title: Comparative study of intravenous amiodarone and procainamide in the treatment of atrial fibrillation of recent onset. Estimating the Power of Indirect Comparisons: A Simulation Study Efficacy and tolerability of oral propafenone versus quinidine in the treatment of recent onset atrial fibrillation: A randomized, prospective study. Intravenous magnesium sulfate versus diltiazem in paroxysmal atrial fibrillation. Conversion efficacy of intravenous ibutilide compared with intravenous amiodarone in patients with recent-onset atrial fibrillation and atrial flutter. Impact of Emergency Department Management of Atrial Fibrillation on Hospital Charges Randomised double blind trial of oral versus intravenous flecainide for the cardioversion of acute atrial fibrillation A comparative study of the efficacy and safety of procainamide versus propafenone versus amiodarone for the conversion of recent-onset atrial fibrillation. Progression of atrial fibrillation in the REgistry on Cardiac rhythm disORDers assessing the control of Atrial Fibrillation cohort: clinical correlates and the effect of rhythm-control therapy. Safety of oral propafenone in the conversion of recent onset atrial fibrillation to sinus rhythm: a prospective parallel placebo-controlled multicentre study. Conversion of recent onset paroxysmal atrial fibrillation to normal sinus rhythm: the effect of no treatment and high-dose amiodarone. A randomized, placebo-controlled study. A prospective, randomized controlled trial comparing the efficacy and safety of sotalol, amiodarone, and digoxin for the reversion of new-onset atrial fibrillation. Ranolazine enhances the efficacy of amiodarone for conversion of recent-onset atrial fibrillation. Effectiveness of verapamil-quinidine versus digoxin-quinidine in the emergency department treatment of paroxysmal atrial fibrillation. Ranolazine Added to Amiodarone Facilitates Earlier Conversion of Atrial Fibrillation Compared to Amiodarone‐Only Therapy Cardioversion of acute atrial fibrillation in the short observation unit: comparison of a protocol focused on electrical cardioversion with simple antiarrhythmic treatment Comparison of sotalol with digoxin-quinidine for conversion of acute atrial fibrillation to sinus rhythm (the Sotalol-Digoxin-Quinidine Trial). Effectiveness of amiodarone as a single oral dose for recent-onset atrial fibrillation. Vernakalant is superior to ibutilide for achieving sinus rhythm in patients with recent-onset atrial fibrillation: a randomized controlled trial at the emergency department A randomized active-controlled study comparing the efficacy and safety of vernakalant to amiodarone in recent-onset atrial fibrillation. Safety and efficacy of intravenously administered tedisamil for rapid conversion of recent-onset atrial fibrillation or atrial flutter. Comparison of intravenous flecainide, propafenone, and amiodarone for conversion of acute atrial fibrillation to sinus rhythm. Projections on the number of individuals with atrial fibrillation in the European Union, from 2000 to 2060. Intravenous propafenone versus intravenous amiodarone in the management of atrial fibrillation of recent onset: a placebo-controlled study. A randomized clinical trial of early invasive intervention for atrial fibrillation (EARLY-AF) - methods and rationale. Early Risks of Death, Stroke/Systemic Embolism, and Major Bleeding in Patients With Newly Diagnosed Atrial Fibrillation: Results From the GARFIELD-AF Registry Benefits of Rhythm Control and Rate Control in Recent-onset Atrial Fibrillation: The HERMES-AF Study. Early or Delayed Cardioversion in Recent‐Onset Atrial Fibrillation Comparison of effectiveness of ranolazine plus amiodarone versus amiodarone alone for conversion of recent-onset atrial fibrillation.
abstract: AIM The aim of the present study was to compare the safety and efficacy of amiodarone and procainamide in the acute cardiology setting . METHODS The study population consisted of 223 patients with symptomatic atrial fibrillation ( AF ) . After administration of digoxin for ventricular rate control , all patients who failed to restore sinus rhythm ( SR ) were r and omized into 2 groups : group A ( 113 patients ) were administered 300 mg amiodarone intravenously over 30 min and , in case of failure to restore SR , amiodarone of 20 mg/kg/24 h was administered intravenously . Group B ( 110 patients ) were intravenously administered a bolus dose of 1 gm procainamide , at an infusion rate 50/mg/min , and , in case of failure to restore SR , 2 mg/min for the next 24 h. RESULTS The rate of cardioversion to SR was similar between amiodarone ( 81.4 % ) and procainamide ( 82.7 % ) ( P = NS ) . Procainamide loading recorded faster cardioversion times than amiodarone loading ( P=0.02 ) , but there was no significant difference after that . Amiodarone caused a significant decrease on systolic blood pressure compared to procainamide for the first 18 h ( P<0.001 ) , and a significant decrease in the diastolic blood pressure for the first 6 h ( P<0.001 ) . Side-effects for either medication were sparse . The only real prognostic factor for successful cardioversion remains the size of left atrium . CONCLUSION Both drugs were equally effective in restoring SR , though procainamide acts quicker in the loading phase . Both medications are safe and side effects develop only in the maintenance phase Background Indirect comparisons are becoming increasingly popular for evaluating medical treatments that have not been compared head-to-head in r and omized clinical trials ( RCTs ) . While indirect methods have grown in popularity and acceptance , little is known about the fragility of confidence interval estimations and hypothesis testing relying on this method . Methods We present the findings of a simulation study that examined the fragility of indirect confidence interval estimation and hypothesis testing relying on the adjusted indirect method . Findings Our results suggest that , for the setting s considered in this study , indirect confidence interval estimation suffers from under-coverage while indirect hypothesis testing suffers from low power in the presence of moderate to large between- study heterogeneity . In addition , the risk of overestimation is large when the indirect comparison of interest relies on just one trial for one of the two direct comparisons . Interpretation Indirect comparisons typically suffer from low power . The risk of imprecision is increased when comparisons are unbalanced BACKGROUND A prospect i ve , r and omized study was conducted to evaluate the efficacy and tolerability of oral propafenone and quinidine for the conversion of paroxysmal atrial fibrillation ( AF ) . METHODS Eighty one consecutive patients ( female/male 46/35 ; mean age 64.0 + /- 11.6 ) , admitted to hospital with AF lasting no longer than 48 hours , were r and omized in terms of their pharmacological therapy . Forty three patients ( 55 % ) were r and omly assigned to Group I and received propafenone 600 mg orally as the initial therapy , with an additional dose of 300 mg after eight hours , if the sinus rhythm had not been restored by then . Thirty eight patients ( 45 % ) ( Group II ) received 1 mg digoxin IV followed by an oral loading of quinidine ( 400 mg followed by 200 mg every two hours ) . RESULTS The conversion rate assessed after 24 hours was the same in both groups ( Gr . I vs. Gr . II : 90.7 vs. 91.4 % ) , with the same number of mild side effects ( Gr . I vs. Gr . II : 37.2 % vs. 45.7 % ) . No life-threatening adverse events were reported . Propafenone achieved a higher efficacy rate during the first eight hours ( 83.3 vs. 54.3 % ; p = 0.01 ) , with a significantly shorter time required to sinus rhythm recovery throughout the study period , with a median time of 165 min ( 95 % confidence interval 120 - 278 ) vs. 360 min ( 95 % confidence interval 298 - 650 ; p < 0.05 ) . There was some indication of greater effectiveness of propafenone than quinidine in early sinus rhythm restoration in patients with : no structural heart disease , in those with an AF duration shorter than 12 hours , and in patients with an ejection fraction > 55 % . CONCLUSIONS Although both drugs revealed the same effectiveness , the conversion to sinus rhythm in the group treated with propafenone was observed more quickly despite the longer paroxysmal AF episode duration BACKGROUND Drugs currently available for the acute treatment of paroxysmal atrial fibrillation have significant limitations . We assessed the safety and effectiveness of intravenous magnesium sulfate versus diltiazem therapy in patients with prolonged episodes of paroxysmal atrial fibrillation . METHODS In a prospect i ve r and omized trial , 46 symptomatic patients presenting with paroxysmal atrial fibrillation were given intravenous magnesium sulfate ( n=23 ) or diltiazem ( n=23 ) therapy . Primary outcome measures were effects on ventricular rate control and proportion of patients restored to sinus rhythm at 6 h after initiation of treatment . RESULTS There were no differences in baseline characteristics between the two groups . Both forms of treatment were well tolerated , with no adverse clinical events . Both drugs had similar efficacy in reducing the ventricular rate at the first hour of treatment ( P<0.05 ) with a tendency toward a further decrease during infusion times of 2 ( P<0.01 ) , 3 , 4 , 5 and 6 h , respectively ( P<0.001 ) . However , at the end of the 6-h treatment period , restoration of sinus rhythm was observed in a significantly higher proportion of patients in the magnesium group compared with the diltiazem group [ 13 of 23 patients , ( 57 % ) , versus five of 23 patients , ( 22 % ) , P=0.03 ] . CONCLUSIONS Magnesium sulfate favorably affects rate control and seems to promote the conversion of long lasting episodes of paroxysmal atrial fibrillation to sinus rhythm , representing a safe , reliable and cost-effective alternative treatment strategy to diltiazem AIM The aim of our study was to compare the efficacy and safety of ibutilide and amiodarone ( intravenously ) in converting  recent-onset atrial fibrillation ( AF ) and atrial flutter ( Af )  to sinus rhythm ( SR ) . METHODS The study was prospect i ve , r and omized and included 152 ( 103 men and 49 women ) consecutive patients with AF or Af of 3 - 48 h duration .  Ibutilide is a selective class III antiarrhythmic agent which when administered intravenously can terminate AF and Af .  Amiodarone is also a class III antiarrhythmic agent that when given intravenously or orally has proved to be more effective than other agents in terminating AF and Af [ B.N. Singh , F.V. Mody , B. Lopez , J.S. Sarma . Antiarrhythmic agents for atrial fibrillation : focus on prolonging atrial repolarization . Am J Cardiol 1999 Nov 4 ; 84 : 161R-173R . ] . Seventy-nine patients ( 56 with AF and 23 with Af ) that consisted group A were treated with ibutilide .  Seventy-three ( 52 with AF and 21 with Af ) consisted group B and were treated with intravenous infusion of amiodarone . RESULTS The conversion rate of group A ( ibutilide ) was significantly higher than the conversion rate of group B ( amiodarone ) ( 80 % vs. 57 % , p=0.0054 ) . As regards the kind of arrhythmia separately , for AF there was n't significant difference ( 77 % vs. 69 % , p = ns ) whereas for Af ibutilide was superior to amiodarone ( 87 % vs. 29 % , p=0.003 ) . The conversion rates of ibutilide did n't differ for AF and Af ( 77 % vs. 87 % , p = ns ) . CONCLUSIONS Ibutilide is more effective than amiodarone in converting recent-onset Af to SR whereas both drugs are equally effective in converting recent-onset AF to SR Introduction Emergency department ( ED ) cardioversion ( EDCV ) and discharge of patients with recent onset atrial fibrillation or atrial flutter ( AF ) has been shown to be a safe and effective management strategy . This study examines the impact of such aggressive ED management on hospital charges . Methods : A r and om sample of 300 AF patients were identified from an ED electronic data base and screened for timing of onset of their symptoms . Patients were considered eligible for EDCV if either nursing or physician notes documented an onset of symptoms less than 48 hours prior to ED presentation and the patient was less than 85 years of age . An explicit chart review was then performed to determine patient management and disposition . Cardioversion attempts were defined as ED administration of procainamide , flecainide , propafenone , ibutilide , amiodarone or direct current cardioversion ( DCCV ) .  Total hospital charges for each patient were obtained from the hospital billing office . Differences across medians were analyzed utilizing through Wilcoxon rank sum tests and chi square . Results : A total of 51 patients were included in the study .  EDCV  was attempted on 24 ( 47 % ) patients , 22 ( 92 % ) were successfully cardioverted to normal sinus rhythm ( NSR ) . An additional 12 ( 23 % ) spontaneously converted to NSR . Twenty ( 91 % ) of those successfully cardioverted were discharged from the ED along with 4 ( 33 % ) of those spontaneously converting . Pharmacologic cardioverson was attempted in six patients and was successful in three ( 50 % ) , one after failed DCCV attempt .  