Procainamide versus synchronized cardioversion for hemodynamically stable pre-excited atrial fibrillation: a systematic review
DOI:
https://doi.org/10.65759/f8sm2m36Keywords:
Pre-excited atrial fibrillation, Wolff-Parkinson-White syndrome, procainamide, synchronized cardioversion, accessory pathwayAbstract
Background: Hemodynamically stable pre-excited atrial fibrillation represents an emergency rhythm in which rapid atrial impulses bypass the atrioventricular node through an accessory pathway. Objective: This systematic review compared intravenous procainamide with synchronized cardioversion for acute rhythm control in stable patients with pre-excited atrial fibrillation. Methods: PubMed/MEDLINE, Scopus, Web of Science Core Collection, and Cochrane CENTRAL were searched for cohort studies, and randomized trials relevant to Wolff-Parkinson-White syndrome, pre-excited atrial fibrillation, procainamide, accessory pathway conduction, and electrical cardioversion. Eligible evidence included adult or mixed-age populations with manifest pre-excitation, acute atrial fibrillation, or emergency department cardioversion data. Results: No randomized trial directly compared procainamide with synchronized cardioversion in hemodynamically stable pre-excited atrial fibrillation. Procainamide evidence consisted mainly of electrophysiology studies and small acute-treatment cohorts showing accessory pathway refractoriness, longer pre-excited RR intervals, and pharmacological conversion in selected patients. Cardioversion evidence consisted mainly of guideline recommendations, observational pre-excited atrial fibrillation cohorts, and acute atrial fibrillation trials outside the pre-excitation population. The overall certainty remained low for direct comparative effectiveness and moderate for the principle that accessory pathway blocking is central to pharmacological safety. Conclusion: Procainamide is the best-supported drug option for stable pre-excited atrial fibrillation, while synchronized cardioversion remains the most definitive immediate rhythm-control strategy when rapid conversion is prioritized or drug therapy is unsuitable.
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