Off label and unlicensed drugs use in paediatric cardiology

OBJECTIVES

The use of drugs in an off label or unlicensed manner to treat children is a widespread phenomenon in Europe and the United States. The incidence of unlicensed and off label prescribing in paediatric cardiology practice has not been studied to date. This study was designed to assess the extent and nature of off label and unlicensed drug use in paediatric cardiology inpatients.

METHODS

In a prospective study, drug prescriptions in a paediatric cardiology ward were reviewed during a 2-year period. Data were collected and analyzed by special software created for this purpose.

RESULTS

The children (n = 544) studied varied in age from 4 h to 18 years. One or more off label and unlicensed prescriptions were given to 414 (76%) patients. Of the 2,130 prescriptions given during the 2-year period, more than one-half were unlicensed (11%) or off label (47%). While children aged 2-11 years received most of the unlicensed drug prescriptions (17%), neonates, who did not receive unlicensed drugs, led (64%) in the use of off label drugs. CONCLUSIONS. This study showed that the problem of off label and unlicensed drug use also exists in paediatric cardiology. The findings imply that the phenomenon of off label and unlicensed use of drugs in children can be correlated with the deficiency of paediatric drug formulations on the global market and insufficient data from clinical studies which must be performed to confirm the efficacy and safety of drugs in the paediatric population. Therefore, efforts to improve paediatric labelling are important and need the full support of all involved.

Amyloid heart disease mimicking hypertrophic cardiomyopathy

OBJECTIVE

To investigate the importance of transthyretin (TTR) gene mutations in explaining the phenotypic expression in patients diagnosed with hypertrophic cardiomyopathy (HCM) in northern Sweden.

BACKGROUND

Hypertrophic cardiomyopathy is relatively common and often caused by mutations in sarcomeric protein genes. Mutations in the TTR gene are also common, one of which causes familial amyloid polyneuropathy (FAP), with peripheral polyneuropathy and frequently, cardiac hypertrophy. These circumstances were highlighted by the finding of an index case with amyloidosis, presenting itself as HCM. Initial rectal and fat biopsies did not show amyloid deposits. Later on, the patient was shown to carry a TTR gene mutation, and cardiac amyloidosis was confirmed by myocardial biopsy. Only then was a repeated fat biopsy positive for amyloid deposits.

DESIGN

Cross-sectional study.

SETTING

Cardiology tertiary referral centre.

SUBJECTS

Forty-six unrelated individuals with HCM and the index case were included. Common diagnostic criteria for HCM were used. The 46 patients with HCM were previously analysed for mutations in eight sarcomeric protein genes and the TTR gene was now analysed by denaturing high-performance liquid chromatography and direct sequencing.

RESULTS

One mutation in the TTR gene (Val30Met) was found in three individuals and the index case.

CONCLUSIONS

Three of the 46 cases with HCM carried the Val30Met mutation, and were considered likely to have cardiac amyloidosis, like the index case. As a correct diagnosis of cardiac amyloidosis is mandatory for a potentially life-saving treatment, TTR mutation analysis should be considered in cases of HCM not explained by mutations in sarcomeric protein genes.

Improving patient care through patient-family education programs

The author's purpose of this study was to investigate patients' beliefs about the effectiveness of a patient education program. The authors interviewed general medicine and cardiac patients and their families at a large teaching hospital. They asked participants to describe the kind of information the hospital provided about patients' illnesses, pain management, and self-care following discharge and asked participants if they were satisfied with the information provided. The findings revealed that cardiac patients had greater access to information about their illnesses than general medicine patients. Overall, patients received verbal communication from doctors and nurses about their condition. All of the patients relied on pharmacological interventions for managing their pain and were unclear about how to manage their care following discharge. The authors describe recommendations for developing a written patient education curriculum, including information that addresses pain management options and discharge protocols.

[Smoking cessation among patients with acute heart disease. A randomised intervention project]

INTRODUCTION

Our goal was to investigate whether ambulatory smoking cessation among patients in a cardiologic department would (1) reduce the number of smokers by at least 25% after 12 months compared to a control group and (2) influence whether the individual patient was readmitted to hospital. We used a randomised, controlled, prospective intervention project design.