Direct current cardioversion  was attempted in 21 ( 88 % ) and was successful in 19 ( 90 % ) , two after failed pharmacologic attempts . Median charges for patients cardioverted and discharged from the ED were $ 5,460 ( IQR $ 4,677–$6,190 ) . Median charges for admitted patients with no attempt at cardioversion were $ 23,202 ( IQR $ 19,663–$46,877 ) . Median charges for patients whose final ED rhythm was NSR were $ 5,641 ( IQR $ 4,638–$12,339 ) while for those remaining inAF median charges were $ 30,299 ( IQR $ 20,655 – $ 69,759 ) . Conclusion : ED cardioversion of recent onset AF patients results in significant hospital savings OBJECTIVE To investigate whether an oral loading dose of flecainide is as safe and effective as intravenous flecainide for the cardioversion of acute atrial fibrillation . DESIGN Prospect i ve , r and omised , double blind , double placebo study . SETTING Cardiac care unit of a large district general hospital in the UK . PATIENTS AND METHODS 79 patients presenting with symptomatic acute atrial fibrillation : patients were given either intravenous flecainide ( n = 39 ) or a solution of oral flecainide ( n = 40 ) , with appropriate placebos . All patients were heparinised during the study . PRIMARY OUTCOME MEASURES Safety ; mean time to cardioversion ; proportion of patients restored to sinus rhythm at two hours and eight hours after treatment . Analysis was by intention to treat . RESULTS There were no differences in baseline characteristics between the oral and intravenous groups . Both forms of flecainide were well tolerated , with no adverse clinical events during the study . The mean time to cardioversion was 110 minutes in the oral group and 52 minutes in the intravenous group ( p = 0.002 ) . Two hours after treatment , 27 of the 40 patients in the oral group ( 68 % ) and 25 of the 39 in the intravenous group ( 64 % ) had reverted to sinus rhythm ( p = 0.74 ) . Eight hours after treatment , 30 patients in the oral group ( 75 % ) and 28 in the intravenous group ( 72 % ) had reverted to sinus rhythm ( p = 0.76 ) . CONCLUSIONS Intravenous flecainide restored sinus rhythm more rapidly than oral flecainide , but at two hours and eight hours after treatment there was no difference in the proportion of patients cardioverted by the two approaches . These results suggest a role for oral loading doses of flecainide in the treatment of acute or symptomatic paroxysmal atrial fibrillation The appropriate treatment for the restoration of sinus rhythm in patients with atrial fibrillation ( AF ) of recent onset is still the subject of controversy . In this prospect i ve , r and omized , single-blind , placebo-controlled clinical study , we investigated the effectiveness and safety of procainamide , propafenone , and amiodarone , administered intravenously , for the conversion of recent-onset AF . We enrolled 362 consecutive patients ( 183 men ; age 34 to 86 years ; mean 65+/-10 ) with AF duration of no > 48 hours . Of these patients , 89 were given procainamide , 91 propafenone , 92 amiodarone , and 90 placebo . Treatment was considered successful if conversion to sinus rhythm was achieved within the 24-hour study period . Baseline clinical characteristics were similar in the 4 groups . The treatment was successful in 61 of the 89 patients who received procainamide ( 68.53 % ; median time 3 hours ) , 73 of the 91 patients who received propafenone ( 80.21 % ; median time 1 hour ) , 82 of the 92 patients who received amiodarone ( 89.13 % ; median time 9 hours ) , and 55 of the 90 patients who received placebo ( 61.11 % ; median time 17 hours ; p<0.05 for all medicated groups vs placebo ; p<0.05 for amiodarone and propafenone vs procainamide ) . In conclusion , all 3 medications , when administered intravenously , are effective in the restoration of sinus rhythm in recent-onset AF . Amiodarone and propafenone are more effective whereas procainamide and propafenone are faster INTRODUCTION Paroxysmal atrial fibrillation ( AF ) may progress to persistent AF . We studied the clinical correlates and the effect of rhythm-control strategy on AF progression . METHODS RecordAF was a worldwide prospect i ve survey of AF management . Consecutive eligible patients with recent-onset AF were included and allocated to rate or rhythm control according to patient/physician choice . A total of 2,137 patients were followed up for 12 months . Atrial fibrillation progression was defined as a change from paroxysmal to persistent/permanent AF . RESULTS Progression of AF occurred in 318 patients ( 15 % ) after 1 year . Patients with AF progression  were older ; had a higher diastolic blood pressure ; and more often had a history of coronary artery disease , stroke or transient ischemic attack , hypertension , or heart failure . Patients treated with rhythm control were less likely to show progression than those treated only with rate control ( 164/1542 [ 11 % ] vs 154/595 [ 26 % ] , P < .001 ) . Multivariable analysis showed that history of heart failure ( odds ratio [ OR ] 2.2 , 95 % CI 1.7 - 2.9 , P < .0001 ) , history of hypertension ( OR 1.5 , 95 % CI 1.1 - 2.0 , P = .01 ) , and rate control rather than rhythm control ( OR 3.2 , 95 % CI 2.5 - 4.1 , P < .0001 ) were independent predictors of AF progression . The propensity score-adjusted OR of AF progression in patients with rate rather than rhythm control was 3.3 ( 95 % CI 2.4 - 4.6 , P < .0001 ) . CONCLUSIONS Although heart failure and hypertension are associated with AF progression , rhythm control is associated with lower risk of AF progression AIM Oral propafenone is effective in restoring sinus rhythm however the proarrhythmic effects are still unknown . The Safety Antiarrhythmic Therapy Evaluation ( SATE ) trial was a prospect i ve r and omized placebo-controlled multicentre study which evaluated the safety of acute oral loading dose of propafenone in patients with recent onset atrial fibrillation . Secondary end-points were to evaluate the effect of digitalis added to propafenone in ventricular rate control and the efficacy of propafenone alone or added to digitalis compared with efficacy of digitalis plus quinidine . METHODS AND RESULTS 246 patients ( 126 male ; 58+/-11 years ) with atrial fibrillation of < 48 h duration were r and omly allocated to one of four groups : digitalis 0.75 - 1 mg i.v . plus quinidine 1100 mg ( D+Q , 70 patients ) ; propafenone 450 - 600 mg orally ( PNF , 66 patients ) ; propafenone 450 - 600 mg orally plus digitalis 0.750 - 1 mg i.v . ( PNF+D , 70 patients ) ; placebo ( Pl , 40 patients ) . All patients underwent 24-h ECG Holter monitoring . Safety was assessed by evaluating the appearance of adverse events classified as mild , moderate and severe . No severe adverse events were reported . Short lasting asymptomatic atrial flutter episodes with atrio-ventricular conduction > or = 2:1 were observed in 14 % of the D+Q group , 21 % PNF , 18 % PNF+D and in 8 % Pl . One patient in the D+Q group and four in the PNF+D group showed asymptomatic runs of 3 - 4 ventricular ectopic beats . Reversible sinus atrial blocks ( <3 s ) were detected in two patients of the D+Q group and in two of the PNF group . In patients with persistent atrial fibrillation the ventricular rate was similar in the four study groups . At 3 h the high efficacy of propafenone was confirmed . At the 24th hour no differences were found between active treatment and placebo arms . CONCLUSION Propafenone in a single oral loading dose is safe and promptly effective in patients with recent onset atrial fibrillation BACKGROUND Spontaneous conversion of recent onset paroxysmal atrial fibrillation  to  normal sinus rhythm  occurs commonly and is not affected by low-dose amiodarone treatment . METHODS In a r and omized , placebo-controlled trial of 100 patients with paroxysmal atrial fibrillation of recent onset ( < 48 h ) we compared the effects of treatment with continuous intravenous amiodarone 125 mg per hour ( total 3 g ) and intravenous placebo .  