety of combination pharmacological cardioversion of permanent atrial fibrillation in out patients following prosthetic mitral valve replacement . The study group comprised 99 out patients who were r and omly divided into two groups . In group 1 ( n = 50 ) , only ventricular heart rate was controlled . In group 2 ( n = 49 ) , combination pharmacological cardioversion therapy with low-dose oral amiodarone ( 2 mg/kg ) , captopril ( 0.25 mg/kg ) and simvastatin ( 0.3 mg/kg ) was administered daily . During 12 months of serial pharmacological treatment , the cardioversion rate was 6 % for group 1 and 39 % for group 2 ; the likelihood of cardioversion differed significantly between the two groups . In group 2 , one patient developed severe pruritus that necessitated withdrawal from the study and six patients ceased  captopril treatment after contracting a persistent cough . In summary , combination pharmacological cardioversion was found to be effective and safe in out patients who had undergone prosthetic mitral valve replacement Objective To compare the efficacy of electrical versus pharmacological cardioversion following prosthetic cardiac valve replacement in patients with permanent atrial fibrillation ( AF ) . Methods Patients with permanent AF who had undergone prosthetic cardiac valve replacement , who had a cardiothoracic ratio ≤0.5 and a left atrial diameter ≤50 mm for ≥6 months after surgery were r and omly divided to receive either electrical or pharmacological cardioversion . Patients in the electrical cardioversion group were given direct-current synchronized electrical defibrillation under general anaesthesia . Patients in the pharmacological cardioversion group were given oral combination therapy with amiodarone , captopril and simvastatin for 3 months . Results A total of 115 patients received either electrical cardioversion ( n = 59 ) or pharmacological cardioversion ( n = 56 ) ; reversion to sinus rhythm occurred in 98.3 % and 26.8 % , respectively . Recurrence rates were similar in the two groups ( 3.4 % and 6.7 % for electrical and pharmacological cardioversion , respectively ) . No deaths or severe complications were reported . Conclusion Electrical cardioversion has a favourable safety profile and appears to be a more effective method than pharmacological cardioversion for the treatment of permanent AF after cardiac valve replacement , once the heart has returned close to its normal size BACKGROUND Atrial fibrillation is the most common sustained cardiac arrhythmia and has an important impact on costs of medical assistance . Traditional interventions to convert atrial fibrillation to sinus rhythm are antiarrhythmic drugs and external electrical cardioversion . However , the best option for starting the cardioversion is not well established . METHODS In a multicentre r and omised trial of 139 patients with persistent atrial fibrillation lasting less than 6 months , we compared the effectiveness and the cost-effectiveness ratio of initial treatment with chemical or electrical cardioversion .  Subjects who did not achieve sinus rhythm with chemical cardioversion  were considered to undergo electrical cardioversion and vice-versa . RESULTS The efficacy of the initial attempt for cardioversion was similar with chemical or electrical cardioversion ( 74 vs. 73 % , P=0.95 ) . However , the strategy of starting with antiarrhythmic drugs was more effective than with electrical procedure ( 96 vs. 84 % , P=0.0016 ) . Initiating with chemical cardioversion  was also less expensive than with electrical cardioversion ( 1240 US dollars vs. 1917 US dollars ; P=0.002 ) . Life-threatening complications occurred only during chemical cardioversion ( 5 % ) , all of them in patients with structural heart disease . CONCLUSIONS In patients with persistent atrial fibrillation of less than 6 months , initial chemical or electrical cardioversion appear to be similar but the strategy of starting the cardioversion with antiarrhythmic drugs is more effective and less expensive than starting with the electrical procedure . Patients with structural heart disease undergoing chemical cardioversion seem to be more susceptible to severe complications Biphasic shocks are more effective than damped sine wave monophasic shocks for