Atrial fibrillation: procainamide plus digoxin was more effective than digoxin for cardioversion.

Clinical bottom line (level 1b)

  1. Patients with atrial fibrillation and a fast ventricular rate who received procainamide and digoxin compared to digoxin alone were more likely to revert to sinus rhythm (NNT = 4 at 60 minutes) .
Kochiadakis et al: Cardiovascular drugs and therapy 1998; 12: 75-81
Expires August 2003

The study

Double-blinded concealed randomised trial with intention-to-treat
Setting: acute hospital, Greece

114 patients (aged range 27 to 78 years; mean 59, 52% male) with atrial fibrillation for <6 months and a ventricular rate >100 beats/min

Excluded if
  • taken any antiarrhythmic (except digoxin) within 5 half-lives
  • sick sinus syndrome, history of 2nd or 3rd degree heart block
  • aged < 18
  • thyroid disease
  • electrolyte disturbances
  • pregnancy or lactation
  • liver or kidney failure
  • recent MI, unstable angina, acute myocarditis, acute pericarditis
  • heart surgery within six months
  • severe uncontrolled heart failure (ejection fraction <30%) or cardiogenic shock
  • significant COPD, pulmonary embolism, pneumonia


    • Control Group: (n = 57, 57 analysed): placebo
    Experimental Group: (n = 57, 57 analysed): procainamide 1 g iv over 30 minutes, followed by 2 mg/min over 1 hour
    All patients received digoxin 0.5 mg over 30 minutes, and acenocoumarol for at least 21 days (adjusted so INR 3.0). Treatment was continued for at least 21 days after cardioversion.
    100% followed for 60 minutes
    Outcome notes:
    • no conversion to sinus rhythm : based on a blinded reading of a 12-lead ECG

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    no conversion to sinus rhythm 60 minutes 41
    (71.9%)    		 28
    (49.1%)    		 32%
    (7% to 50%)    		 22.8%
    (5.36% to 40.3%)    		 4
    (2 to 19)

    Comments

    1. The study is too short to comment on the long-term effectiveness of procainamide.

    Citation

    1. Kochiadakis GE, Igoumenidis NE, Solomou MC, et al: conversion of atrial fibrillation to sinus rhythm using acute intravenous procainamide infusion. Cardiovascular drugs and therapy 1998; 12: 75-81
    Contributor: Chris Ball and Clare Wotton, August 1999
    Reviewer:

    Clinical Question.
    Patient atrial fibrillation and a fast ventricular rate
    Intervention or Exposure procainamide and digoxin
    Comparison digoxin
    Outcome conversion to sinus rhythm