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Pharmacological cardioversion for atrial fibrillation and flutter
1NHS Lothian - University Hospitals Division, 6 Northfield Park Grove, Edinburgh, UK, EH8 7RS. cordina@johnandsteph.fsnet.co.uk
Insights
Pharmacological cardioversion for atrial fibrillation (AF) does not reduce stroke risk or mortality compared to rate control. Rhythm control leads to more adverse events and hospitalizations, with no proven quality of life benefits.
Area of Science:
- Cardiology
- Clinical Trials
- Pharmacology
Background:
- Atrial fibrillation (AF) is the most prevalent cardiac dysrhythmia, contributing to significant morbidity and mortality.
- Management strategies for AF include ventricular rate control and rhythm control via cardioversion.
- The comparative effectiveness of these AF management approaches requires thorough investigation.
Purpose of the Study:
- To evaluate the impact of pharmacological cardioversion of atrial fibrillation (AF) in adults.
- To assess the annual risks of stroke, peripheral embolism, and mortality associated with AF cardioversion.
- To compare rhythm control strategies against rate control in AF patients.
Main Methods:
- Systematic literature search of multiple databases (Cochrane, MEDLINE, EMBASE, CINAHL, Web of Science) and hand-searched journals.
- Inclusion of randomized controlled trials and controlled clinical trials comparing pharmacological cardioversion with rate control in adult AF patients.
- Data extraction and quality assessment performed by a single reviewer using RevMan software.
Main Results:
- Two major studies (AFFIRM and PIAF) involving 4060 and 252 patients, respectively, were analyzed.
- No significant difference in mortality was observed between rhythm control and rate control groups (RR 1.14, 95% CI 1.00 to 1.31).
- Rhythm control was associated with higher hospitalization rates and adverse events, with no improvement in quality of life; stroke incidence was similar between groups.
Conclusions:
- Pharmacological cardioversion to sinus rhythm offers no demonstrated superiority over rate control for atrial fibrillation (AF).
- Rhythm control strategies in AF are linked to increased adverse effects and hospitalizations, without reducing stroke risk.
- Findings may not be generalizable to all AF populations, particularly younger individuals without cardiovascular risk factors.
Background:
Atrial fibrillation is the commonest cardiac dysrhythmia. It is associated with significant morbidity and mortality. There are two approaches to the management of atrial fibrillation: controlling the ventricular rate or converting to sinus rhythm in the expectation that this would abolish its adverse effects.
Objectives:
To assess the effects of pharmacological cardioversion of atrial fibrillation in adults on the annual risk of stroke, peripheral embolism, and mortality.
Search Strategy:
We searched the Cochrane Controlled Trials Register (Issue 3, 2002), MEDLINE (2000 to 2002), EMBASE (1998 to 2002), CINAHL (1982 to 2002), Web of Science (1981 to 2002). We hand searched the following journals: Circulation (1997 to 2002), Heart (1997 to 2002), European Heart Journal (1997-2002), Journal of the American College of Cardiology (1997-2002) and selected abstracts published on the web site of the North American Society of Pacing and Electrophysiology (2001, 2002).
Selection Criteria:
Randomised controlled trials or controlled clinical trials of pharmacological cardioversion versus rate control in adults (>18 years) with acute, paroxysmal or sustained atrial fibrillation or atrial flutter, of any duration and of any aetiology.
Data Collection And Analysis:
One reviewer applied the inclusion criteria and extracted the data. Trial quality was assessed and the data were entered into RevMan.
Main Results:
We identified two completed studies AFFIRM (n=4060) and PIAF (n=252). We found no difference in mortality between rhythm control and rate control relative risk 1.14 (95% confidence interval 1.00 to 1.31). Both studies show significantly higher rates of hospitalisation and adverse events in the rhythm control group and no difference in quality of life between the two treatment groups. In AFFIRM there was a similar incidence of ischaemic stroke, bleeding and systemic embolism in the two groups. Certain malignant dysrhythmias were significantly more likely to occur in the rhythm control group. There were similar scores of cognitive assessment. In PIAF, cardioverted patients enjoyed an improved exercise tolerance but there was no overall benefit in terms of symptom control or quality of life.
Authors' Conclusions:
There is no evidence that pharmacological cardioversion of atrial fibrillation to sinus rhythm is superior to rate control. Rhythm control is associated with more adverse effects and increased hospitalisation. It does not reduce the risk of stroke. The conclusions cannot be generalised to all people with atrial fibrillation. Most of the patients included in these studies were relatively older (>60 years) with significant cardiovascular risk factors.
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