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Treatment of Atrial Fibrillation
Comparative Effectiveness Reviews, No. 119
Investigators: Sana M Al-Khatib, MD, MHS, Nancy Allen Lapointe, PharmD, Ranee Chatterjee, MD, MPH, Matthew J Crowley, MD, Matthew E Dupre, PhD, David F Kong, MD, Renato D Lopes, MD, PhD, MHS, Thomas J Povsic, MD, PhD, Shveta S Raju, MD, Bimal R Shah, MD, Andrzej Kosinski, PhD, Amanda J McBroom, PhD, Megan M Chobot, MSLS, Rebecca Gray, DPhil, and Gillian D Sanders, PhD.
Author Information and AffiliationsStructured Abstract
Objectives:
There are two generally accepted strategies for managing atrial fibrillation (AF): rate control and rhythm control. However, within each strategic approach there are a large number of potential pharmacological and nonpharmacological therapies, and the comparative safety and effectiveness of these therapies—both within and between strategies—are uncertain.
Data sources:
We searched PubMed®, Embase®, and the Cochrane Database of Systematic Reviews for relevant English-language comparative studies.
Review methods:
Two investigators screened each abstract and full-text article for inclusion, abstracted data, rated quality and applicability, and graded evidence. When possible, random-effects models were used to compute summary estimates of effects.
Results:
Our review included 182 articles (148 unique studies): 14 studies relevant to rate-control drugs, 3 relevant to strict versus lenient rate control, 6 relevant to rate-control procedures versus drugs in patients for whom initial pharmacotherapy was ineffective, 42 relevant to antiarrhythmic drugs and electrical cardioversion for conversion to sinus rhythm, 83 relevant to rhythm-control procedures and drugs for maintenance of sinus rhythm, and 14 focusing on the comparison of rate- and rhythm-control strategies. Our ability to draw conclusions for the Key Questions addressing rate-control strategies was limited by the small number of available studies that assessed comparable therapies and outcomes, although we found a high strength of evidence for consistent benefit of calcium channel blockers (verapamil or diltiazem) compared with digoxin for ventricular rate control. For comparisons of methods for electrical cardioversion for conversion to sinus rhythm, there was high strength of evidence that use of a single biphasic waveform was more effective than use of a single monophasic waveform (odds ratio [OR] 4.39; 95% confidence interval [CI], 2.84 to 6.78) and that a 200 Joules (J) biphasic shock was less effective than a 360 J monophasic shock (OR 0.16; 95% CI, 0.05 to 0.53). Drug enhancement of external electrical cardioversion demonstrated a benefit compared with no drug enhancement (moderate strength of evidence), but data evaluating whether any one antiarrhythmic agent was more effective than others at restoring sinus rhythm were inconclusive. Our review found high strength of evidence supporting pulmonary vein isolation (PVI) versus antiarrhythmic drugs for maintenance of sinus rhythm in a select subset of patients (those with paroxysmal AF who were younger and with no more than mild structural heart disease; OR 6.51; 95% CI, 3.22 to 13.16) and moderate strength of evidence for adding a surgical Maze procedure at the time of other cardiac surgery (specifically mitral valve surgery) as opposed to mitral valve surgery alone (OR 5.80; 95% CI, 1.79 to 18.81). Comparing rate- and rhythm-control strategies, there was moderate strength of evidence supporting comparable efficacy with regard to all-cause mortality (OR 1.34; 95% CI, 0.89 to 2.02); cardiovascular mortality (OR 0.96; 95% CI, 0.77 to 1.20); stroke (OR 0.99; 95% CI, 0.76 to 1.30); and bleeding events (OR 1.10; 95% CI, 0.87 to 1.38). Cardiovascular hospitalizations were lower with rate-control strategies than with rhythm-control strategies (OR 0.25; 95% CI, 0.14 to 0.43; high strength of evidence). We were unable to conclude whether treatment effects varied by patient characteristics due to the paucity of studies that focused on specific patient subgroups.
Conclusions:
In assessing clinical outcomes associated with rate- versus rhythm-control strategies, our review of recent evidence agrees with prior reviews demonstrating little overall difference in outcomes between these two strategic approaches. Uncertainties still exist within specific subgroups of interest, among the wide variety of pharmacological and procedural therapies within each strategic approach, and in the impact of strategies on long-term clinical outcomes. Specifically, our review highlights the need for additional studies evaluating final outcomes such as mortality, stroke, and cardiovascular hospitalizations.
Contents
- Report Addendum (Submitted June 13, 2014)
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Introduction
- Results of Literature Searches
- Description of Included Studies
- Key Question 1 Rate-Control Drugs
- Key Question 2 Strict Versus Lenient Rate-Control Strategies
- Key Question 3 Rate-Control Procedures Versus Drugs or Versus Other Procedures in Patients for Whom Initial Pharmacotherapy Was Ineffective
- Key Question 4 Antiarrhythmic Drugs and Electrical Cardioversion for Conversion to Sinus Rhythm
- Key Question 5 Rhythm-Control Procedures and Drugs for Maintenance of Sinus Rhythm
- Key Question 6 Rate- Versus Rhythm-Control Therapies
- Discussion
- References
- Abbreviations
- Appendix A Exact Search Strings
- Appendix B Data Abstraction Elements
- Appendix C List of Included Studies
- Appendix D List of Excluded Studies
- Appendix E Key to Included Primary and Companion Articles
- Appendix F Study Characteristics Tables
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10066-I. Prepared by: Duke Evidence-based Practice Center, Durham, NC
Suggested citation:
Al-Khatib SM, Allen Lapointe N, Chatterjee R, Crowley MJ, Dupre ME, Kong DF, Lopes RD, Povsic TJ, Raju SS, Shah BR, Kosinski A, McBroom AJ, Chobot MM, Gray R, Sanders GD. Treatment of Atrial Fibrillation. Comparative Effectiveness Review 119. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2007-10066-I.) AHRQ Publication No.13-EHC095-EF. Rockville, MD: Agency for Healthcare Research and Quality; June 2013. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Duke Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10066-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report.
- 1
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.ahrq.gov
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