Article, Cardiology

Management of patients with acute atrial fibrillation in the ED

Original Contribution

Management of patients with acute atrial fibrillation in the ED

Alberto Conti MD a,?, Beatrice Del Taglia MD a, Yuri Mariannini MD a,

Giuseppe Pepe MD b, Simone Vanni MD b, Stefano Grifoni MD b, Rosanna Abbate MD c,

Antonio Michelucci MD c, Luigi Padeletti MD c, Gian Franco Gensini MD c

aEmergency Medicine and chest pain unit, Careggi University Hospital, 50121 Florence, Italy

bEmergency Department, Careggi University Hospital, 50121 Florence, Italy

cHeart and Vessels Department, Careggi University Hospital, 50121 Florence, Italy

Received 2 April 2009; revised 28 April 2009; accepted 3 May 2009

Abstract

Background: Patients with acute atrial fibrillation with a history of mild structural heart disease could be considered for rhythm conversion.

Methods: Patients received intravenous flecainide, propafenone, or amiodarone on presentation and a second dose after 6 hours if atrial fibrillation persisted. No randomization was used, and drugs were given at the discretion of the treating physician. Primary end point was rhythm conversion within the first 6 hours from presentation. Secondary end points included rhythm conversion, time to rhythm conversion, and Adverse drug effects within 24 hours.

Results: Among the 378 patients enrolled, 37 (10%) recovered sinus rhythm before therapy was given. Of the remaining 341 patients, 43 (13%) received flecainide, 187 (55%) received propafenone, and 111 (32%) received amiodarone. Baseline clinical characteristics were homogeneous among groups. Rhythm conversion was obtained in 87% of treated patients overall. Within 6 hours, the primary end point was achieved in a higher proportion in the flecainide and propafenone groups (72% and 55%, respectively) as compared with the amiodarone group (30%; P b .001). The mean time to the end point overall was shorter in the flecainide and propafenone groups (178 +- 227 and 292 +- 285 minutes, respectively) as compared with the amiodarone group (472 +- 269 minutes; P b .001). Length of in-hospital stay in the amiodarone group was significantly higher (26.1 +- 22.4 hours) compared with the flecainide and propafenone groups (8.9 +- 10.3 and 11.0 +- 13.8 hours; respectively; P = .001). No significant differences were found in adverse drug effects.

Conclusions: Flecainide and propafenone achieve Rhythm control in a higher proportion of patients as compared with amiodarone within a 6-hour management.

(C) 2010

Introduction

* Corresponding author. Tel.: +39 338 7472294; +39 055 7947748.

E-mail address: [email protected] (A. Conti).

Atrial fibrillation is the most common cardiac dysrhythmia, affecting young and elderly patients, and represents a major therapeutic challenge for emergency physicians and clinical cardiologists. Moreover, AF has

0735-6757/$ – see front matter (C) 2010 doi:10.1016/j.ajem.2009.05.005

reached epidemic proportion worldwide and has became a Public health problem, both in North America and Europe, where it accounts for up to 2.3 and 4.5 million of patients, respectively [1-5].

The prevalence of this disorder increases with time, ageing of population, and structural heart disease [6,7], and it is approximately 1 in 4 for people older than 40 years [8]. Atrial fibrillation is a major cause of morbidity and mortality; it is associated with a 1.5 to 1.9 relative risk of mortality and a relative risk of up to 4.5 for ischemic stroke [9,10]. Moreover, AF may worsen the prognosis in heart failure and increase the risk of mortality in this setting [11-13].

In the Primary care setting, appropriate recognition and management of acute AF, which represents approximately one third of hospital admissions for cardiac dysrhythmia, are important in preventing adverse consequences and hospita- lizations [14,15]. The goals are hemodynamic stabilization, ventricular Rate control, and prevention of embolic complica- tions [15,16]. Major clinical trials concerning the long-term management of AF have demonstrated no differences between rate control and rhythm control strategies with respect to major clinical outcomes, including death [17], and at best, rhythm control has been shown to only relieve symptoms and modestly improve functional capacity [18]. However, in the setting of short-term management of acute AF, rapid rhythm control to promptly relieve symptoms, improve hemodynamic status, and shorten hospitalization should be considered the primary goal of management [19]. Early successful cardioversion indeed may also reduce the incidence of recurrent AF [20,21] and simplify the manage- ment as the disease progresses [15,22]. Thus, when AF does not terminate spontaneously, the ventricular rate should be treated to slow ventricular response, and if appropriate, efforts should be made to terminate AF and restore sinus rhythm [15,16]. Because of debate, current guidelines on the management of acute AF are based mainly on expert opinions, and there are wide variations in clinical practice [16,21,23,24].