transthoracic cardioversion ( CV ) of atrial fibrillation ( AF ) , but the optimal protocol for CV with biphasic shocks has not been defined . We conducted a prospect i ve , r and omized study of 120 consecutive patients with persistent AF to delineate the dose-response curve for CV of AF with a biphasic truncated exponential shock waveform and to identify clinical predictors of shock efficacy . Our data suggest that the initial shock energy for CV with this waveform should be 200 J if the patient weighs < 90 kg and 360 J if the patient weighs > /=90 kg BACKGROUND Atrial fibrillation ( AF ) is the most common sustained arrhythmia with serious clinical consequences in the absence of treatment . However , there are limited data on the treatment of these patients in Argentina . The objective was to describe the therapeutic management of patients with nonacute AF by Argentinean cardiologists and to determine the incidence of clinical events after 12 months follow-up . METHODS The Atrial Fibrillation study in Argentina ( FARAON ) was an observational , descriptive , prospect i ve , national , and multicentric study that included out patients with AF , followed for 12 months . The study included 38 sites in Argentina . Each research er included the first 10 patients who met the inclusion criteria of being over 21 and also being an AF carrier documented by electrocardiogram or Holter within 12 months prior to or at the time of enrollment . RESULTS A total of 373 patients were included , mean age 70 ± 11.5 years , 40 % women ; 65 % had AF rhythm at the time of inclusion , 57 % had permanent AF , and 56 % were asymptomatic . At the time of enrollment , 40 % of physicians opted for rhythm control strategy . β-blockers and amiodarone were the most used drugs . Patients with rhythm control drugs had higher success rate than those with frequency control drug therapy ( 80 % vs 57 % ) . CONCLUSION Cardiologists in Argentina receive patients with AF that are mostly permanent AF . More than half of the patients are asymptomatic . They opt primarily by controlling the pace . When choosing antiarrhythmic drugs , nearly half of them indicated amiodarone Objective : To compare the success rates and short-term complications of three treatment approaches , pharmacological and direct-current cardioversion ( DCC ) , or ‘ wait- and -watch ’ among stable atrial fibrillation ( AF ) patients in the emergency department ( ED ) . Methods : All AF-related ED admissions during a 1-year period were retrospectively review ed , and those meeting criteria of eligibility for immediate cardioversion , based on clinical stability , AF duration and adequacy of anticoagulation , were included . The propensity score approach generalized for the three groups was used to adjust for the observational non-r and omized study nature . Results : Among 374 eligible patients , the rate of successful cardioversion was higher in DCC than in pharmacological or wait- and -watch groups ( 78.2 , 59.2 and 37.9 % respectively , p < 0.001 ) , with corresponding percentages of patients discharged from ED ( 52.9 , 47.9 and 32.1 % , p < 0.01 ) and respective odds ratios of 6.00 , 2.47 and 1 , adjusting for seniority of the treating physician , age , gender and patient comorbidities . DCC was 2.43 times more effective than pharmacological treatment in achieving sinus rhythm ( 95 % confidence interval = 1.36–4.33 , p = 0.003 ) . Rehospitalization within 14 days due to probable AF-treatment-related complications of home-discharged patients was 3.4 % . Conclusions : DCC was found to be the most effective treatment , with few short-term complications following conversion of stable AF patients to sinus rhythm in the ED The pivotal r and omized clinical trials ( RCTs ) of non – vitamin K antagonist oral anticoagulants ( NOACs ) for stroke prevention in atrial fibrillation ( AF ) established the efficacy and safety of these drugs for patients with AF without mechanical prosthetic heart valves or significant ( rheumatic ) mitral valve stenosis.1 A clinical trial setting with strict inclusion and exclusion criteria was needed to obtain high- quality scientific evidence on the effects of NOACs compared with st and ard care ( ie , warfarin ) , but these results in highly selected trial cohorts may not be fully applicable to a diversity of patients or clinical circumstances encountered in daily practice OBJECTIVES This study compared the efficacy and safety of sotalol and quinidine for conversion and prevention of recurrent  atrial fibrillation .  