Comparison of intravenous flecainide, propafenone, and amiodarone for conversion of acute atrial fibrillation to sinus rhythm

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Abstract

In a prospective, single-blind trial, we randomized 150 consecutive symptomatic patients with acute (≤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.

Section snippets

Patients

This prospective, randomized, single-blind trial included all patients presenting at the emergency room with acute AF (≤48 hours duration). Patients were recruited during a period of 18 months. Criteria defining the onset of the arrhythmia included an abrupt, well-defined onset of symptoms, such as palpitations, chest discomfort, or dyspnea. AF was confirmed with a 12-lead electrocardiogram in all patients.

Patients were excluded for the following criteria: (1) uncertain or >48 hours duration of

Patient characteristics

Overall, 150 consecutive patients were enrolled in the trial. Gender was male in 70 cases (47%) and age was 60 ± 13 years. Median time from onset of symptoms to the start of therapy was 6 hours (range 1 to 48). Fifty patients were randomly assigned to each treatment group. Table 1lists the clinical characteristics of patients in each study group.

Conversion rate

Table 2lists conversion rates at 1, 8, and 12 hours. There was a significantly greater proportion of patients reverting to sinus rhythm in the

Major findings

The present study is the first to compare intravenous flecainide, propafenone, and amiodarone directly in patients with acute AF (onset within 48 hours). Our results show that flecainide is more effective than propafenone and amiodarone in converting acute AF to sinus rhythm after 12 hours of observation. This higher reversion rate with flecainide was present from the first hour of the study period when compared with amiodarone, and only after administering a second bolus when compared with

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