Hypertensive, valvular, and ischemic disease and other types of structural heart disease underlie most cases of AF, and the presence of structural heart disease finally results in guiding treatment strategy; thus, rate control is often a valuable option in this setting [15]. Because of its high prevalence, hypertension may be the Underlying etiology of many cases of AF in the general population more than any other risk factor; hypertension is more likely associated with apparently normal or mild structural heart disease at the beginning of its clinical history, at the least. Thus, a large portion of patients with hypertension seem to be otherwise structurally and functionally normal as far as patients with “solitary AF.”

Patients with hypertension or solitary AF represent up to one third of cases in the general population presenting to the emergency department and could be considered for rhythm conversion leading to prompt improvement of symptoms and hemodynamics [20,25]. In addition, the same hemodynamic

pattern is shown by patients with mild valvulopathies and mild Respiratory insufficiency, too.

Therefore, the aim of this study was to compare the clinical safety and efficacy of intravenous (IV) flecainide, propafenone, or amiodarone for rhythm conversion and time to rhythm conversion in patients with hypertension or solitary AF or mild structural heart disease presenting with acute symptomatic AF.

Materials and methods

Study design and setting

This prospective, open-label cohort study involved enrolling patients presenting with AF to the emergency department of Careggi University Hospital in Florence, Italy (tertiary care teaching hospital). Facilities for triage of patients with suspected tachyarrhythmias include an emergency department observation unit with beds equipped with monitors and dedicated personnel (resident, faculty, and cardiologist on call). Data were collected prospectively on a prespecified electronic data sheet from June 2006 to June 2008.

Patient selection

Consecutive patients complaining of palpitations last- ing from less than 48 hours were considered, and those with AF were admitted to observation and enrolled in the study. Inclusion criteria were age 18 years or more, mean ventricular rate greater than 90 beats/min, and New York Heart Association functional class II or less, irrespective of history of hypertension, without clinically detectable complications. Final inclusion in the study population required electrocardiographic confirma- tion of AF.

Patients who fulfilled the following criteria obtained by history or physical examination or ECG or echocardiogram were excluded: permanent AF, persistent AF lasting more than 48 hours, history of paroxysmal or persistent AF, and evidence of coronary heart disease or congestive heart failure before or at the time of AF diagnosis (overt heart failure, history of myocardial infarction, and unstable angina pectoris); evidence of moderate to severe valvulo- pathies; present or past ECG evidence of ventricular preexcitation, complete bundle branch block, or sick sinus syndrome; presence of hypokalemia consisting of a potassium level less than 3.5 mEq/L, renal or hepatic insufficiency, severe metabolic disturbances, and thyroid dysfunction or thyrotoxicosis; and evidence of hemody- namic instability (eg, angina and hypotension). Also, patients with a history of World Health Organization class

III hypertension, moderate to severe respiratory insuffi- ciency, severe hypoxia consisting of arterial partial pressure

of oxygen of less than 60 mm Hg, or malignancy or otherwise a Life expectancy of less than 6 months were excluded from the study. All patients gave their written consent for study participation. The study was approved by the local institutional review board.

