Atrial fibrillation: acute: amiodarone or sotalol were better than digoxin for cardioversion

Clinical bottom line (level 1b)

  1. Patients with acute atrial fibrillation who received sotalol compared with digoxin were more likely to revert to sinus rhythm (NNT = 6 at 48 hours) and had fewer adverse effects (NNT = 6 at 48 hours) .
  2. Patients with acute atrial fibrillation who received amiodarone compared with digoxin were more likely to revert to sinus rhythm (NNT = 6 at 48 hours) and had fewer adverse effects (NNT = 5 at 48 hours) .
  3. There was no clear difference between sotalol and amiodarone.
Joesph and Ward: Annals of Emergency Medicine 2000; 36 : 1-9
Expires November 2003

The study

Unblinded concealed randomised trial without intention-to-treat
Setting: emergeny departments, 3 acute hospitals, USA

115 patients (aged , 56% male) with atrial fibrillation of < 24 hours and a ventricular rate > 100 beats/min

Excluded if
  • aged < 18
  • left ventricular dysfunction
  • pregnancy
  • serum K < 3.5 mmol/l, > 5.5 mmol/l
  • serum creatinine > 200 micromol/l
  • current beta-blocker use; or digoxin or sotalol treatment within previous week; or amiodarone within previous month
  • hypotension
  • known thyroid disease
  • contraindication to anticoagulation or study medication
  • broad complex tachycardias

    Control Group: (n = 36, 36 analysed): digoxin 500 microgram iv over 30 minutes, followed by 250 microgram orally every 6 hours for 4 doses, then 250 microgram daly (125 microgram if serum creatinine > 125 micromol/l)
    Experimental Group: (n = 40, 40 analysed): sotalol 1.5 mg/kg iv over 30 min, then 80 mg orally every 8 hours for 6 doses
    Experimental Group: (n = 39, 39 analysed): amiodarone 5 mg/kg iv over 30 min, then 400 mg orally every 8 hours for 6 hours

    100% followed for 48 hours

    The evidence

    sotalol v. digoxin
    Outcome Time to outcome CER EER RRR
    (95% CI)    		 ARR
    (95% CI)    		 NNT
    (95% CI)
    sinus rhythm 48 hours 28
    (77.8%)    		 38
    (95.0%)    		 22%
    (1% to 47%)    		 17.2%
    (2.06% to 32.4%)    		 6
    (3 to 49)
    adverse effects 48 hours 10
    (27.8%)    		 2
    (5.00%)    		 82%
    (23% to 96%)    		 22.8%
    (6.66% to 38.9%)    		 4
    (3 to 15)

    amiodarone v. digoxin
    Outcome Time to outcome CER EER RRR
    (95% CI)    		 ARR
    (95% CI)    		 NN T
    (95% CI)
    sinus rhythm 48 hours 28
    (77.8%)    		 37
    (94.9%)    		 22%
    (1% to 47%)    		 17.1%
    (1.85% to 32.3%)    		 6
    (3 to 54)
    adverse effects 48 hours 10
    (27.8%)    		 3
    (7.69%)    		 72%
    (7% to 92%)    		 20.1%
    (3.23% to 36.9%)    		 5
    (3 to 31)

    Comments

    1. The study was too small to show any difference in adverse effects or successful cardioversion between the two groups.

    Citation

    1. Joesph AP, and Ward MR: a prospective, randomized controlled trial comparing the efficacy and safety of sotalol, amiodarone and digoxin for the reversion of new-onset atrial fibrillation. Annals of Emergency Medicine 2000; 36 : 1-9
    Search Terms:
    Contributor: Chris Ball, November 2001
    Reviewer:

    Clinical Question.
    Patient acute atrial fibrillation
    Intervention or Exposure amiodarone, sotalol
    Comparison digoxin
    Outcome sinus rhythm, adverse effects