BACKGROUND Atrial fibrillation is the most common arrhythmia . Pharmacologic therapy has been advocated for both immediate restoration of sinus rhythm and prevention of recurrent atrial fibrillation .  Quinidine is the therapeutic mainstay for both purpose s , but its safety has recently been question ed . Although sotalol has been used successfully to maintain sinus rhythm after direct current cardioversion , its efficacy in pharmacologically reverting atrial fibrillation has not been examined . METHODS Fifty consecutive patients with persistent atrial fibrillation were r and omized to receive quinidine or sotalol for up to 7 days to restore sinus rhythm . Patients were followed up for 6 months . RESULTS Quinidine was more effective than sotalol in terminating atrial fibrillation ( 60 % vs. 20 % , p = 0.009 ) . When nonresponders to drug therapy underwent subsequent direct current cardioversion , total conversion rates in the quinidine and sotalol groups were comparable ( 88 % vs. 68 % , p = 0.17 ) , as was the efficacy of the two drugs in preventing recurrent atrial fibrillation . Side effects necessitating drug discontinuation were more often observed with quinidine . No patient receiving sotalol but four patients receiving quinidine had drug-associated arrhythmia ( torsade de pointes in three patients , sustained ventricular tachycardia in one patient ) . Precordial QT dispersion determined on the surface electrocardiogram ( ECG ) increased with quinidine ( mean + /- SD 34 + /- 9 vs. 44 + /- 16 ms , p = 0.02 ) , indicating enhanced inhomogeneity in ventricular repolarization . There was no change in QT dispersion in patients receiving sotalol ( 36 + /- 18 vs. 40 + /- 17 ms , p = 0.44 ) . CONCLUSIONS Quinidine is more effective than sotalol in terminating atrial fibrillation but is associated with more side effects . The proarrhythmic risk may be related to quinidine 's propensity to increase disparity in ventricular repolarization . This risk warrants careful ECG monitoring during the 1st 4 to 7 days of therapy . Because most proarrhythmic effects occurred shortly after restoration of sinus rhythm , observation should continue > or = 2 to 3 days after sinus rhythm is reestablished Background Direct current cardioversion ( DCC ) has been shown to be effective for the management of  atrial fibrillation ( AF )  in the emergency department ( ED ) . Pharmacological cardioversion was compared with a strategy including DCC on patients with uncomplicated , recent-onset ( < 48 h ) AF managed in a short observation unit ( SOU ) . Methods A prospect i ve observational study was undertaken over a period of 13 months in two institutions . A DCC-centred protocol was applied to 171 AF cases in a hospital ( DCC-cohort ) and pharmacological cardioversion to 151 AF cases in another hospital ( P-cohort ) . Patients remaining in AF after 24 h were admitted . The outcomes were rate of discharge in sinus rhythm , length of stay in the ED-SOU , rate of hospitalisation and complications of treatment . Data collected were analysed according to Student t test and χ2 statistics . Results Discharge in sinus rhythm was achieved in 159/171 cases in the DCC-cohort and 77/151 cases in the P-cohort ( 93 % vs 51 % ; number needed to treat ( NNT ) 2.4 ; 95 % CI 2.0 to 3.1 , p<0.001 ) , whereas mean length of stay was 7 + 7 h in the DCC-cohort and 9 + 6 h in the P-cohort ( p=0.43 ) . Eleven cases from the DCC-cohort and 67 from the P-cohort were admitted ( admission rate 6 % vs 44 % ; NNT 2.6 ; 95 % CI 2.2 to 3.5 , p<0.001 ) . Three short-term complications occurred in the DCC-cohort and five in the P-cohort ( 2 % vs 3 % , p=0.59 ) . Two strokes were registered in the DCC-cohort during 6-month follow-up ( p undefined ) . Conclusions Electrical cardioversion of recent-onset AF in the SOU is safe , effective and reduces hospitalisations . Further studies are needed to identify the most cost-effective strategy for the management of AF patients in emergency setting OBJECTIVES This study evaluated the efficacy of antiarrhythmic drugs for the treatment of  atrial fibrillation ( AF ) .  