Comparison of dronedarone vs. flecainide in the maintenance of sinus rhythm, following electrocardioversion in adults with persistent atrial fibrillation: a systematic review and meta-analysis

Abstract Aims To compare flecainide and dronedarone for sinus rhythm (SR) maintenance following electrocardioversion of persistent atrial fibrillation (AF), in patients with minimal or no structural heart disease. Methods and results A systematic search of publications using EMBASE, CENTRAL, CINAHL, and MEDLINE (1989–2019), identified a total of 595 articles. No limitations were applied. Nine articles met the inclusion criteria [five randomized controlled trials (RCTs) and four cohort studies], encompassing 1349 persistent AF candidates. Two retrospective studies compared flecainide with dronedarone, indicating a 6% reduced risk of AF recurrence with flecainide; however, results were not statistically significant [risk ratio (RR) 0.94, 95% confidence interval (CI) 0.71–1.24; P = 0.66]. One RCT compared dronedarone to placebo, demonstrating a 28% reduced risk of AF recurrence at 6 months (RR 0.72, 95% CI 0.58–0.90; P = 0.004). Two RCTs compare flecainide to placebo, when a 16% decreased risk of AF recurrence at 6–12 months was indicated; however, these results were not statistically significant (RR 0.84, 95% CI 0.66–1.07; P = 0.16). Within a 6- to 12-month follow-up period, a combined recurrence rate of AF was examined, in which flecainide and dronedarone maintained SR in 50% and 42%, respectively. Four articles satisfied quality appraisal, one of which focused on flecainide data. Conclusion Dronedarone and flecainide displayed similar efficacy in maintaining SR in patients following electrocardioversion for persistent AF. The SR maintenance was numerically but not statistically significant in the flecainide group. Side effects uncovered similar pro-arrhythmic activity. However, in light of the deficiency of volume and quality of available evidence, the writer acknowledges the requirement for future research.

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P1903Efficacy and safety of dronedarone after recent cardioversion in patients with atrial fibrillation/flutter: a post-hoc analysis of the EURIDIS/ADONIS trials

European Heart Journal ◽

10.1093/eurheartj/ehz748.0650 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

M Thind ◽

H J Crijns ◽

G V Naccarelli ◽

J A Reiffel ◽

V Corp Dit Genti ◽

...

Keyword(s):

Atrial Fibrillation ◽

New York ◽

Heart Disease ◽

Adverse Events ◽

Sinus Rhythm ◽

Structural Heart Disease ◽

Hazard Ratio ◽

Post Hoc ◽

Rheumatic Heart ◽

Af Recurrence

Abstract Background Cardioversion is commonly performed prior to antiarrhythmic drug initiation for atrial fibrillation/flutter (AF). There are limited data describing baseline differences in patients requiring cardioversion to maintain sinus rhythm compared to those who do not. Likewise, response to antiarrhythmic drugs, including dronedarone, specifically in patients requiring cardioversion has not been well defined. Purpose To evaluate efficacy and safety of dronedarone versus placebo in patients with non-permanent AF who had cardioversion within 5 days prior to randomization in EURIDIS/ADONIS. Methods To qualify for enrolment in EURIDIS/ADONIS patients were required to be in sinus rhythm for at least 1 hour preceding randomization. Of 1237 patients randomized (2:1 dronedarone to placebo), 364 needed cardioversion for study entry (dronedarone 243, placebo 121). AF recurrence was evaluated by ECG obtained during study visits, scheduled transtelephonic monitoring, or at symptom recurrence. Results Cardioversion patients were more likely to have rheumatic heart disease, valvular heart disease, any structural heart disease, and heart failure. Nonetheless, the median time to 1st AF recurrence was longer for dronedarone versus placebo both in cardioversion patients (50 versus 15 days, hazard ratio 0.76, 95% CI 0.59, 0.97) and no cardioversion patients (150 versus 77 days, hazard ratio 0.76, 95% CI 0.64, 0.90), as was time to 1st symptomatic recurrence (cardioversion: 347 versus 87 days, hazard ratio 0.65, 95% CI 0.49, 0.87; no cardioversion: 288 versus 120 days, hazard ratio 0.74, 95% CI 0.62, 0.90) (Figure 1). There was a trend towards fewer 1st AF hospitalizations within 12 months for dronedarone versus placebo (7.8 versus 12.4%, hazard ratio 0.60, 95% CI 0.31, 1.18 in cardioversion patients; 8.4 versus 10.4%, hazard ratio 0.74, 95% CI 0.47, 1.17 in no cardioversion patients). In cardioversion patients, rates of treatment-emergent adverse events with dronedarone versus placebo were 64 versus 66%, serious treatment-emergent adverse events were 19 versus 26%, permanent discontinuations were 9 versus 6%, and deaths were 0 versus 1%. Conclusions 1) Cardioversion-requiring patients have more baseline structural heart disease and overall shorter time to AF recurrence. 2) Dronedarone effectively delayed 1st AF recurrence versus placebo in patients with or without recent cardioversion. 3) Safety of dronedarone in cardioversion patients was similar to placebo and overall observations from EURIDIS/ADONIS despite baseline differences in comorbidities. Acknowledgement/Funding Sanofi, New York, New York, United States of America

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Vernakalant for cardioversion of recent-onset atrial fibrillation: a systematic review and meta-analysis

EP Europace ◽

10.1093/europace/euz175 ◽

2019 ◽

Vol 21 (8) ◽

pp. 1159-1166 ◽

Cited By ~ 6

Author(s):

William F McIntyre ◽

Jeff S Healey ◽

Akash K Bhatnagar ◽

Patrick Wang ◽

Jacob A Gordon ◽

...