Patients in the placebo group who did not convert to normal sinus rhythm within 24 h were started on amiodarone therapy . RESULTS Conversion to normal sinus rhythm occurred within 24 h in 32 of 50 patients ( 64 % ) in the placebo group , most of whom converted within 8 h. Lower conversion rates were observed in patients with hypertension , ischaemic heart disease or congestive heart failure and in patients with echocardiographic findings of left atrial diameter above 45 mm , ejection fraction below 45 % or significant mitral regurgitation . However , in most patients these clinical or echocardiographic risk factors of decreases in conversion rate were not present . In such patients the spontaneous conversion rate was approximately 90 % . The conversion rate during 24 h of treatment in the amiodarone group was 92 % ( P=0.0017 , compared to the placebo group ) . In this group , the conversion rate was largely unaffected by baseline characteristics . Of the 18 patients who did not convert with placebo , 15 ( 85 % ) converted after being crossed over to amiodarone . All patients not responding to high-dose amiodarone were in chronic atrial fibrillation within 1 month . In patients still in atrial fibrillation after 8 h of treatment , the pulse rate decreased significantly more in the amiodarone as compared to the placebo group ( 83+/-15 vs 114+/-20 beats . min(-1 ) , P=0.0014 ) . CONCLUSION The spontaneous conversion of recent onset paroxysmal atrial fibrillation is high and approaches 90 % in specific clinical and echocardiographically defined subgroups . Intravenous high-dose amiodarone safely facilitates conversion of paroxysmal atrial fibrillation . However , such treatment should be reserved for patients with unfavourable risk factor profiles , not converting during 8 h of observation or requiring rate control STUDY OBJECTIVE A prospect i ve , r and omized controlled trial of new-onset atrial fibrillation was conducted to compare the efficacy and safety of sotalol and amiodarone ( active treatment ) with rate control by digoxin alone for successful reversion to sinus rhythm at 48 hours . METHODS We prospect ively r and omly assigned 120 patients with atrial fibrillation of less than 24 hours ' duration to treatment with sotalol , amiodarone , or digoxin using a single intravenous dose followed by 48 hours of oral treatment . Patients had ECG monitoring for 48 hours , and time of reversion , adequacy of rate control , and numbers of adverse events were compared . After 48 hours , those still in atrial fibrillation underwent cardioversion according to a st and ardized protocol . After 48 hours of therapy and attempted cardioversion , the number of patients whose rhythms had successfully reverted were compared . RESULTS There was a significant reduction in the time to reversion with both sotalol ( 13 . 0+/-2.5 hours , P < .01 ) and amiodarone ( 18.1+/-2.9 hours , P < .05 ) treatment compared with digoxin only ( 26.9+/-3.4 hours ) . By 48 hours , the active treatment group was significantly more likely to have reverted to sinus rhythm than the rate control group ( 95 % versus 78 % , P < .05 ; risk ratio 5.4 , 95 % confidence interval [ CI ] 1.5 to 19.2 ) . In those patients whose rhythms did not revert to sinus rhythm , there was superior ventricular rate control in the sotalol group at both 24 and 48 hours compared with those who received either amiodarone or digoxin . There were also fewer adverse events in the active treatment group compared with the rate control group . CONCLUSION Immediate pharmacologic therapy for new-onset atrial fibrillation with class III antiarrhythmic drugs ( sotalol or amiodarone ) improves complication-free 48-hour reversion rates compared with rate control with digoxin AIMS Amiodarone is used commonly for pharmacological cardioversion of atrial fibrillation ( AF ) , but it is limited by moderate efficacy and delayed action . Ranolazine and amiodarone are markedly synergistic in suppressing experimental AF in vitro , yet the clinical efficacy of ranolazine combined with amiodarone for AF conversion has only undergone minimal investigation . This prospect i ve , single-blinded , r and omized study compared the safety and efficacy of ranolazine added to amiodarone vs. amiodarone alone for conversion of recent-onset AF . METHODS AND RESULTS We enroled 121 patients ( 64 ± 10 years , 45 % male ) with recent-onset ( < 48 h duration ) AF who were eligible for pharmacological cardioversion . Patients received either 24 h amiodarone infusion ( loading dose 5 mg/kg followed by maintenance dose of 50 mg/h ; n = 60 ) , or amiodarone infusion at the same dosage plus a single oral dose of ranolazine 1500 mg ( n = 61 ) . Patients in the amiodarone plus ranolazine group compared with the amiodarone-only group showed significantly higher conversion rates at 24 h ( 87 vs. 70 % , respectively ; P = 0.024 ) and at 12 h ( 52 vs. 32 % ; P = 0.021 ) , and shorter time to conversion ( 10.2 ± 3.3 vs. 13.3 ± 4.1 h ; P = 0.001 ) . Subgroup analysis identified higher 24 h conversion in patients with left atrial ( LA ) diameter > 46 mm who received the combination treatment vs. amiodarone alone ( 81 vs. 54 % ; P = 0.02 ) , whereas the efficacy of the two interventions did not differ among patients with LA diameter ≤46 mm ( P = 0.77 ) . There was modest QT prolongation in both the groups , no serious adverse reactions , and no pro-arrhythmic events . CONCLUSION Addition of ranolazine to amiodarone was safe and well tolerated in this study , and it demonstrated efficacy superior to amiodarone alone for conversion of recent-onset AF . These findings may have clinical implication s by offering a simple therapeutic manoeuvre to enhance amiodarone 's effectiveness for conversion of