MATERIALS AND METHODS

Everyone hospitalised during the project period was screened. Those who fulfilled the criteria for inclusion were randomised for inclusion in either the intervention group or the control group. Both groups were given the department's smoking cessation information. In addition, the intervention group attended five ambulatory smoking cessation intervention sessions. Each patient's smoking status was registered after 12 months. chi2-test and logistic regression analysis were used to test differences, associations and control of confounders.

RESULTS

In all, 3,982 patients were screened, 29.5% of whom were smokers. The study included 105 patients: 54 in the intervention group and 51 in the control group. After 12 months, 52% of those in the intervention group compared to 39% in the control group had become non-smokers, which was non-significant (p = 0,14). Ischemic heart disease (IHS) was significantly associated with smoking cessation. After adjustment for this confounder, the result was enhanced (p = 0,06). Readmission to hospital was not affected by smoking cessation (p = 0,73).

DISCUSSION

Ambulatory smoking cessation intervention had no significant effect on smoking cessation on an unselected group of patients in a cardiologic hospital department. The project does indicate that ambulatory smoking cessation interventions could have an effect on patients with IHS.

Medication performance measures and mortality following acute coronary syndromes

PURPOSE

To identify patient and health care factors which are related to the use of medical treatments that comprise quality measures and to assess the relation of these measures with mortality.

METHODS

The study sample consisted of 20 140 patients with acute coronary syndromes from the international GRACE registry. Multivariable logistic regression modeling was used to determine predictors of quality performance. Quality indicators were use of aspirin and beta-blockers within 24 hours and at hospital discharge, use of angiotensin-converting enzyme (ACE) inhibitors at discharge, and in-hospital mortality.

RESULTS

Use of medications in eligible patients at discharge ranged from 73% for ACE inhibitors to 93% for aspirin. High-risk features (eg, heart failure, older age) were related to failure to use aspirin and beta-blockers. Being at a teaching hospital and care by a cardiologist were associated with better use of aspirin and beta-blockers. Coronary artery bypass surgery was associated with failure to use ACE inhibitors and aspirin. When hospitals were divided into quartiles of quality performance, adjusted in-hospital mortality was 4.1% in the top versus 5.6% in the bottom quartile, representing a 27% (95% confidence interval: 11% to 42%) lower relative mortality.

CONCLUSION

Identification of factors associated with failure to use proven treatments, including high-risk groups that would derive particular benefit from effective therapies, provides an opportunity to focus quality improvement interventions. The association of lower hospital mortality with better use of selected medical treatments supports their measurement to improve quality of care.

Cardiac revascularization in specialty and general hospitals

BACKGROUND

The emergence of specialty hospitals focusing on narrow procedural areas has generated controversy, although little is known about their quality.

METHODS

We conducted a retrospective cohort study of 42,737 Medicare beneficiaries who underwent percutaneous coronary intervention (PCI) and 26,274 who underwent coronary-artery bypass grafting (CABG) during 2000 and 2001 in specialty cardiac hospitals (15 for PCI and 15 for CABG) and general hospitals (82 for PCI and 75 for CABG) in the same markets. Administrative data were used to compare patients' characteristics, hospital procedural volumes, and patient outcomes.

RESULTS

Patients undergoing PCI or CABG in specialty hospitals were less likely to have coexisting conditions than those being treated at general hospitals and were less likely to have had an acute myocardial infarction (P<0.001). The better health of the patients at specialty hospitals than of those at general hospitals was reflected by the lower mean predicted risk of death (2.1 percent vs. 3.1 percent for PCI and 5.0 percent vs. 5.8 percent for CABG; P<0.001 for each comparison). Mean volumes of PCI and CABG procedures in 2000 and 2001 were higher in specialty hospitals than in general hospitals (799 vs. 375 PCI procedures, P<0.001; and 571 vs. 236 CABG procedures, P<0.001). The unadjusted rate of death during the index hospitalization or within 30 days after admission was lower in specialty hospitals than in general hospitals (2.1 percent vs. 3.2 percent for PCI and 4.7 percent vs. 6.0 percent for CABG; P<0.001 for both comparisons). In multivariate analyses adjusted for patients' characteristics, the odds ratio for death after PCI in specialty hospitals and general hospitals was similar (0.89; 95 percent confidence interval, 0.69 to 1.15; P=0.39), but the odds ratio for death after CABG was lower in specialty hospitals than in general hospitals (0.84; 95 percent confidence interval, 0.72 to 0.99; P=0.05). In stratified analyses comparing specialty and general hospitals with similar volumes, differences in mortality were not significant.

