• Gerard C Markey, Nigel Salter, and John Ryan.
• Department of Emergency Medicine, St. Vincent's University Hospital, Dublin, Ireland; Department of Emergency Medicine, University Hospital Waterford, Waterford, Ireland.
• J Emerg Med. 2018 Mar 1; 54 (3): 320-327.

BackgroundAtrial fibrillation (AF) is the most commonly encountered dysrhythmia in the emergency department, and its prevalence is increasing. A substantial proportion of these patients have recent-onset AF (<48 h). The poor prognosis associated with AF is being increasingly recognized, and there is some evidence for better outcomes in younger patients with recent-onset AF when sinus rhythm is restored. Flecainide is recommended in the latest international guidelines for cardioversion of recent-onset AF, but its safety and efficacy relative to other recommended agents are unclear.ObjectiveOur aim was to clarify the Level 1 evidence for the use of i.v. flecainide in acute AF.MethodsWe performed a systematic review and meta-analysis of the literature. Medline, Ovid, Embase, and Cochrane Central databases were searched for relevant studies. Only randomized controlled trials (RCTs) of i.v. flecainide for acute conversion of recent-onset AF were selected for meta-analysis.ResultsFour hundred and three studies were screened, of which 11 RCTs were eligible for meta-analysis. Flecainide had high efficacy for cardioversion within 2 h (number needed to treat [NNT] = 1.8). Efficacy was superior to propafenone, amiodarone, procainamide, ibutilide, and sotalol (NNT = 4.3). There was no statistically significant difference in pro-dysrhythmia compared to these anti-dysrhythmics or placebo.ConclusionsIntravenous flecainide cardioversion could be a safe and effective option for emergency physicians to restore sinus rhythm in selected patients with acute AF.Copyright © 2017 Elsevier Inc. All rights reserved.

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