Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation

Abstract

BackgroundAtrial fibrillation is the most frequent sustained arrhythmia. Atrial fibrillation frequently recurs after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence, but the effect of these drugs on all-cause mortality and other clinical outcomes is unclear. This is an update of a review previously published in 2007, 2012 and 2015. risk of mortality was higher in people taking quinidine, although the confidence interval also includes the possibility of no difference (RR 2.01, 95% CI 0.84 to 4.77; participants = 1646).No effect on mortality was apparent with the remaining drugs studied, but less data was available for them and it could be underpowered to detect small increases in mortality. In particular, very few data was available for flecainide (no death reported in any treatment arm in 4 RCTs studying flecainide, participants = 511) and propafenone (only 2 deaths reported in 5 included RCTs, participants = 998).

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation

“…The following antiarrhythmic drugs are recommended in patients with AF to maintain sinus rhythm, depending on underlying heart disease and comorbidities (Level of Evidence: A) : Amiodarone (314, 347-349)Dofetilide (332, 336)Dronedarone (350-352)Flecainide (347, 353)Propafenone (347, 354-357)Sotalol (347, 355, 358)…”

“…Several systematic reviews have summarized the efficacy and safety of antiarrhythmic drugs for treating AF (347, 359, 363, 364). In a meta-analysis of 44 trials, antiarrhythmic drug therapy significantly reduced recurrence of AF (with a number needed to treat ranging from 2 to 9).…”

“…Much like with other antiarrhythmic drugs, with the exception of amiodarone, the rates of maintaining sinus rhythm at 1 year for sotalol are in the range of 30% to 50% (347). Sotalol is renally cleared and should be used with caution or avoided in patients with CKD or unstable renal function.…”

2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures

“…Sotalol is effective for reducing the incidence of recurrent AF in patients with paroxysmal AF [86] and after conversion to sinus rhythm [87]. Sotalol has not been shown to be effective for conversion of AF to sinus rhythm.…”

Making better scar: Emerging approaches for modifying mechanical and electrical properties following infarction and ablation

“…(January et al, 2014) One of the potential reasons that rhythm control has not demonstrated superiority to rate control strategies is the ineffective and often unsafe nature of currently available anti-arrhythmic medications, which at best maintain sinus rhythm for 1 year in 50% of patients, and are associated with an increase in mortality. (Lafuente-Lafuente et al, 2007) When interrogating only patients who have achieved and maintained sinus rhythm, post-hoc analyses of rhythm vs. rate control strategies have shown a consistent pattern of improvement in quality of life measures. (Guédon-Moreau et al, 2010; Singh et al, 2006) In the PIAF and HOT CAFE trials for example, 6-minute walk times and maximal treadmill workloads were increased.…”