AF STUDY OBJECTIVE To determine the relative effectiveness of a verapamil-quinidine sequential combination versus digoxin-quinidine in the emergency department treatment of paroxysmal atrial fibrillation ( PAF ) . METHOD This prospect i ve , double-blind , r and omized , controlled trial involved patients , aged 18 to 75 years , with new-onset ( < 48 hours ) atrial fibrillation who presented to a community-based urban hospital with an annual ED census of 65,000 . Exclusion criteria included ventricular response rate lower than 100 or higher than 200 beats/minute , allergy to study drugs , hypotension with evidence of end-organ hypoperfusion , and conduction abnormalities . Consenting patients were r and omly assigned to receive rapid digitalization ( 1.0 mg over 2 hours ) or i.v . verapamil ( sequential 5-mg boluses up to 20 mg ) . After ventricular rate was controlled ( < 100 beats/minute ) , oral quinidine ( 200 mg ) was initiated and repeated every 2 hours until conversion to normal sinus rhythm ( NSR ) occurred , until 1 g of quinidine was administered , or until adverse effects supervened . Heart rate , blood pressure , cardiac rhythm , time to conversion , and adverse effects were documented . RESULTS Forty-four patients received the study drugs . Three were withdrawn , leaving 19 in the verapamil-quinidine ( VER-Q ) group and 22 in the digoxin-quinidine ( DIG-Q ) group . Sixteen patients ( 84 % ) in the VER-Q group and 10 ( 45 % ) in the DIG-Q group converted to NSR within 6 hours ( P < .02 ) . Mean time to conversion ( + /-SD ) was 185 + /- 146 minutes for VER-Q and 368 + /- 386 minutes for DIG-Q patients ( P = NS ) . Twelve VER-Q patients ( 63 % ) and 6 DIG-Q patients ( 27 % ) were discharged from the ED ( P < .05 ) . Minor adverse effects were more common in the VER-Q group . No mortality or significant morbidity occurred . CONCLUSION The sequential combination of verapamil and quinidine , in the doses studied , is an effective treatment for PAF and is superior to digoxin-quinidine . Digoxin should no longer be considered the treatment of choice for uncomplicated PAF Background : Amiodarone ( AMIO ) is for many years effectively used to control ventricular rate during atrial fibrillation ( AF ) and to convert it into sinus rhythm . However , due to its delayed onset of action , ranolazine ( RAN ) , a new antianginal agent with atrial‐selective electrophysiologic properties , has recently been attempted as add‐on therapy with AMIO to facilitate AF conversion . Methods : To establish the role of this combination therapy , we enrolled 173 consecutive patients ( 68 ± 10 years , 54 % male ) with recent‐onset ( < 48‐hour duration ) AF who were eligible for pharmacologic cardioversion . Patients were r and omized to intravenous AMIO ( loading dose 5 mg/kg in 1 hour followed by 50 mg/h ; n = 81 ) , or AMIO plus a single oral dose of RAN 1 g ( n = 92 ) . Results : Mean left atrial diameter did not significantly differ between groups , AMIO and AMIO + RAN ( 4.2 ± 0.5 cm vs 4.1 ± 0.4 cm , P = 0.18 ) . The AMIO + RAN group compared with the AMIO‐only group showed significantly shorter time to conversion ( 8.6 ± 2.8 hours vs 19.4 ± 4.4 hours , P < 0.0001 ) and higher conversion rate at 24 hours ( 98 % vs 58 % , P < 0.001 ) . Left ventricular ejection fraction did not markedly vary between the two groups and ranged within moderately reduced values . No serious clinical ly evident adverse effects were observed in any of the patients receiving either AMIO or the combination treatment . Conclusions : Our data demonstrate faster sinus rhythm restoration and enhanced conversion rate of AF  after AMIO plus RAN in patients with preserved ejection fraction and left atrial size , implicating a synergistic effect of the two agents 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 We r and omized 61 patients with paroxysmal atrial fibrillation ( AF ) ( < 48 hours from onset ) to either sotalol or quinidine treatment .  Conversion of rhythm was recorded by Holter monitoring . The starting 80 mg dose of sotalol was repeated at 2 , 6 , and 10 hours if AF persisted ( heart rate > 80 beats/min ) , and if systolic blood was > or = 120 mm Hg . In the quinidine group , if heart rate > 100 beats/min , it was decreased with intravenous digoxin , whereafter 200 mg of oral quinidine sulfate was given maximally 3 times , each dose 2 hours apart . Conversion of AF to sinus rhythm occurred in 17 or 33 patients ( 52 % ) taking sotalol , and in 24 of 28 patients ( 86 % ) taking quinidine ( p < 0.0001 ) . Electric cardioversion was necessary in 39 % of the former and in 14 % of the latter group . The mean delay from first trial drug to sinus rhythm with the trial medication was 10.2 + /- 7.6 hours in the sotalol group and 4.0 + /- 2.9 hours in the quinidine group ( p < 0.01 ) . Treatment was discontinued in 16 patients taking sotalol ( 48 % ) because of asymptomatic bradycardia or hypotension , and in 20 taking quinidine ( 71 % ) because of rhythm conversion . Asymptomatic wide complex tachycardia ( QRS > 0.12 second ) was found in 13 % and 27 % of patients taking sotalol and quinidine , respectively . The longest RR intervals were 6.4 and 3.8 seconds in the sotalol and quinidine groups , respectively . Oral sotalol did not appear as effective as quinidine sulfate treatment in conversion of paroxysmal AF . ( ABSTRACT TRUNCATED AT 250 WORDS The efficacy of amiodarone has been proved in long-term maintenance of sinus rhythm ( SR ) in patients with paroxysmal atrial fibrillation ( AF ) . The present study evaluates the efficacy and safety of a single oral dose of amiodarone in patients with recent-onset AF ( < 48 hours ) . Seventy-two patients were r and omized to receive 30 mg/kg of either amiodarone or placebo .  Conversion to SR was verified by 24-hour Holter monitoring . Ten patients were excluded because of SR in the beginning of monitoring or technical failure during Holter monitoring . The remaining study groups were comparable ( n = 31 for each ) , except that in the placebo group beta blockers were more common . The patients receiving amiodarone  converted to SR more effectively than those receiving placebo ( p<0.0001 ) . At 8 hours , approximately 50 % of patients in the amiodarone group and 20 % in the placebo group ( Holter successful ) had converted to SR , whereas after 24 hours the corresponding figures were 87 % and 35 % , respectively . The median time for conversion ( 8.7 hours for amiodarone and 7.9 hours for placebo ) did not differ in the groups . Amiodarone was hemodynamically well tolerated , and the number of adverse events in the study groups was similar . Amiodarone as a single oral dose of 30 mg/kg appears to be effective and safe in patients with recent-onset AF Aims Ibutilide is a rapid‐acting antiarrhythmic drug with worldwide use for conversion of recent‐onset atrial fibrillation . Vernakalant , approved in the EU in 2010 , is likewise used intravenously , with proven efficacy and safety compared with placebo and amiodarone in r and omized clinical trials . The aim of our study was to compare the time to conversion and the conversion rate within 90 min in patients with recent‐onset atrial fibrillation treated with vernakalant or ibutilide .  