Definition of subtype of AF and comorbidities

Permanent or persistent vs paroxysmal AF was defined by whether there were recognizable intervening episodes of sinus rhythm [27]. Systemic hypertension was defined by history, that is, a physician’s diagnosis, needed considera- tion for Antihypertensive therapy, systolic blood pressure greater than 140 mm Hg, or diastolic blood pressure greater than 90 mm Hg on 2 or more occasions that were not associated with acute illness or injury. Coronary artery disease was defined by angiographic findings of lesions greater than 50% in any of the 3 main arterial distributions, effort angina, or history of myocardial infarction. Myocar- dial infarction was defined by at least 2 of the 3 diagnostic criteria: compatible clinical presentation, diagnostic cardiac enzymes, and consistent ECG changes. Clinically diag- nosed valvular heart disease was defined by history, the presence of moderate to severe murmur on physical examination, and echocardiogram. Echocardiogram-con- firmed valvular heart disease was defined by moderate to severe stenosis or regurgitation or prior valve repair/ replacement. Carotid artery disease referred to the presence of greater than 50% stenosis in the Carotid arteries by neurovascular imaging or prior intervention. Stroke was defined by the clinical documentation of the diagnosis with or without confirmatory findings on imaging studies. Diabetes mellitus was defined by physician’s diagnosis and treatment with insulin or oral hypoglycemic agents. Hyperlipemia was defined by a total cholesterol level greater than 200 mg/dL, triglyceride level greater than 150 mg/dL, low-density lipoprotein cholesterol level greater than 130 mg/dL, or high-density lipoprotein cholesterol level less than 40 mg/dL on 2 or more occasions or treatment with lipid-lowering agents. smoking history was considered both as past (N6 months prior) or current smoker. Regular alcohol use was defined by self-reported consumption of more than 1 drink per day regularly. Excessive alcohol consumption was considered as a risk factor for the development of AF. Chronic obstructive pulmonary disease was defined by documented clinical diagnoses [26]. Solitary AF or lone AF was defined by AF in the absence of overt cardiovascular disease or precipitat- ing illness [15,25].

Management of patients and study protocol

All patients underwent evaluation with medical history, physical examination, blood-gas analysis, and chest x-ray. Serial 12-lead ECGs were recorded at presentation and as

required by the clinical status. Two serum levels of troponin I were assessed. Abnormal values of troponin I were set by our laboratory as greater than 0.15 ng/mL. Moreover, the presence of Arterial hypertension, diabetes mellitus, hypercholesterolemia, smoking, and familial history of coronary artery disease or diabetes mellitus was evaluated.

As soon as possible, within the first-line 6-hour period, patients received IV bolus (a few minutes) flecainide (2 mg/kg), propafenone (2 mg/kg), or amiodarone (5 mg/kg). No randomization was used, and drugs were given at the discretion of the treating physician. Patients who did not recover sinus rhythm were submitted, after 6 hours, to a second dose. Indeed, within the second period up to 24 hours, patients received a second IV bolus plus oral administration of the same drug previously given (flecai- nide, 2 mg/kg plus 100 mg twice a day; propafenone, 2 mg/kg plus 150 mg three times a day; or amiodarone, 5 mg/kg plus 200 mg thrice a day). After the drug was administered, cardiac rhythm was continuously monitored, as required. Echocardiography was performed in all patients during the second-line approach at the least. In each case, a 12-lead ECG was recorded at admission, before and after therapy was given, and again after sinus rhythm conversion. Patients who failed to recover sinus rhythm within 24 hours were submitted to electrical cardioversion (DC shock).

Endpoint

Primary end point was represented by rhythm conversion within the first-line 6-hour approach. Secondary end points included rhythm conversion within the second-line approach up to 24 hours from presentation to the emergency department, time to rhythm conversion, and adverse effects including bradycardia (heart rate b50 beats/min associated with hypotension), hypotension (systolic arterial pressure b90 mm Hg), onset of congestive heart failure, and evidence of myocardial ischemia.

Statistical analysis

Summary data are expressed as mean +- SD. Statistical comparisons of demographic and clinical features among the 3 groups were performed using ?2 test, Fisher exact test, t test, and analysis of variance F test as appropriate. Fisher exact test was used when expected frequencies are less than 5. P values are 2 sided, and a P value of less than .05 was considered to indicate statistical signifi- cance. Kaplan-Meier survival analysis with the log-rank test was used to assess the time to the primary end point among the 3 groups. A P value b .05 was considered statistically significant. Calculations were performed with use of version 14, SPSS statistical package (SPSS Inc, Chicago, IL).

Results

From June 2006 to June 2008, 2019 patients presenting with AF to the emergency department (2.4% of total visits per year) were considered.

Of these, 1641 were excluded from the study because of evidence of comorbidities as follows: coronary heart disease (n = 407), congestive heart failure (n = 115), evidence of moderate to severe valvulopathies (n = 161), thyroid dysfunction or thyrotoxicosis (n = 166), hemodynamic instability (n = 63), moderate to severe respiratory insuffi- ciency (n = 80), life expectancy less than 6 months (n = 69), submitted to cardiac surgery or pacing (n = 115), or younger than 18 years (n = 29).

