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Objective: To conduct a meta-analysis of randomised controlled trials to estimate the effectiveness of antiarrhythmic drugs at promoting sinus rhythm in patients with atrial fibrillation. Design: Articles were identified by using a comprehensive search of English language papers indexed in Medline from 1966 to August 2001. For the outcomes of sinus rhythm and death, a random effects model was used to model repeated assessments within a study at different time points. Setting: Emergency departments and ambulatory clinics. Patients: Patients with atrial fibrillation. Interventions: Antiarrhythmic agents grouped according to their Vaughan-Williams class. Main outcome measures: Sinus rhythm and mortality. Results: 91 articles met a priori criteria for inclusion in the analysis. Median duration of follow up was one day (range 0.04–1096, mean (SD) 46 (136) days). The median proportion of patients in sinus rhythm at follow up was 55% (range 0–100%) and 32% (range 0–90%) receiving active treatment and placebo, respectively. Median survival was 99% (range 55–100%) and 99% (range 55–100%). Compared with placebo, the following drug classes were associated with increased sinus rhythm at follow up: IA (treatment difference 21.5%, 95% confidence interval (CI) 16.3% to 26.8%); IC (treatment difference 33.1%, 95% CI 23.3% to 42.9%); and III (treatment difference 17.4%, 95% CI 11.5% to 23.3%). Class IC drugs were associated with increased sinus rhythm at follow up compared with class IV drugs (treatment difference 43.2%, 95% CI 11.5% to 75.0%). There was no significant difference in mortality between any drug classes. Conclusions: Class IA, IC, and III drugs are associated with increased sinus rhythm at follow up compared with placebo. It is unclear whether any antiarrhythmic drug class is associated with increased or decreased mortality.

Atriobiventricular pacing (cardiac resynchronisation) is a promising treatment for patients with advanced heart failure and conduction abnormality.1 These patients have severely impaired exercise tolerance and this has been shown to be multifactorial. The present study examined, in detail, the effect of cardiac resynchronisation on maximal and submaximal exercise capacity as evaluated by metabolic exercise testing. A consecutive series of patients from a single centre with cardiac resynchronisation therapy, able to perform baseline and follow up treadmill tests, were enrolled in the study. Inclusion criteria were New York Heart Association (NYHA) functional class III/IV heart failure on maximal medical treatment, left ventricular ejection fraction 60 mm, and QRS duration > 130 ms. Patients with chronic atrial fibrillation were excluded. The protocol was approved by the hospital research and ethics committee and all subjects gave written informed consent. Left ventricular (LV) stimulation was accomplished by a lead inserted into an LV branch of the coronary sinus. Specially designed leads were used (Medtronic 2187 or 2188, Medtronic Inc, Minneapolis, Minnesota, USA). Right atrial and ventricular leads were positioned in the right atrial appendage and right ventricular apex, respectively. All patients received cardiac resynchronisation devices (InSync, Medtronic Inc) with one atrial and two ventricular ports. Optimal atrioventricular delays were …