Methods and results A r and omized controlled trial registered at clinical trials.gov ( NCT01447862 ) was performed in 100 patients with recent‐onset atrial fibrillation treated at the emergency department of a tertiary care hospital . Patients received up to two short infusions of vernakalant ( n = 49 ; 3 mg/kg followed by 2 mg/kg if necessary ) or ibutilide ( n = 51 ; 1 mg followed by another 1 mg if necessary ) according to the manufacturer 's instructions . Clinical and laboratory variables , adverse events , conversion rates , and time to conversion were recorded . Time to conversion of AF to sinus rhythm was significantly shorter in the vernakalant group compared with the ibutilide group ( median time : 10 vs. 26 min , P = 0.01 ) , and likewise the conversion success within 90 min was significantly higher in the vernakalant group ( 69 vs. 43 % , log‐rank P = 0.002 ) . No serious adverse events occurred . Conclusion Vernakalant was superior to ibutilide in converting recent‐onset atrial fibrillation to sinus rhythm in the emergency department setting OBJECTIVES This r and omized double-blind study compared the efficacy and safety of intravenous vernakalant and amiodarone for the acute conversion of  recent-onset atrial fibrillation ( AF ) .  BACKGROUND Intravenous vernakalant has effectively converted recent-onset AF and was well tolerated in placebo-controlled studies . METHODS A total of 254 adult patients with AF ( 3 to 48 h duration ) eligible for cardioversion were enrolled in the study . Patients received either a 10-min infusion of vernakalant ( 3 mg/kg ) followed by a 15-min observation period and a second 10-min infusion ( 2 mg/kg ) if still in AF , plus a sham amiodarone infusion , or a 60-min infusion of amiodarone ( 5 mg/kg ) followed by a maintenance infusion ( 50 mg ) over an additional 60 min , plus a sham vernakalant infusion . RESULTS Conversion from AF to sinus rhythm within the first 90 min ( primary end point ) was achieved in 60 of 116 ( 51.7 % ) vernakalant patients compared with 6 of 116 ( 5.2 % ) amiodarone patients ( p < 0.0001 ) . Vernakalant result ed in rapid conversion ( median time of 11 min in responders ) and was associated with a higher rate of symptom relief compared with amiodarone ( 53.4 % of vernakalant patients reported no AF symptoms at 90 min compared with 32.8 % of amiodarone patients ; p = 0.0012 ) . Serious adverse events or events leading to discontinuation of study drug were uncommon . There were no cases of torsades de pointes , ventricular fibrillation , or polymorphic or sustained ventricular tachycardia . CONCLUSIONS Vernakalant demonstrated efficacy superior to amiodarone for acute conversion of recent-onset AF . Both vernakalant and amiodarone were safe and well tolerated in this study . ( A Phase III Superiority Study of Vernakalant vs Amiodarone in Subjects With Recent Onset Atrial Fibrillation [ AVRO ] ; NCT00668759 ) OBJECTIVES The goal of the present study was to assess the efficacy and safety of intravenous tedisamil , a new antiarrhythmic compound , for conversion of recent-onset atrial fibrillation ( AF ) or atrial flutter ( AFL ) to normal sinus rhythm ( NSR ) . BACKGROUND Tedisamil is a novel antiarrhythmic drug with predominantly class III activity . Its efficacy and safety for conversion of recent onset AF or AFL to NSR is not known . METHODS This was a multicenter , double-blind , r and omized , placebo-controlled , sequential ascending dose-group trial . A total of 201 patients with symptomatic AF or AFL of 3 to 48 h duration were enrolled in a two-stage study . During stage 1 , patients were r and omized to receive tedisamil at 0.4 mg/kg body weight or matching placebo ; during stage 2 , patients received tedisamil at 0.6 mg/kg body weight or matching placebo . Treatments were given as single intravenous infusions . The primary study end point consisted of the percentage of patients converting to NSR for at least 60 s within 2.5 h. RESULTS Of 175 patients representing the intention-to-treat sample , conversion to NSR was observed in 41 % ( 25/61 ) of the tedisamil 0.4 mg/kg group , 51 % ( 27 of 53 ) of the tedisamil 0.6 mg/kg group , and 7 % ( 4/59 ) of the placebo group ( p < 0.001 for both tedisamil groups vs. placebo ) . Average time to conversion was 35 min in patients receiving tedisamil . There were two instances of self-terminating ventricular tachycardia : one episode of torsade de pointes and one of monomorphic ventricular tachycardia , both in patients receiving 0.6 mg/kg tedisamil . CONCLUSIONS Tedisamil at dosages of 0.4 and 0.6 mg/kg was superior to placebo in converting AF or AFL . Tedisamil has a rapid onset of action leading to conversion within 30 to 40 min in the majority of responders In a prospect i ve , single-blind trial , we r and omized 150 consecutive symptomatic patients with acute ( < or = 48 hours ' duration ) atrial fibrillation to receive intravenous flecainide , propafenone , or amiodarone . Flecainide and propafenone were administered as a bolus dose of 2 mg/kg in 20 minutes . A second bolus dose of 1 mg/kg in 20 minutes was administered if conversion to sinus rhythm was not achieved after 8 hours . Amiodarone was administered as a bolus of 5 mg/kg in 20 minutes followed by a continuous infusion of 50 mg/hour . By the end of a 12-hour observation period , conversion to sinus rhythm was achieved in 45 patients ( 90 % ) in the flecainide group , 36 ( 72 % ) in the propafenone group , and 32 ( 64 % ) in the amiodarone group ( p = 0.008 for the overall comparison , p = 0.002 for flecainide vs amiodarone , p = 0.022 for flecainide vs propafenone , and p = 0.39 for propafenone vs amiodarone ) . When compared with amiodarone , this higher reversion rate with flecainide was present from the first hour of the study period . However , only after administering the second bolus was there a significant difference between flecainide and propafenone .  Median time to conversion to sinus rhythm was different among groups ( p < 0.001 ) , and it was lower in the flecainide ( 25 minutes ; range 4 to 660 ) and propafenone ( 30 minutes ; range 10 to 660 ) groups than in the amiodarone group ( 333 minutes ; range 15 to 710 ; p < 0.001 for both comparisons ) . Flecainide , at the doses administered in this study , is more effective than propafenone and amiodarone for conversion of acute atrial fibrillation to sinus rhythm .  