Of the remaining 814 patients, 436 (53.6%) were excluded because of AF lasting more than 48 hours. Thus, the study population consisted of 378 patients with AF lasting 48 hours or less.

Among the 378 patients enrolled, 37 (9.8%) recovered sinus rhythm before therapy was given. Of the remaining 341 patients, 43 (12.6%) were treated with flecainide, 187

(54.8%) were treated with propafenone, and 111 (32.6%) were treated with amiodarone.

The baseline clinical characteristics of the patients enrolled in the study are reported in Table 1. Hypertension accounts for at least 50% of enrolled patients, and solitary AF accounts for 40%. Overall, 10% of patients had mild valvulopathies or mild respiratory insufficiency. Pharma- cological treatments did not differ in the 3 groups because no statistical differences existed among them in mean age, sex, heart rate, smoking status, and the presence of diabetes mellitus, hypertension, hyperlipidemia, mild structural heart disease, and solitary AF. No patient in our series demonstrated excessive alcohol consumption.

Overall results

Rhythm conversion was obtained in 296 (86.8%) treated patients overall within the 24-hour management, without significant differences among groups (Fig. 1). The mean time to the end point overall was shorter in the flecainide and

Table 1 Baseline clinical characteristics of patients enrolled in the study by treatment with flecainide, propafenone, or amiodarone (n = 378)

Fig. 1 Time course to sinus rhythm by treatment within the 24- hour management (n = 341).

propafenone groups (178 +- 227 and 292 +- 285 minutes, respectively) as compared with the amiodarone group (472 +- 269 minutes; P b .001; Table 2).

Primary end point

Rhythm conversion within the first-line 6-hour approach was achieved in a higher proportion in the flecainide and propafenone groups (72.1% and 54.5%, respectively) as compared with the amiodarone group (29.7%; P b .001; Fig. 2 and Table 2), and the mean time was shorter in the flecainide and propafenone groups (73 +- 104 and 113 +- 105 minutes, respectively) as compared with the amiodarone group (224 +- 119 minutes; P b .001; Fig. 2 and Table 2).

Secondary end points

Conversely, within the second-line approach up to 24 hours, 20.9% and 31.6% of patients treated with flecainide and propafenone, respectively, achieved rhythm conversion compared with those treated with amiodarone (56.8%; P b

Total (n = 378)

Amiodarone (n = 111)

Propafenone (n = 187)

Flecainide (n = 43)

P

Age (y)

67.1 +- 13.5

68.8 +- 11.9

67.1 +- 13.8

63.2 +- 15.8

.066

Sex (male)

199 (52.6)

56 (50.4)

99 (52.9)

24 (55.8)

.831

Diabetes

48 (12.7)

16 (14.4)

23 (12.3)

5 (11.6)

.849

Hypertension

186 (49.2)

55 (49.5)

96 (51.3)

14 (32.6)

.084

Hyperlipemia

33 (8.7)

9 (8.1)

18 (9.6)

2 (4.7)

.677

Smokers

24 (6.3)

8 (7.2)

9 (4.8)

4 (9.3)

.401

No risk factors

146 (38.6)

44 (39.6)

68 (36.4)

23 (53.5)

.121

Heart rate (beats/min)

122 +- 26

124 +- 25

124 +- 24

118 +- 32

.512

Data are presented as mean +- SD or no. (%), where appropriate.

Flecainide (n = 43)

Propafenone (n = 187)

Amiodarone (n = 111)

P

First-line approach

Sinus rhythm

31 (72.1)

102 (54.15)

33 (29.7)

b.001

Time to sinus rhythm (min)

73 +- 104

113 +- 105

224 +- 119

b.001

Length of in-hospital stay (h)

3.5 +- 1.8

3.8 +- 2.6

5.4 +- 6.5

.376

Overall results

Sinus rhythm

40 (93.0)

161 (86.1)

96 (86.5)

.533

Time to sinus rhythm (min)

178 +- 227

292 +- 285

472 +- 269

b.001

Length of in-hospital stay (h)

8.9 +- 10.3

11.0 +- 13.8

26.1 +- 22.4

.001

treatment failure

Sinus rhythm by DC shock

3 (7.0)

23 (12.3)

15 (13.5)

.577

Permanent AF

0

3 (1.6)

0

.531

Data are presented as mean +- SD or no. (%), where appropriate.