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Meta Analysis ◽

Structural Heart Disease ◽

Quality Of Evidence ◽

Recent Onset ◽

Assessment Development ◽

Significant Difference ◽

Pharmacological Cardioversion

AbstractAimsTo evaluate the efficacy and safety of vernakalant for the cardioversion of atrial fibrillation (AF).Methods and resultsWe reviewed the literature for randomized trials that compared vernakalant to another drug or placebo in patients with AF of onset ≤7 days. We used a random-effects model to combine quantitative data and rated the quality of evidence using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation). From 441 total citations in MEDLINE, EMBASE, and CENTRAL (December 2018), we identified nine trials evaluating 1358 participants. Six trials compared vernakalant to placebo, two trials compared vernakalant to ibutilide, and one trial compared vernakalant to amiodarone. We found significant methodological bias in four trials. For conversion within 90 min, vernakalant was superior to placebo [50% conversion, risk ratio (RR) 5.15; 95% confidence interval (CI); 2.24–11.84, I2 = 91%], whereas we found no significant difference in conversion when vernakalant was compared with an active drug (56% vs. 24% conversion, RR 2.40; 95% CI 0.76–7.58, I2 = 94). Sinus rhythm was maintained at 24 h in 85% (95% CI 80–88%) of patients who converted acutely with vernakalant. Overall, we judged the quality of evidence for efficacy to be low based on inconsistency and suspected publication bias. There was no significant difference in the risk of significant adverse events between vernakalant and comparator (RR 0.95; 95% CI 0.70–1.28, I2 = 0, moderate quality evidence). Vernakalant is safe and effective for rapid and durable restoration of sinus rhythm in patients with recent-onset AF.ConclusionVernakalant should be a first line option for the pharmacological cardioversion of patients with haemodynamically stable recent-onset AF without severe structural heart disease.

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Restoration of Sinus Rhythm Improves Exercise Capacity in Patients with Persistent Atrial Fibrillation: A Meta-Analysis

Heart Lung and Circulation ◽

10.1016/j.hlc.2017.06.295 ◽

2017 ◽

Vol 26 ◽

pp. S172

Author(s):

C. Verdicchio ◽

P. Wijaithum ◽

A. Elliott ◽

D. Lau ◽

P. Sanders ◽

...

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Exercise Capacity ◽

Meta Analysis ◽

Persistent Atrial Fibrillation

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Comparative efficacy and safety of different catheter ablation strategies for persistent atrial fibrillation: a network meta-analysis of randomized clinical trials

European Heart Journal - Quality of Care and Clinical Outcomes ◽

10.1093/ehjqcco/qcab066 ◽

2021 ◽

Author(s):

Andrea Saglietto ◽

Andrea Ballatore ◽

Fiorenzo Gaita ◽

Marco Scaglione ◽

Roberto De Ponti ◽

...

Keyword(s):

Atrial Fibrillation ◽

Clinical Trials ◽

Catheter Ablation ◽

Left Atrium ◽

Randomized Clinical Trials ◽

Meta Analysis ◽

Persistent Atrial Fibrillation ◽

Linear Lesions ◽

Procedural Complications ◽

Reduced Risk

Abstract Aims Whereas pulmonary vein isolation (PVI) is the universally agreed target in catheter ablation of paroxysmal atrial fibrillation (AF), an ideal ablation set in persistent AF remains questioned. Aim of this study is to conduct a network meta-analysis (NMA) of randomized clinical trials (RCTs) comparing different ablation strategies in persistent AF patients. Methods and results Network meta-analysis was performed in a frequentist framework with the different ablation strategies constituting the competitive arms of interest. Primary efficacy endpoint was recurrences of atrial tachyarrhythmia (AF, atrial flutter, and/or organized atrial tachycardia). Secondary endpoints included major peri-procedural complications, procedure, and fluoroscopy duration. PubMED/MEDLINE and EMBASE databases were searched through June 2020. 2548 records were screened and 57 full-text articles assessed. Eventually 24 RCTs were included, encompassing 3245 patients (median follow-up 15 months, IQR 12–18). Compared to PVI alone, PVI plus linear lesions in the left atrium and elimination of extra-PV sources was the only strategy associated with a reduced risk of arrhythmia recurrence (RR 0.49, 95%CI 0.27–0.88). Most treatment arms were associated with longer procedural time compared with PVI; however, major peri-procedural complications and fluoroscopy time did not differ. Conclusion A comprehensive strategy including PVI, linear lesions in the left atrium, and elimination of extra-PV sources (constrained by a heterogeneous definition across studies) was associated with reduced risk of recurrent atrial tachyarrhythmias compared to PVI alone. All investigated treatment arms yielded similar safety profiles. Further research should rely on enhanced substrate-based approach definitions to solve one of the most evident knowledge gaps in interventional electrophysiology.

