Marlene R. Miller, MD, MSc Robert L. McNamara, MD, MHS Jodi B. Segal, MD, MPH Nina Kim, MA Karen A. Robinson, MSc Steven N. Goodman, MD, PhD Neil R. Powe, MD, MPH, MBA Eric B. Bass, MD, MPH Baltimore, Maryland From the Division of Pediatric Cardiology (M.R.M.), Division of Cardiology (R.L.N.), Division of General Internal Medicine (J.B.S., N.R.P., E.B.B.), Oncology Center (S.N.G.), Division of Biostatistics at Johns Hopkins University School of Medicine; Graduate Training Program in Clinical Investigation (M.R.M.), Department of Epidemiology at Johns Hopkins University School of Hygiene and Public Health (R.L.M., N.R.P.); and the Baltimore Cochrane Center at University of Maryland (N.K., K.A.R.). This material was previously presented orally at the American College of Cardiology 48th Annual Scientific Session, March 1999. Dr Miller completed this study while she was a clinical fellow at Johns Hopkins University School of Medicine and a graduate student at Johns Hopkins University School of Hygiene and Public Health.
Reprint requests should be addressed to Marlene R. Miller, MD, MSc, Center for Quality, Measurement and Improvement, Agency for Healthcare Research and Quality, 2101 East Jefferson Street, Suite 502, Rockville, MD 20852. Email: mmiller@ahrq.gov.
References
Conclusions
Our formal data synthesis of 36 randomized clinical trials of pharmacologic AF conversion and MSR found evidence consistent with superior efficacy relative to control treatment for AF conversion with ibutilide/dofetilide and flecainide. The strength of evidence for MSR relative to control treatment was strong and comparable for quinidine, disopyramide, flecainide, propafenone, and sotalol. Most important, despite the high prevalence of AF the data for the relative efficacy of the antiarrhythmic agents for both conversion and MSR are sparse and inconclusive. Defining these relative efficacies should be a research priority.
Recommendations for clinical practice
On the basis of data from randomized clinical trials, ibutilide, dofetilide, and flecainide have superior efficacy for conversion of AF. However, the data are sparse for ibutilide and dofetilide, and use of flecainide needs to be considered in the context of other comorbidities, such as ventricular ectopy and coronary artery disease. For maintenance of sinus rhythm, no one agent has been shown to have superior efficacy. Clinical practices need to focus on upcoming trial results that involve direct comparisons among agents to better understand relative efficacies of the antiarrhythmic agents for both aspects of AF management.
Acknowledgments
Our study was conducted by the Johns Hopkins Evidence-Based Practice Center through contract No. 290-97-0006 from the Agency for Health Care Policy and Research, Rockville, Maryland. We are responsible for its contents including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the United States Department of Health and Human Services. Dr Miller was supported by the Hayden Whitney Smith Research Scholarship. We thank Hanan S. Bell, PhD; Ronald D. Berger, MD; Gary Gerstenblith, MD; David E. Haines, MD; Michael L. Lefevre, MD, MSPH; Andrew Epstein, MD; John A. Kastor, MD; Chris Burton, MD; Jerome A. Osheroff, MD; Barbara J. Drew, RN, PhD; and Kathleen McCauley, RN, PhD, for their assistance as expert advisers for this study. We also thank David Yu, MD, and Paul Abboud for their assistance with this study.
We are especially grateful to Donna Lea for her secretarial support.