.01). Rhythm conversion was obtained within 538 +- 144 and 602 +- 224 minutes by flecainide and propafenone, respectively, as compared with amiodarone (602 +- 232 minutes).

Table 2 Sinus rhythm, time course to sinus rhythm, and length of in-hospital stay by treatment with flecainide, propafenone, or amiodarone (n = 341)

Electrical cardioversion

A total of 44 patients were submitted to DC shock, and 41 (12.9%) patients recovered sinus rhythm, whereas 3 (0.9%) patients were discharged with AF.

Adverse drug effects

Adverse effects occurred in 6 patients after drug infusion, but no significant differences were found among groups by treatment with flecainide, propafenone, or amiodarone (P = 0.168; Table 3).

In particular, 1 patient in each group of treatment demonstrated a minor adverse effect consisting of hypoten-

Fig. 2 Time course to sinus rhythm by treatment within the first- line 6-hour approach (n = 341).

sion requiring bed resting. Substantial serious adverse effects were shown by 1 patient who received propafenone and 1 patient who received flecainide because they demonstrated symptomatic hypotension and widened QRS requiring bed resting. Moreover, in our series, 1 patient treated with propafenone demonstrated prodysrhythmic effect consisting of tachycardia with widened QRS requiring DC shock. There was no evidence of Acute congestive heart failure or acute coronary syndromes in all the 3 treatment groups during observation.

Hospital stay

The mean length of in-hospital stay by treatment is shown in Table 2. There was a significantly shorter hospital stay in the flecainide and propafenone group (8.9 +- 10.3 and 11.0 +- 13.8 hours, respectively) as compared with the amiodarone group (26.1 +- 22.4 hours; P = .001) within the entire management.

Discussion

The present study shows that 87% of patients with acute symptomatic uncomplicated AF managed in the emergency department by a pharmacological treatment strategy with flecainide, propafenone, or amiodarone achieved sinus rhythm during the 24-hour management from presentation. Within the first-line 6-hour approach, patients treated with

IV flecainide or propafenone more likely achieve sinus rhythm (72% and 55%, respectively) than were patients treated with amiodarone (30%; P b .001). The mean time to the end point overall was shorter in the flecainide and propafenone groups as compared with the amiodarone group (P b .001).

Present data suggest that time-related action of the different drugs is the most important variable; as a consequence, the time to sinus conversion was almost 2- to 3-fold longer for amiodarone as compared with propafenone

Total (n = 341) Flecainide (n = 43) Propafenone (n = 187) Amiodarone (n = 111) P

Adverse drug effects

6 (1.8%)

2

(4.7%)

3 (1.6%)

1

(0.9%)

.168

Hypotension

3

1

1

1

Widened QRS and hypotension

2

1

1

0

Widened QRS and tachycardia

1

0

1

0

and flecainide, respectively, in the first-line approach and overall. Thus, treatment with flecainide and propafenone involved shorter in-hospital stay (P = .001). Very few patients experienced serious adverse drug effects without major Cardiovascular complications.

Table 3 Adverse drug effects in patients enrolled in the study by treatment with flecainide, propafenone, or amiodarone (n = 341)

In the present study, we investigated the pharmacological treatment of patients with AF in clinical practice, including patients with mild structural heart disease as far as with solitary AF, and we demonstrated that these 2 subsets of patients could be considered for safe pharmacological treatment without further investigation. The present strategy could represent an attractive option in the emergency medicine of public Health care delivery settings.

The strengths of our study are the following:

One-half of patients submitted to acute pharmaco- logical cardioversion achieved sinus rhythm within the first 6 hours, economizing on time management and hospital admission.

One-half of patients presented with history of

hypertension.

This study evaluates the safety and efficacy of acute pharmacological sinus conversion of AF in patients with mild structural heart disease, as in patients with hypertension, mild valvulopathies or mild respiratory insufficiency, without known coronary artery disease and history and overt hemodynamic instability.