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50Restoration of sinus rhythm improves exercise capacity in patients with persistent atrial fibrillation: a meta-analysis

EP Europace ◽

10.1093/europace/euy015.012 ◽

2018 ◽

Vol 20 (suppl_1) ◽

pp. i6-i6

Author(s):

C Verdicchio ◽

A Elliott ◽

P Wijaithum ◽

D Lau ◽

P Sanders ◽

...

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Exercise Capacity ◽

Meta Analysis ◽

Persistent Atrial Fibrillation

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Left Atrial Voltage during Sinus Rhythm in Paroxysmal and Persistent Atrial Fibrillation Patients without Structural Heart Disease

Journal of Nihon University Medical Association ◽

10.4264/numa.74.161 ◽

2015 ◽

Vol 74 (4) ◽

pp. 161-165 ◽

Cited By ~ 1

Author(s):

Sonoko Ashino ◽

Ichiro Watanabe ◽

Masayoshi Kofune ◽

Yasuo Okumura ◽

Kazumasa Sonoda ◽

...

Keyword(s):

Atrial Fibrillation ◽

Heart Disease ◽

Sinus Rhythm ◽

Left Atrial ◽

Structural Heart Disease ◽

Persistent Atrial Fibrillation

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Faculty Opinions recommendation of The impact of adjunctive complex fractionated atrial electrogram ablation and linear lesions on outcomes in persistent atrial fibrillation: a meta-analysis.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.725932128.793537245 ◽

2017 ◽

Author(s):

Brian Olshansky

Keyword(s):

Atrial Fibrillation ◽

Meta Analysis ◽

Persistent Atrial Fibrillation ◽

Linear Lesions ◽

Atrial Electrogram ◽

The Impact ◽

Complex Fractionated Atrial Electrogram

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Advanced interatrial block precedes atrial fibrillation and stroke. The prospective interatrial Block And Yearly EventS (BAYES) registry

European Heart Journal ◽

10.1093/ehjci/ehaa946.0485 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Martinez-Selles ◽

R Elosua ◽

M Ibarrola ◽

M De Andres ◽

P Diez-Villanueva ◽

...

Keyword(s):

Atrial Fibrillation ◽

Heart Disease ◽

Sinus Rhythm ◽

Structural Heart Disease ◽

P Wave ◽

Wave Duration ◽

P Wave Duration ◽

Previous Diagnosis ◽

Surface Ecg ◽

Interatrial Block

Abstract Background Advanced interatrial block (IAB), prolonged and bimodal P waves in surface ECG inferior leads, is an unrecognized surrogate of atrial dysfunction and a trigger of atrial dysrhythmias, mainly atrial fibrillation (AF). Our aim was to prospectively assess whether advanced IAB in sinus rhythm precedes AF and stroke in elderly outpatients with structural heart disease, a group not previously studied. Methods Prospective observational registry that included outpatients aged ≥70 years with structural heart disease and no previous diagnosis of AF. Patients were divided into three groups according to P-wave characteristics. Results Among 556 individuals, 223 had normal P-wave (40.1%), 196 partial IAB (35.3%), and 137 advanced IAB (24.6%). After a median follow-up of 694 days; 93 patients (16.7%) developed AF, 30 stroke (5.4%), and 34 died (6.1%). Advanced IAB was independently associated with AF (hazard ratio [HR] 2.9, 95% confidence interval [CI] 1.7–5.1, p<0.001), stroke (HR 3.8, 95% CI 1.4–10.7, p=0.010), and AF/stroke (HR 2.6, 95% CI 1.5–4.4, p=0.001). P-wave duration (ms) was independently associated with AF (HR 1.05, 95% CI 1.03–1.07, p<0.001), AF/stroke (HR 1.04, 95% CI 1.02–1.06, p<0.001), and mortality (HR 1.04, 95% CI 1.00–1.08, p=0.021). Conclusions The presence of advanced IAB in sinus rhythm is a risk factor for AF and stroke in an elderly population with structural heart disease and no previous diagnosis of AF. P-wave duration was also associated with all-cause mortality. Figure. Age- and sex-adjusted linear and non-linear association between P-wave duration (msec) and atrial fibrillation (A), stroke (B), and atrial fibrillation or stroke (C) risk. Results of a generalized additive model with spline smoothing functions and 4 degrees of freedom. Figure 1. Kaplan-Meyer curves of survival free of atrial fibrillation (A), stroke (B) and atrial fibrillation or stroke (C) in patients with normal P-wave, partial interatrial block (IAB) and advanced IAB. Funding Acknowledgement Type of funding source: None

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