PRE- AND POST-TREATMENT WITH ANTIARRHYTHMIC DRUGS FOR ELECTRICAL CARDIOVERSION OF ATRIAL FIBRILLATION: A NETWORK META-ANALYSIS
CCC ePoster Library. Um K. 10/26/19; 280302; 244
Dr. Kevin Um
Dr. Kevin Um
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BACKGROUND: Clinicians perform electrical cardioversion for patients with symptomatic atrial fibrillation (AF). Antiarrhythmic drugs (AADs) administered before electrical cardioversion may improve the acute restoration and maintenance of sinus rhythm.

METHODS AND RESULTS: We performed a systematic review and network meta-analysis of randomized controlled trials (RCTs) evaluating the acute restoration and maintenance of sinus rhythm following pre-treatment with different AADs. We grouped AADs into 5 categories: (1) placebo or rate control, (2) class Ia, (3) class Ic, (4) class III and (5) amiodarone. We searched MEDLINE and EMBASE from inception to July 2018. We used RevMan 5.3 for pairwise meta-analysis and R 3.5.1 for network meta-analysis. We evaluated risk of bias for individual studies using the Cochrane tool and overall certainty of evidence using the GRADE framework. The network meta-analysis included 33 RCTs (Table 1). Compared with placebo or rate control, all AAD classes were associated with increased acute restoration of sinus rhythm: class Ia (odds ratio [OR] 2.8; 95% credible interval [CI] 1.2, 6.9, high certainty of evidence); class Ic (OR 2.4; CI 1.2, 5.5, high certainty); class III (OR 2.6; CI 1.4, 5.3, moderate certainty); and amiodarone (OR 2.7; CI 1.5, 4.8, high certainty). Class Ia AADs were most likely to be effective (SUCRA 0.668)—followed by amiodarone (0.654), class III (0.606), class Ic (0.566) and placebo or rate control (0.006). The mean duration of follow-up was 7 months. Amiodarone was associated with improved maintenance of sinus rhythm long-term when compared with placebo or rate control (OR 5.4; CI 4, 7.4, high certainty), class Ic (OR 1.9; CI 1.1, 3.5, moderate certainty) and class III (OR 2.2; CI 1.4, 3.3, high certainty). According to SUCRA, amiodarone ranked first for this outcome (0.934)—followed by class Ia (0.626), class Ic (0.520), class III (0.413) and placebo or rate control (0.007). Node splitting analysis did not demonstrate incoherence between direct and indirect estimates for all comparisons within both outcomes.

CONCLUSION: In patients with AF, as compared with placebo or rate control, treatment with either class Ia or Ic AADs or amiodarone prior to cardioversion improves the acute restoration of sinus rhythm. Amiodarone is the most effective agent for the maintenance of sinus rhythm after electrical cardioversion.
BACKGROUND: Clinicians perform electrical cardioversion for patients with symptomatic atrial fibrillation (AF). Antiarrhythmic drugs (AADs) administered before electrical cardioversion may improve the acute restoration and maintenance of sinus rhythm.

METHODS AND RESULTS: We performed a systematic review and network meta-analysis of randomized controlled trials (RCTs) evaluating the acute restoration and maintenance of sinus rhythm following pre-treatment with different AADs. We grouped AADs into 5 categories: (1) placebo or rate control, (2) class Ia, (3) class Ic, (4) class III and (5) amiodarone. We searched MEDLINE and EMBASE from inception to July 2018. We used RevMan 5.3 for pairwise meta-analysis and R 3.5.1 for network meta-analysis. We evaluated risk of bias for individual studies using the Cochrane tool and overall certainty of evidence using the GRADE framework. The network meta-analysis included 33 RCTs (Table 1). Compared with placebo or rate control, all AAD classes were associated with increased acute restoration of sinus rhythm: class Ia (odds ratio [OR] 2.8; 95% credible interval [CI] 1.2, 6.9, high certainty of evidence); class Ic (OR 2.4; CI 1.2, 5.5, high certainty); class III (OR 2.6; CI 1.4, 5.3, moderate certainty); and amiodarone (OR 2.7; CI 1.5, 4.8, high certainty). Class Ia AADs were most likely to be effective (SUCRA 0.668)—followed by amiodarone (0.654), class III (0.606), class Ic (0.566) and placebo or rate control (0.006). The mean duration of follow-up was 7 months. Amiodarone was associated with improved maintenance of sinus rhythm long-term when compared with placebo or rate control (OR 5.4; CI 4, 7.4, high certainty), class Ic (OR 1.9; CI 1.1, 3.5, moderate certainty) and class III (OR 2.2; CI 1.4, 3.3, high certainty). According to SUCRA, amiodarone ranked first for this outcome (0.934)—followed by class Ia (0.626), class Ic (0.520), class III (0.413) and placebo or rate control (0.007). Node splitting analysis did not demonstrate incoherence between direct and indirect estimates for all comparisons within both outcomes.

CONCLUSION: In patients with AF, as compared with placebo or rate control, treatment with either class Ia or Ic AADs or amiodarone prior to cardioversion improves the acute restoration of sinus rhythm. Amiodarone is the most effective agent for the maintenance of sinus rhythm after electrical cardioversion.
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