Previous studies suggest that physicians should use medical cardioversion only after careful consideration of the possibility of adverse effects as prodysrhythmic compli- cations or negative inotropic action, particularly in patients with structural heart disease or congestive heart failure [15,27]. However, in patients with AF, acute restoration of sinus rhythm could improve symptoms, prevent atrial stunning and electrical remodelling associated with the persistent dysrhythmia, reduce risk of thromboembolism, and remove the need for indefinite anticoagulation [15]. The adverse hemodynamic effects of AF, indeed, stem not only from the loss of atrial contraction but also from impaired exercise tolerance that lower quality of life and the induction of tachycardia cardiomyopathy [28-31]. In addition, phar- macological cardioversion may be appropriate when patients have never been in AF before and, in this setting, reduces the incidence of recurrent AF [21]. Current treatment options for restoring sinus rhythm span from electrical to IV or oral pharmacological cardioversion. The success rate for elec- trical cardioversion of acute AF is high (90%), but proper

equipment and expertise are necessary for safe performance [21], and in clinical practice, strong indication to electrical cardioversion is to be considered only in patients with effective hemodynamic instability [15]. Accordingly, phar- macological cardioversion should be considered a reasonable approach and an attractive option in heterogeneous condi- tion, including patients with mild structural heart disease detectable at presentation.

The overall high percentage of pharmacological cardio- version within the first 6 hours with class IC antidysrhyth- mic drugs in our series compared favorably with studies previously reported on pharmacological treatment of acute solitary AF [32,33]. In fact, recent studies show that the overall efficacy of class IC antidysrhythmic drugs was very high (72%-95%) in patients who received treatment within

24 hours of dysrhythmia onset [32,33]. However, other studies report a very low overall positive cardioversion rate, substantially with use of other drugs [21]. A randomized comparison showed a significant difference in efficacy among IV flecainide, propafenone, and amiodarone, with 90%, 72%, and 64% of patients, respectively, reverting to sinus rhythm within 12 hours of drug administration [34]. Furthermore, sinus rhythm may be restored also by loading oral propafenone or not loading oral propafenone or flecainide as well, but its use is to be restricted to previously hospitalized patients [35,36]. Amiodarone seems to be the most effective drug for restoration of sinus rhythm in persistent AF lasting more than 2 days, with reported success from 44% up to 68% [37]; however its use, considered a first-choice treatment for AF in some countries, can cause serious noncardiac complications [38]. Digoxin and calcium antagonists are reported to a have mild effect on the rate of conversion of AF of recent onset to sinus rhythm or on the prevention of its recurrence [39]. However, IV ?– blockers and calcium antagonists can effectively control ventricular rate in patients presenting with AF, but the cardioversion is low; moreover, ?-blockers need close hemodynamic monitoring because of the risk of hypotension and bradycardia [15,33,40,41].

Nonetheless, patients with AF have the same underlying clinical history related to age, underlying cardiac disease, and symptoms, and treatment of AF must be individualized with IV drugs or with the wait-and-see approach, in the hopes that the AF may convert to sinus rhythm on its own or with the pill-in-the-pocket approach [36]. However, for symptomatic patients, restoration of sinus rhythm remains the first-choice therapy. Whether these will improve prognosis remains speculative at present.

Limitations of the study

The weaknesses of our study are represented by the open-label design and a relatively small sample size, although the sample is representative of a large series of patients. In fact, no randomization was used, and drugs for rhythm conversion were given at the discretion of the treating physician. Finally, the 3 groups of enrolled patients, although homogeneous in baseline clinical characteristics, varied concerning the number of patients enrolled. More- over, patients admitted with moderate structural heart disease or complicated acute AF were excluded; therefore, the findings of this study are not applicable to all patients with AF.

Conclusions

Rhythm conversion in patients with acute AF, including patients with hypertension, solitary AF, and mild valvulo- pathies or mild respiratory insufficiency, treated with flecainide, propafenone, or amiodarone is safe and effective. Almost 90% of patients achieved sinus rhythm within the 24-hour management. The mean time to the end point overall was shorter in the flecainide and propafenone groups as compared with the amiodarone group. Moreover, within the first 6 hours, patients were more likely achieve sinus rhythm when treated with IV flecainide or propafenone than with amiodarone.

Summary

Patients presenting to the emergency department with acute AF and history of mild structural heart disease could be considered for rhythm conversion.

The present study compares the safety and efficacy of IV flecainide, propafenone, or amiodarone.

Rhythm conversion was achieved in 87% of treated patients overall. Within the first 6 hours, sinus rhythm was achieved in a higher proportion of patients in the flecainide and propafenone groups as compared with the amiodarone group. The mean time to sinus rhythm was shorter in the flecainide and propafenone groups as compared with the amiodarone group. Length of in-hospital stay in the amiodarone group was significantly higher as compared with the flecainide and propafenone groups.

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