CONCLUSIONS

The lower unadjusted mortality rate after cardiac revascularization in specialty cardiac hospitals is accounted for by their healthier patients and higher procedural volumes.

Effect of an Ongoing Educational Program on the Use of Antiplatelet Drugs, β-Blockers, Angiotensin-Converting Enzyme Inhibitors, and Lipid-Lowering Drugs in Patients With Coronary Artery Disease Seen in an Academic Cardiology Clinic

The effect of an ongoing educational program on the use of cardiovascular drugs in patients with coronary artery disease without contraindications to these drugs seen in an academic cardiology clinic was assessed in 100 patients seen during the 6-month period prior to the educational program and in 200 patients seen 9 to 20 months after the onset of the educational program. Following the educational program, the use of aspirin, clopidogrel, or warfarin increased from 69 to 99%, the use of beta- blockers increased from 57 to 98%, the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers increased from 41 to 97%, and the use of lipid-lowering drugs in patients with dyslipidemia increased from 54 to 98% in patients without contraindications to these drugs.

Spectrum and prognostic significance of arrhythmias on ambulatory Holter electrocardiogram in hypertrophic cardiomyopathy

OBJECTIVES

The goal of this study was to assemble a profile and assess the significance of arrhythmias in a nontertiary-based hypertrophic cardiomyopathy (HCM) cohort.

BACKGROUND

Hypertrophic cardiomyopathy is associated with arrhythmia-related consequences, particularly sudden death. Ventricular tachyarrhythmias on Holter electrocardiograms (ECG) have been reported as markers for sudden death in highly selected HCM populations.

METHODS

We assessed the profile of ventricular and supraventricular ectopy and bradyarrhythmia on ambulatory 24-h Holter ECG and also related these findings to clinical outcome in 178 HCM patients.

RESULTS

Of the 178 study patients, 157 (88%) had premature ventricular complexes (PVCs), including 21 (12%) with >/=500 PVCs, 74 (42%) had couplets, 67 (37%) had supraventricular tachycardia (SVT), and 56 (31%) had nonsustained ventricular tachycardia (NSVT). Mean number of PVCs was 330 +/- 763 (range 1 to 5,435) and increased with age (p < 0.01); NSVT was associated with greater left ventricular hypertrophy (p = 0.01) and severe symptoms (New York Heart Association functional classes III and IV) (p = 0.04); SVT occurred more commonly in patients with outflow obstruction (p = 0.02). Over a follow-up of 5.5 +/- 3.4 years, 11 (6%) patients died suddenly (annual mortality rate, 1.1%) including 5 patients with NSVT. For sudden death, NSVT on Holter ECG had negative and positive predictive values of 95% and 9%, and sensitivity and specificity of 45% and 69%, respectively.

CONCLUSIONS

In this nontertiary-based HCM cohort, ventricular and supraventricular tachyarrhythmias were particularly frequent and demonstrated a broad spectrum on ambulatory (Holter) ECG. Paradoxically, despite such a highly arrhythmogenic substrate, sudden death events proved to be relatively uncommon. Ventricular tachyarrhythmias had a low positive and relatively high negative predictive value for sudden death in this HCM population.

The association between clinical integration of care and transfer of veterans with acute coronary syndromes from primary care VHA hospitals

Background

Few studies report on the effect of organizational factors facilitating transfer between primary and tertiary care hospitals either within an integrated health care system or outside it. In this paper, we report on the relationship between degree of clinical integration of cardiology services and transfer rates of acute coronary syndrome (ACS) patients from primary to tertiary hospitals within and outside the Veterans Health Administration (VHA) system.