BACKGROUND The most effective and safest antiarrhythmic drug for the treatment of AF is unknown . METHODS The Atrial Fibrillation Follow-up Investigation of Rhythm Management ( AFFIRM ) study compared two treatment strategies -- rate control and rhythm control -- in patients with AF and risk factors for stroke or death . This sub study , performed in patients r and omized to rhythm control , compared different antiarrhythmic drugs by r and omly assigning the first drug treatment to : 1 ) amiodarone , 2 ) sotalol , or 3 ) a class I drug . The primary end point was the proportion of patients alive , in sinus rhythm , with no additional cardioversions and still taking the assigned drug at one year . Comparisons were made between patients eligible for each of three drug pairs . RESULTS At one year , in 222 patients r and omized between amiodarone and class I agents , 62 % were successfully treated with amiodarone , compared with 23 % taking class I agents ( p < 0.001 ) . In 256 patients r and omized between amiodarone and sotalol , 60 % versus 38 % were successfully treated , respectively ( p = 0.002 ) . In 183 patients r and omized between sotalol and class I agents , 34 % versus 23 % were successfully treated , respectively ( p = 0.488 ) , although this portion of the sub study was stopped early when amiodarone was shown to be better than class I agents . Sinus rhythm was achieved in nearly 80 % of patients at one-year follow-up with serial therapy . Adverse effects were common . CONCLUSIONS Amiodarone was more effective at one year than either sotalol or class I agents for the strategy of maintenance of sinus rhythm without cardioversion Atrial fibrillation ( AF ) is one of the most frequent dysrhythmias in patients coming to emergency departments ( EDs ) , and pharmacological treatment is frequently performed . The aim of this r and omized placebo-controlled multicenter trial was to compare propafenone ( a class 1C antidysrhythmic agent ) , administered i.v . in the ED , with placebo in the treatment of recent-onset AF ( < 72 h ) . We r and omly allocated 156 patients ( 88 males ; 68 females ) from 18 to 80 years old , with recent-onset AF , to receive i.v . propafenone ( 2 mg/kg for 10 min ) or the matching placebo . The patients were followed for 2 h. Exclusion criteria were the presence of one of the following : lack of informed consent , clinical evidence of heart failure , clinical hyperthyroidism , recent acute myocardial infa rct ion , atrioventricular block , cardiac valve dysfunction , a history of bronchial asthma , and current treatment with antidysrhythmic agents including digitalis . The two groups did not differ significantly in terms of sex , age , body weight , or estimated time elapsed since the beginning of atrial fibrillation . Conversion to sinus rhythm occurred in 13 of the 75 patients who received the placebo ( 17.3 % ) and in 57 of the 81 patients who were given propafenone ( 70.3 % ) . In conclusion , intravenous propafenone administration in the ED can be considered a safe and effective approach for converting AF to sinus rhythm OBJECTIVES Our aim was to identify shortcomings in the management of patients with both atrial fibrillation ( AF ) and heart failure ( HF ) . BACKGROUND AF and HF often coincide in cardiology practice , and they are known to worsen each other 's prognosis , but little is known about the quality of care of this combination . METHODS In the observational Euro Heart Survey on AF , 5,333 AF patients were enrolled in 182 centers across 35 European Society of Cardiology member countries in 2003 and 2004 . A follow-up survey was performed after 1 year . RESULTS At baseline , 1,816 patients ( 34 % ) had HF .  Recommended therapy for HF with left ventricular systolic dysfunction ( LVSD ) with a beta-blocker and either an angiotensin-converting enzyme inhibitor ( ACEI ) or angiotensin II receptor blocker was prescribed in 40 % of HF patients , while 29 % received the recommended drug therapy for both LVSD-HF and AF , consisting of the combination of a beta-blocker , either ACEI or angiotensin II receptor blocker , and oral anticoagulation .  