Propafenone and amiodarone have similar conversion rates , although propafenone was faster in achieving the conversion to sinus rhythm AIMS Since atrial fibrillation ( AF ) is associated with increased risks of cardiovascular and cerebrovascular complications , estimations on the number of individuals with AF are relevant to healthcare planning . We aim ed to project the number of individuals with AF in the Netherl and s and in the European Union from 2000 to 2060 . METHODS AND RESULTS Age- and sex-specific AF prevalence estimates were obtained from the prospect i ve community-based Rotterdam Study . Population projections for the Netherl and s and the European Union were obtained from the European Union 's statistics office . In the age stratum of 55 - 59 years , the prevalence of AF was 1.3 % in men ( 95 % CI : 0.4 - 3.6 % ) and 1.7 % in women ( 95 % CI : 0.7 - 4.0 % ) . The prevalence of AF increased to 24.2 % in men ( 95 % CI : 18.5 - 30.7 % ) , and 16.1 % in women ( 95 % CI : 13.1 - 19.4 % ) , for those > 85 years of age . This age- and sex-specific prevalence remained stable during the years of follow-up . Furthermore , we estimate that in the European Union , 8.8 million adults over 55 years had AF in 2010 ( 95 % CI : 6.5 - 12.3 million ) . We project that this number will double by 2060 to 17.9 million ( 95 % CI : 13.6 - 23.7 million ) if the age- and sex-specific prevalence remains stable . CONCLUSION We estimate that from 2010 to 2060 , the number of adults 55 years and over with AF in the European Union will more than double . As AF is associated with significant morbidities and mortality , this increasing number of individuals with AF may have major public health implication UNLABELLED The efficacy and safety of intravenous propafenone , amiodarone , or placebo were compared in the treatment of atrial fibrillation ( AF ) of recent onset ( duration < or = 48 hours ) . METHODS 143 patients ( 77 men , mean age 63 + /- 12 years ) were studied , of whom 46 received propafenone ( 2 mg/kg over 15 minutes followed by 10 mg/kg over the next 24 hours ) , 48 received amiodarone ( 300 mg intravenously over 1 hour , followed by 20 mg/kg over the next 24 hours , plus 1,800 mg/day orally , in 3 divided doses ) , and 49 received placebo ( the equivalent amount of saline i.v . over 24 hours ) . Digoxin was administered to all patients who had not previously received it . RESULTS Conversion to normal sinus rhythm occurred in 36 of 46 patients ( 78.2 % ) receiving propafenone , in 40 of 48 patients ( 83.3 % ) receiving amiodarone , and in 27 of the 49 ( 55.10 % ) controls ( P < 0.02 , drug vs placebo , between drugs NS ) . The mean time to conversion was 2 + /- 3 hours for propafenone , 7 + /- 5 hours for amiodarone , and 13 + /- 9 for placebo ( P < 0.05 ) . Patients who converted had smaller atria than those who did not ( diameter : 42.7 + /- 5 vs 47.2 + /- 7 mm , P < 0.001 for all ) . Treatment was discontinued in one patient in the amiodarone group because of an allergic reaction and in two patients in the propafenone group because of excessive QRS widening . No side effects were observed in the placebo group . CONCLUSIONS Both drugs tested intravenously were equally effective and safe for the rapid conversion of recent-onset atrial fibrillation to sinus rhythm . However , propafenone offered the advantage of more rapid conversion than amiodarone BACKGROUND The ideal management of patients with newly diagnosed symptomatic atrial fibrillation ( AF ) remains unknown . Current practice guidelines recommend a trial of antiarrhythmic drugs ( AAD ) prior to considering an invasive ablation procedure . However , earlier ablation offers an opportunity to halt the progressive patho-anatomical changes associated with AF , as well as impart other important clinical benefits . OBJECTIVE The aim of this study is to determine the optimal initial management strategy for patients with newly diagnosed , symptomatic atrial fibrillation . METHODS / DESIGN The EARLY-AF study ( Clinical Trials.govNCT02825979 ) is a prospect i ve , open label , multicenter , r and omized trial with a blinded assessment of outcomes . A total of 298 patients will be r and omized in a 1:1 fashion to first-line AAD therapy , or first-line cryoballoon-based pulmonary vein isolation .  Patients with symptomatic treatment naïve AF will be included . Arrhythmia outcomes will be assessed by implantable cardiac monitor ( ICM ) . The primary outcome is time to first recurrence of AF , atrial flutter , or atrial tachycardia ( AF/AFL/AT ) between days 91 and 365 following AAD initiation or AF ablation . Secondary outcomes include arrhythmia burden , quality of life , and healthcare utilization . DISCUSSION The EARLY-AF study is a r and omized trial design ed to evaluate the optimal first management approach for patients with AF . We hypothesize that catheter ablation will be superior to drug therapy in prevention of AF recurrence Background : Atrial fibrillation is associated with increased risks of death , stroke/systemic embolism , and bleeding ( incurred by antithrombotic therapy ) , which may occur early after diagnosis . Methods : We assessed the risk of early events ( death , stroke/systemic embolism , and major bleeding ) over 12 months and their relation to the time after diagnosis of atrial fibrillation in 52 014 patients prospect ively enrolled in the GARFIELD-AF registry ( Global Anticoagulant Registry in the FIELD – Atrial Fibrillation ) between March 2010 and August 2016 . Results : Over 12 months , 2140 patients died ( mortality rate , 4.3 ; 95 % CI , 4.2–4.5 per 100 person-years ) , of whom 288 ( 13.5 % ) died in the first month ( 6.8 ; 95 % CI , 6.1–7.6 ) . Over 12 months , 657 patients had a stroke/systemic embolism ( 1.3 ; 95 % CI , 1.2–1.4 ) and 411 had a major bleeding ( 0.8 ; 95 % CI , 0.8–0.9 ) . During the first month , the rates ( per 100 person-years ) of stroke/systemic embolism and major bleed were 2.3 ( 95 % CI , 1.9–2.8 ) and 1.5 ( 95 % CI , 1.2–1.9 ) , respectively . The elevated 1-month mortality rate was mostly attributable to cardiovascular mortality ( 3.5 ; 95 % CI , 3.0–4.1 ) , in particular , heart failure , sudden death , and acute coronary syndromes ( 1.0 [ 95 % CI , 0.8–1.4 ] , 0.6 [ 95 % CI , 0.4–0.8 ] , and 0.5 [ 95 % CI , 0.3–0.8 ] , respectively ) . Age , heart failure , prior stroke , history of cirrhosis , vascular disease , moderate-to-severe kidney disease , diabetes mellitus , and living in North or Latin America were independent predictors of a higher risk of early death , whereas anticoagulation and living in Europe or Asia were independent