Methods

Prospective cohort study. Transfer rates were obtained for all patients with ACS diagnoses admitted to 12 primary VHA hospitals between 1998 and 1999. Binary variables measuring clinical integration were constructed for each primary VHA hospital reflecting: presence of on-site VHA cardiologist; referral coordinator at the associated tertiary VHA hospital; and/or referral coordinator at the primary VHA hospital. We assessed the association between the integration variables and overall transfer from primary to tertiary hospitals, using random effects logistic regression, controlling for clustering at two levels and adjusting for patient characteristics.

Results

Three of twelve hospitals had a VHA cardiologist on site, six had a referral coordinator at the tertiary VHA hospital, and four had a referral coordinator at the primary hospital. Presence of a VHA staff cardiologist on site and a referral coordinator at the tertiary VHA hospital decreased the likelihood of any transfer (OR 0.45, 95% CI 0.27–0.77, and 0.46, p = 0.002, CI 0.27–0.78). Conversely, having a referral coordinator at the primary VHA hospital increased the likelihood of transfer (OR 6.28, CI 2.92–13.48).

Conclusions

Elements of clinical integration are associated with transfer, an important process in the care of ACS patients. In promoting optimal patient care, clinical integration factors should be considered in addition to patient characteristics.

Shelf-price agreements: the next frontier in competitive bidding for coronary intervention supplies

In an attempt to further reduce operating costs, in 2004 our institution embarked on a novel approach in which we defined the price to be paid for interventional cardiology supplies and challenged vendors to meet that price. The results suggest that this strategy can further reduce supply costs while maintaining collaborative relationships with vendors.

The challenges of implementing a cardiovascular information system

The past decade has seen the expansion of the cardiac catheterization laboratory's hemodynamic monitoring system from an instrument for capturing essential physiologic information to the hub of an integrated cardiovascular information system. This evolution has increased the complexity of equipment replacement and necessitates a structured, coordinated effort across multiple hospital departments. This article describes the experience of AnMed Health Medical Center (Anderson, SC) in acquiring and implementing its cardiovascular information system and how proactive planning helped minimize the investment risk.

Clinical multichannel MCG in unshielded hospital environment

From November 5th, 2001 to May 19th, 2004, 545 patients (177 with arrhythmias, 67 with WPW syndrome, 60 with Ischemic Heart Disease (IHD), 129 with different kinds of cardiomyopathy, 106 normals, 6 FMCG) have been consecutively investigated at the Catholic University of Rome, with unshielded Multichannel Magnetocardiographic Mapping (MMCG): 20 with the 9-channel system only and 525 with the 36-channel system (207 of them with both systems). 107 patients were investigated also after physical stress, carried out with a standard bicycle ergometer. In all patients MMCG was recorded at least three times, to check for reproducibility and/or for clinical follow-up, for a total of more than 1600 recordings.

METHOD

MMCG was performed, with both the 9-channel and the 36-channel systems, at 1 kHz in the bandwidth DC-100 Hz. In the last 200 pts, 12-lead ECG was simultaneously recorded with amagnetic electrodes. On each patient file, post-processing and signal analysis for the quantitative assessment of ventricular repolarization and for 3D localization and electroanatomical imaging of cardiac arrhythmias, were carried out independently with two different approaches and software programs developed by CMI and by Neuromag (Finland).

RESULTS

The results with the two methods have been compared. For 3D electroanatomical integration of MMCG localization results, 3D cardiac models have been used, constructed from patient MRI and/or from orthogonal fluoroscopic images taken at the moment of MCG recording.

CONCLUSIONS

Qualitative reproducibility of MMCG was satisfactory. However the estimate of quantitative parameters has shown a certain degree of variability, which deserves further evaluation.

Safety of elective--including "high risk"--percutaneous coronary interventions without on-site cardiac surgery

BACKGROUND

Current guidelines (American College of Cardiology/American Heart Association) for percutaneous coronary intervention (PCI) limit the performance of elective cases to hospitals with the capability for cardiac surgery. The number of hospitals in the United States with this capability is limited, which restricts availability of this proven technology.