Rate control was insufficient with 40 % of all HF patients with permanent AF having a heart rate < or = 80 beats/min . In the total cohort , HF patients had a higher risk for mortality ( 9.5 % vs. 3.3 % ; p < 0.001 ) , ( progression of ) HF ( 24.8 % vs. 5.0 % ; p < 0.001 ) , and AF progression ( 35 % vs. 19 % ; p < 0.001 ) during 1-year follow-up . Of all recommended drugs for AF and LVSD-HF , only ACEI prescription was associated with improved survival during 1-year follow-up ( odds ratio : 0.51 [ 95 % confidence interval : 0.31 to 0.85 ] ; p = 0.011 ) . CONCLUSIONS The prescription rate of guideline -recommended drug therapy for AF and LVSD-HF is low . R and omized controlled trials targeting this highly prevalent subgroup with AF and HF are warranted ACCF : American College of Cardiology Foundation ACCP : American College of Chest Physicians ACS : acute coronary syndrome ACT : Atrial arrhythmia Conversion Trial ADONIS : American – Australian – African trial with DronedarONe In atrial fibrillation or flutter for the maintenance of Sinus rhythm AF : atrial fibrillation AHA : American Heart Association AND ROMEDA : ANtiarrhythmic trial with DROnedarone in Moderate-to-severe congestive heart failure Evaluating morbidity DecreAse APHRS : Asia Pacific Heart Rhythm Society aPTT : activated partial thromboplastin time ARB : angiotensin-receptor blocker ARISTOTLE : Apixaban for Reduction In STroke and Other ThromboemboLic Events in atrial fibrillation ATHENA : A placebo-controlled , double-blind , parallel arm Trial to assess the efficacy of dronedarone 400 mg b.i.d . for the prevention of cardiovascular Hospitalization or death from any cause in patiENts with Atrial fibrillation/atrial flutter ATRIA : AnTicoagulation and Risk factors In Atrial fibrillation AVERROES : Apixaban VErsus acetylsalicylic acid ( ASA ) to Reduce the Rate Of Embolic Stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment AVRO : A prospect i ve , r and omized , double-blind , Active-controlled , superiority study of Vernakalant vs. amiodarone in Recent Onset atrial fibrillation b.i.d : bis in die ( twice daily ) b.p.m . : beats per minute CABANA : Catheter ABlation vs . ANtiarrhythmic drug therapy for Atrial fibrillation CABG : coronary artery bypass graft CAP : Continued Access to Protect AF CHA2DS2-VASc : Congestive heart failure or left ventricular dysfunction Hypertension , Age ≥75 ( doubled ) , Diabetes , Stroke (doubled)-Vascular disease , Age 65–74 , Sex category ( female ) CHADS2 : Congestive heart failure , Hypertension , Age ≥75 , Diabetes , Stroke ( doubled ) CI : confidence interval CRAFT : Controlled R and omized Atrial Fibrillation Trial CrCl : creatinine clearance DAFNE : Dronedarone Atrial FibrillatioN study after Electrical cardioversion DIONYSOS : R and omized Double blind trIal to evaluate efficacy and safety of drOnedarone ( 400 mg b.i.d . ) vs . amiodaroNe ( 600 mg q.d . for 28 daYS , then 200 mg qd thereafter ) for at least 6 mOnths for the maintenance of Sinus rhythm in patients with atrial fibrillation EAST : Early treatment of Atrial fibrillation for Stroke prevention Trial EHRA : European Heart Rhythm Association ECG : electrocardiogram EMA : European Medicines Agency ERATO : Efficacy and safety of dRonedArone for The cOntrol of ventricular rate during atrial fibrillation EURIDIS : EURopean trial In atrial fibrillation or flutter patients receiving Dronedarone for the maIntenance of Sinus rhythm FAST : atrial Fibrillation catheter Ablation vs . Surgical ablation Treatment FDA : Food and Drug Administration Flec-SL : Flecainide Short-Long trial HAS-BLED : Hypertension , Abnormal renal/liver function , Stroke , Bleeding history or predisposition , Labile INR , Elderly , Drugs/alcohol concomitantly HF-PEF : heart failure with preserved ejection fraction HF-REF : heart failure with reduced ejection fraction HR : hazard ratio HRS : Heart Rhythm Society ICH : intracranial haemorrhage INR : international normalized ratio i.v . : intravenous J-RHYTHM : Japanese RHYTHM management trial for atrial fibrillation LAA : left atrial appendage LoE : level of evidence LVEF : left ventricular ejection fraction MANTRA-PAF : Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation NICE : National Institute for Health and Clinical Excellence NOAC : novel oral anticoagulant NSAID : non-steroidal anti-inflammatory drug NYHA : New York Heart Association OAC : oral anticoagulant or oral anticoagulation o.d . : omni die ( every day ) PALLAS : Permanent Atrial fibriLLAtion outcome Study using dronedarone on top of st and ard therapy PCI : percutaneous coronary intervention PREVAIL : Prospect i ve R and omized EVAluation of the LAA closure device In patients with atrial fibrillation v s. Long-term warfarin therapy PROTECT AF : WATCHMAN LAA system for embolic PROTECTion in patients with Atrial Fibrillation PT : prothrombin time RAAFT : Radio frequency Ablation Atrial Fibrillation Trial RE-LY : R and omized Evaluation of Long-term anticoagulant therapY with dabigatran etexilate ROCKET-AF : Rivaroxaban Once daily oral direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in atrial fibrillation RRR : relative risk reduction TE : thromboembolism TIA : transient ischaemic attack t.i.d . : ter in die ( three times daily ) TOE : transoesophageal echocardiogram TTR : time in therapeutic range VKA : vitamin K antagonist Guidelines summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition , taking into account the impact on BACKGROUND Effectiveness , safety , and other factors associated with success of cardioversion ( CV ) of atrial fibrillation ( AF )  have not yet been evaluated in patients with reduced left ventricular ejection fraction . We studied 148 consecutive patients with left ventricular dysfunction ( ejection fraction < or = 45 % ) , who underwent electrical CV for AF in our department . The patients had New York Heart Association heart failure ranging from class II to IV . The overall CV success rate was 71 % . We relied on univariate and multivariate regression and sought variables influencing success rate . Conversion success did not correlate with New York Heart Association class . Instead , we found that the greatest predictor was the degree of heart failure treatment . Patients receiving beta-blockers , angiotensin-converting enzyme inhibitors or angiotension receptor blockers , plus mineralocorticoid receptor blockers had the greatest chance for conversion success . Success was more likely in patients with coronary artery disease ( 91 % ) than in patients with nonischemic cardiomyopathy . CONCLUSIONS Cardioversion is a safe and effective method for the restoration of sinus rhythm in patients with AF and reduced left ventricular ejection fraction . Our findings underscore the value of aggressive heart failure treatment before CV in patients with AF INTRODUCTION  Early recurrent atrial fibrillation ( ERAF ) after external cardioversion of atrial fibrillation ( AF ) occurs in 12 % to 26 % of patients . Whether biphasic cardioversion has an impact on the incidence of ERAF after cardioversion of AF is unclear . METHODS AND RESULTS Consecutive patients ( n = 216 , mean age 66 years , 71 % male , 88 % with structural cardiovascular disease or hypertension ) underwent cardioversion with a biphasic ( Bi ) or monophasic ( Mo ) shock waveform in r and omized fashion . Energies used were 120 - 150 - 200 - 200 Ws ( Bi ) or 200 - 300 - 360 - 360 Ws ( Mo ) . The two study groups ( Bi vs Mo ) did not differ with regard to age , sex , body mass index , underlying cardiovascular disease , left atrial diameter , left ventricular ejection fraction , duration of AF fibrillation , and antiarrhythmic drug therapy . Mean delivered energy was significantly lower in the Bi group ( Bi : 186 + /- 143 Ws vs Mo : 324 + /- 227 Ws ; P < 0.001 ) . Overall incidence of ERAF ( AF relapse within 1 minute after successful cardioversion ) was 8.9 % and showed no difference between the two groups ( Bi : 8.1 % vs Mo : 9.7 % , P = NS ) . Cardioversion was successful in 95.4 % of patients . The success rate was comparable in both groups ( Bi : 94.3 % vs Mo 96.8 % ; P = NS ) . First shock efficacy did not differ between Bi and Mo ( 76.4 % vs 67.7 % ; P = NS ) . Mean number of shocks were 1.4 shocks per patient in both groups . CONCLUSION Biphasic cardioversion allows comparable success rates with significantly lower energies . However , the incidence of ERAF is not influenced by biphasic cardioversion . With the energies used , biphasic and monophasic shock waveforms are comparable with regard to first shock and cumulative shock efficacy OBJECTIVES The purpose of this study was to determine the efficacy and safety of intravenous RSD1235 in terminating  recent onset atrial fibrillation ( AF ) .  