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Amiodarone or flecainide for cardioversion in acute onset atrial fibrillation
  1. Jon Argall, Senior Clinical Fellow,
  2. Ian Crawford, Clinical Research Fellow
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK;


    A short cut review was carried out to establish whether amiodarone is better than flecainide at restoring sinus rhythm in patients with atrial fibrillation. Altogether 42 papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated

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    Report by Jon Argall, Senior Clinical FellowChecked by Ian Crawford, Clinical Research Fellow

    Clinical scenario

    A 50 year old woman presents to the emergency department with acute onset of palpitations of less than two hours duration. She does not have chest pain, her heart rate is about 140–160 with a good systolic blood pressure, and respiratory examination is normal. An ECG confirms the rhythm to be atrial fibrillation. You consider which method of pharmacological cardioversion would be most suitable as the medical and cardiological opinions differ between amiodarone and flecainide.

    Three part question

    In [acute onset atrial fibrillation] is [amiodarone better than flecainide] at [restoring normal sinus rhythm]?

    Search strategy

    Medline 1966-11/03 using the Ovid interface. [exp Atrial Fibrillation OR (atrial adj5 fibrillation).af OR] AND [exp Amiodarone OR OR] AND [exp Flecainide OR OR] AND [Maximally Sensitive RCT Filter] LIMIT to human AND English.

    Search outcome

    Altogether 42 papers were found of which four were directly relevant to the three part question (see table 1).

    Table 1


    There were no significant differences in the patient groups or adverse effects in all studies. Most adverse effects were mild and self limiting, with no fatal events reported.


    In the stable patient with acute onset atrial fibrillation and uncompromised left ventricular function, flecainide is the most efficacious drug at restoring normal sinus rhythm expediently. However about 60% of patients will revert with no treatment.

    Report by Jon Argall, Senior Clinical FellowChecked by Ian Crawford, Clinical Research Fellow