OBJECTIVE

To determine the safety of performing elective, nonselected PCI in hospitals without cardiac surgery capability.

DESIGN, SETTING, AND PATIENTS

A single-center retrospective analysis of the first 1000 patients undergoing elective, including "high-risk," PCI in the county hospital in Phoenix, Arizona.

MAIN OUTCOME MEASURES

A database (Access Microsoft Windows) was established to follow patient characteristics, indications for the procedure, technical aspects of the procedure, outcomes and complications. The Quality Improvement Committee followed each case closely to independently assess the adequacy of indications and patient management, with a monthly case review of every patient who had a periprocedural or postprocedural complication.

RESULTS

Failure to complete target vessel revascularization occurred in 68 of the total 1756 vessels (3.8%). Seven patients (0.7%), required elective referral for coronary artery bypass graft surgery after failed PCI. Coronary perforations occurred in 9 patients (0.9%); all resolved with percutaneous techniques. Postprocedure myocardial infarction was diagnosed in 21 patients (2.1%). Two patients (0.2%) developed a stroke. Periprocedural death (within 48 hours of the procedure) occurred in 2 patients (0.2%). Out of the 1000 interventions performed, none required emergency coronary artery bypass graft surgery.

CONCLUSIONS

Technical advances in interventional cardiology allow for safe performance of PCI in hospitals without on-site cardiac surgery facilities if proposed conditions are met. Our results together with the vast experience in other countries supports a paradigm change that would increase the number of hospitals that can offer interventional cardiology procedures with a corresponding increase in the number of patients that would benefit.

[Prognostic value of high-density lipoproteins in the cardiology unit]

BACKGROUND

Clinical and epidemiological studies have shown an inverse and independent association between high-density lipoproteins (HDL) and risk of developing coronary artery disease. The aim of this study was to estimate the prevalence of the phenotype characterized by low HDL values and to assess the impact of HDL plasma levels on the prognosis of patients hospitalized in the cardiologic unit of our Institute, during 30 months of follow-up.

METHODS

Between February 1999 and February 2002, 1169 patients (778 men and 391 women) who had undergone hospitalization, were enrolled in a cardiovascular registry. The lipid profile was evaluated for all patients; a subgroup (n = 626) underwent coronary angiography. Patients were followed up for a mean period of 30 months, during which the frequency of revascularization procedures (coronary angioplasty or bypass), myocardial infarction and death were recorded.

RESULTS

Nearly half of the subjects (45%, of which 77% men) showed HDL values < 40 mg/dl, and 25% of the population (80% men) were characterized by extremely reduced HDL concentrations (< or = 35 mg/dl). Patients with coronary atherosclerosis showed HDL levels lower than those of subjects with negative angiography (41.0 +/- 10.8 vs 46.6 +/- 10.9 mg/dl, p < 0.0005). An inverse relationship was found between HDL and coronary artery disease: the risk of developing the illness decreased by 4% for each increase of 1 mg/dl in HDL (p < 0.005); in males < 60 years and females < 65 years, the coronary artery disease risk association increased by 3% (p < 0.005). The risk of interventions decreased by 2% for each increase of 1 mg/dl in HDL (p < 0.01), both in the total population and in males < 60 years and females < 65 years. Finally, patients with HDL < 40 mg/dl showed a higher risk of revascularization interventions (+25%, p < 0.01) in comparison to the subjects with HDL > 40 mg/dl.

CONCLUSIONS

This study demonstrates: a) the high prevalence of the phenotype characterized by low plasma concentrations of HDL among patients hospitalized in a cardiologic unit; b) lower HDL values in subjects with coronary atherosclerosis compared to subjects with normal coronary angiography; c) the inverse relationship between HDL and coronary atherosclerosis; d) the prognostic value of HDL as a predictor of surgical revascularization.