BACKGROUND Anti-arrhythmic drugs currently available to terminate AF have limited efficacy and safety . RSD1235 is a novel atrial selective anti-arrhythmic drug . METHODS This was a phase II , multi-centered , r and omized , double-blinded , step-dose , placebo-controlled , parallel group study . Fifty-six patients from 15 U.S. and Canadian sites with AF of 3 to 72 h duration were r and omized to one of two  RSD1235  dose groups or to placebo . The two RSD1235 groups were RSD-1 ( 0.5 mg/kg followed by 1 mg/kg ) or RSD-2 ( 2 mg/kg followed by 3 mg/kg ) , by intravenous infusion over 10 min ; a second dose was given only if AF was present . The primary end point was termination of AF during infusion or within 30-min after the last infusion . Secondary end points included the number of patients in sinus rhythm at 0.5 , 1 , and 24 h post-last infusion and time to conversion to sinus rhythm . RESULTS The RSD-2 dose showed significant differences over placebo in : 1 ) termination of AF ( 61 % vs. 5 % , p < 0.0005 ) ; 2 ) patients in sinus rhythm at 30 min ( 56 % vs. 5 % , p < 0.001 ) ; 3 ) sinus rhythm at 1 h ( 53 % vs. 5 % , p = 0.0014 ) ; and 4 ) median time to conversion to SR ( 14 vs. 162 min , p = 0.016 ) . There were no serious adverse events related to RSD1235 . CONCLUSIONS RSD1235 , a new atrial-selective anti-arrhythmic agent , appears to be efficacious and safe for converting recent onset AF to sinus rhythm BACKGROUND AND OBJECTIVES The relation between cardiac mortality and antiarrhythmic drug administration has not been fully determined . This relation was analyzed in 1,330 patients enrolled in the Stroke Prevention in Atrial Fibrillation Study , a r and omized clinical trial comparing warfarin , aspirin and placebo for the prevention of ischemic stroke or systemic embolism in patients with nonvalvular atrial fibrillation . METHODS Patients who received antiarrhythmic drug therapy for atrial fibrillation in this study were compared with patients not receiving antiarrhythmic agents . The relative risk of cardiac mortality , including arrhythmic death , in patients receiving antiarrhythmic drug therapy  was determined and adjusted for other cardiac risk factors . RESULTS In patients receiving antiarrhythmic drug therapy , cardiac mortality was increased 2.5-fold ( p = 0.006 , 95 % confidence interval [ CI ] 1.3 to 4.9 ) and arrhythmic death was increased 2.6-fold ( p = 0.02 , 95 % CI 1.2 to 5.6 ) . Among patients with a history of congestive heart failure , those given antiarrhythmic medications had a relative risk of cardiac death of 4.7 ( p less than 0.001 , 95 % CI 1.9 to 11.6 ) compared with that of patients not so treated ; the relative risk of arrhythmic death in the treated group was 3.7 ( p = 0.01 , 95 % CI 1.3 to 10.4 ) . Patients without a history of congestive heart failure had no increased risk of cardiac mortality ( relative risk 0.70 , 95 % CI 0.2 to 3.1 ) during antiarrhythmic drug therapy . After exclusion of 23 patients with documented ventricular arrhythmias and adjustment for other variables predictive of cardiac death , patients receiving antiarrhythmic drugs were not at increased risk of cardiac death or arrhythmic death . However , in patients with a history of heart failure who received antiarrhythmic drug therapy , the relative risk of cardiac death was 3.3 ( p = 0.05 , 95 % CI 0.99 to 11.1 ) and that of arrhythmic death was 5.8 ( p = 0.009 , 95 % CI 1.5 to 21.7 ) compared with the risk in patients not taking antiarrhythmic medications . CONCLUSIONS Although antiarrhythmic drug therapy was not r and omly determined in this trial , the data suggest that in patients with atrial fibrillation and a history of congestive heart failure , the risk of such therapy may outweigh the potential benefit of maintaining sinus rhythm
Bayesian network meta- analysis using a r and om-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 .
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 .
AIMS We sought to identify the most effective antidysrhythmic drug for pharmacologic cardioversion of recent-onset atrial fibrillation ( AF ) .