predictors of a lower risk of early death . A predictive model developed for the 1-month risk of death had a C-statistic of 0.81 ( 95 % CI , 0.78–0.83 ) . Conclusions : The increased hazard of early events , in particular , cardiovascular mortality , in newly diagnosed atrial fibrillation points to the importance of comprehensive care for such patients and should alert clinicians to detect warning signs of possible early mortality . Clinical Trial Registration : URL : https://www . clinical trials.gov . Unique identifier : NCT01090362 BACKGROUND Although rhythm control has failed to demonstrate long-term benefits over rate control in longst and ing episodes of atrial fibrillation ( AF ) , there is little evidence concerning recent-onset ones . We analyzed the benefits of rhythm and rate control in terms of symptoms alleviation and need for hospital admission in patients with recent-onset AF . METHODS This was a multicenter , observational , cross-sectional study with prospect i ve st and ardized data collection carried out in 124 emergency departments ( EDs ) . Clinical variables , treatment effectiveness , and outcomes ( control of symptoms , final disposition ) were analyzed in stable patients with recent-onset AF consulting for AF-related symptoms . RESULTS Of 421 patients included , rhythm control was chosen in 352 patients ( 83.6 % ) , a global effectiveness of 84 % . Rate control was performed in 69 patients ( 16.4 % ) and was achieved in 67 ( 97 % ) of them . Control of symptoms was achieved in 396 ( 94.1 % ) patients and was associated with a heart rate after treatment ≤ 110 beats/min ( odds ratio [ OR ] = 14.346 , 95 % confidence interval [ CI ] = 3.90 to 52.70 , p < 0.001 ) and a rhythm control strategy ( OR = 2.78 , 95 % CI = 1.02 to 7.61 , p = 0.046 ) . Sixty patients ( 14.2 % ) were admitted : discharge was associated with a rhythm control strategy ( OR = 2.22 , 95 % CI = 1.20 - 4.60 , p = 0.031 ) and admission was associated with a heart rate > 110 beats/min after treatment ( OR = 29.71 , 95 % CI = 7.19 to 123.07 , p < 0.001 ) and acute heart failure ( OR = 9.45 , 95 % CI = 2.91 to 30.65 , p < 0.001 ) . CONCLUSION In our study , recent-onset AF patients in whom rhythm control was attempted in the ED had a high rate of symptoms ' alleviation and a reduced rate of hospital admissions BACKGROUND Patients with recent‐onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion . However , whether immediate restoration of sinus rhythm is necessary is not known , since atrial fibrillation often terminates spontaneously . METHODS In a multicenter , r and omized , open‐label , noninferiority trial , we r and omly assigned patients with hemodynamically stable , recent‐onset ( < 36 hours ) , symptomatic atrial fibrillation in the emergency department to be treated with a wait‐ and ‐see approach ( delayed‐cardioversion group ) or early cardioversion . The wait‐ and ‐see approach involved initial treatment with rate‐control medication only and delayed cardioversion if the atrial fibrillation did not resolve within 48 hours . The primary end point was the presence of sinus rhythm at 4 weeks . Noninferiority would be shown if the lower limit of the 95 % confidence interval for the between‐group difference in the primary end point in percentage points was more than ‐10 . RESULTS The presence of sinus rhythm at 4 weeks occurred in 193 of 212 patients ( 91 % ) in the delayed‐cardioversion group and in 202 of 215 ( 94 % ) in the early‐cardioversion group ( between‐group difference , ‐2.9 percentage points ; 95 % confidence interval [ CI ] , ‐8.2 to 2.2 ; P=0.005 for noninferiority ) . In the delayed‐cardioversion group , conversion to sinus rhythm within 48 hours occurred spontaneously in 150 of 218 patients ( 69 % ) and after delayed cardioversion in 61 patients ( 28 % ) . In the early‐cardioversion group , conversion to sinus rhythm occurred spontaneously before the initiation of cardioversion in 36 of 219 patients ( 16 % ) and after cardioversion in 171 patients ( 78 % ) . Among the patients who completed remote monitoring during 4 weeks of follow‐up , a recurrence of atrial fibrillation occurred in 49 of 164 patients ( 30 % ) in the delayed‐cardioversion group and in 50 of 171 ( 29 % ) in the early‐cardioversion group . Within 4 weeks after r and omization , cardiovascular complications occurred in 10 patients and 8 patients , respectively . CONCLUSIONS In patients presenting to the emergency department with recent‐onset , symptomatic atrial fibrillation , a wait‐ and ‐see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks . ( Funded by the Netherl and s Organization for Health Research and Development and others ; RACE 7 ACWAS Clinical Trials.gov number , NCT02248753 . Ranolazine , an antianginal agent with antiarrhythmic properties , prevents atrial fibrillation ( AF ) in patients with acute coronary syndrome . In experimental models , the combination of ranolazine and amiodarone has marked synergistic effects that potently suppress AF . Currently , the clinical effect of the ranolazine-amiodarone combination for the conversion of AF is unknown . This prospect i ve r and omized pilot study compared the safety and efficacy of ranolazine plus amiodarone versus amiodarone alone for the conversion of recent-onset AF . We enrolled 51 consecutive patients with AF ( < 48-hour duration ) eligible for pharmacologic cardioversion . Patients ( 33 men , 63 ± 8 years of age ) were r and omized to intravenous amiodarone for 24 hours ( group A , n = 26 ) or to intravenous amiodarone plus oral ranolazine 1,500 mg at time of r and omization ( group A + R , n = 25 ) . The 2 groups were well balanced with respect to clinical characteristics and left atrial diameter . Conversion within 24 hours ( primary end point ) was achieved in 22 patients ( 88 % ) in group A + R versus 17 patients ( 65 % ) in group A ( p = 0.056 ) . Time to conversion was shorter in group A + R than in group A ( 9.8 ± 4.1 vs 14.6 ± 5.3 hours , p = 0.002 ) . According to Cox regression analysis , left atrial diameter and A + R treatment were the only independent predictors of time to conversion ( hazard ratio 5.35 , 95 % confidence interval 2.37 to 12.11 , p < 0.001 ; hazard ratio 0.81 , 95 % confidence interval 0.74 to 0.88 , p < 0.001 , respectively ) . There were no proarrhythmic events in either group . In conclusion , addition of ranolazine to st and ard amiodarone therapy is equally safe and appears to be more effective compared to amiodarone alone for conversion of recent-onset AF
target: 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 .
background: AIMS We sought to identify the most effective antidysrhythmic drug for pharmacologic cardioversion of recent-onset atrial fibrillation ( AF ) .