Usefulness of spironolactone in a specialized heart failure clinic

Several case series published after the Randomized Aldactone Evaluation Study (RALES) have focused on the adverse effects of spironolactone when prescribed to participants not in a trial and the appropriateness of these prescribing practices; however, there is a paucity of data on potential benefits in patients not in a trial. Therefore, we examined data from a prospective cohort study of 1,037 patients with heart failure seen at the University of Alberta Heart Function Clinic. Median age was 69 years, 66% were men, 75% had systolic dysfunction, and mean ejection fraction was 33%. Only 40% of the 136 patients prescribed spironolactone had New York Heart Association class III or IV symptoms, and <25% fulfilled all of the RALES eligibility criteria. Mean daily dose of spironolactone was 23.9 mg; 25% of patients had spironolactone withdrawn after initiation, mostly due to increases in potassium and/or creatinine (9%), gynecomastia (5%), or dehydration/hyponatremia (6%). Only 1 of our spironolactone-treated patients developed serum potassium >6 mmol/L. Cox's proportional hazards analysis confirmed the association between use of spironolactone and increased survival rate (relative risk 0.09, 95% confidence interval 0.02 to 0.39), even though 78% of our patients did not fulfill the RALES eligibility criteria. Thus, although the complication rate was higher, the benefits of spironolactone seen in RALES extended to participants not in a trial who were treated with similar doses and followed closely in a clinic specializing in heart failure.

Acute Coronary Syndrome patients in New Zealand receive less invasive management when admitted to hospitals without invasive facilities

AIM

To compare differences in the presentation and management of acute coronary syndrome (ACS) patients presenting to interventional versus non-interventional New Zealand hospitals.

METHODS

We assessed the data collected by the New Zealand Cardiac Society ACS Audit Group over 14 days from each hospital in New Zealand (n=36) that admits ACS patients. Patient management at intervention centres (5 public, 3 private) was compared with non-intervention centres (28 public). Investigations and revascularisation procedures performed on transferred patients were attributed to the referring centre.

RESULTS

From 0000 hours on 13 May 2002 to 2400 hours on 26 May 2002, 930 patients were admitted to a New Zealand hospital with a suspected or definite ACS: ST-segment-elevation myocardial infarction [STEMI] (11%), non-STEMI (31%), unstable angina pectoris [UAP] (36%), or another cardiac or medical diagnosis (22%). Patients admitted to a non-intervention centre (n=612) were the same age (median 70 years) with similar risk factors, but were more likely to be Maori (8.2% vs 3.8%, p=0.0063) and were less likely to have a history of prior cardiac angiography (26% vs 28%, p=0.02) or percutaneous coronary intervention [PCI] (9.6% vs 14%, p=0.03) than patients admitted to an intervention centre (n=318). Patients admitted to a non-intervention centre were more likely to have a chest X-ray (88% vs 81%, p<0.0024), as likely to have an exercise treadmill test (20% vs 22%, p=0.39), but less likely to receive an echocardiogram (17% vs 26%, p<0.0005), a cardiac angiogram (17% vs 30%, p<0.0001), or neither a treadmill nor a cardiac angiogram (68% vs 53%, p<0.0001) for cardiac risk assessment. For patients with a definite ACS presentation (STEMI, Non-STEMI, UAP, n=721), PCI was performed less often for patients admitted to non-intervention centres: 3% vs 14% (p<0.0001), although the rate of coronary artery bypass grafting was similar: 3% vs 5% (p=0.16).

CONCLUSION

Patients admitted to a hospital without cardiac interventional facilities receive fewer investigations and less revascularisation than patients admitted to Intervention Centres. Hence patients admitted with an acute coronary syndrome in New Zealand receive inequitable management. A comprehensive National strategy is needed to improve access to optimal cardiac care.

[Treatment of atrial fibrillation in a Hungarian hospital department of cardiologic internal medicine at the turn of the millennium]

INTRODUCTION

The atrial fibrillation is a severe and frequent disease, which influences greatly the patients' quality of life. Only a few Hungarian studies exist which discuss the physicians' own experiences in its treatment.

AIM

The description of the experiences acquired in an internal medicine department with cardiological profile during the treatment based on the actual guidelines and the review of the results of one year follow-up.

METHOD

Retrospective analysis of the data of patients treated with atrial fibrillation between 1 january 1999 and 31 december 2001 and a one year follow-up was performed. The age, gender, success in cardioversion, the antiarrhythmic therapy at the discharge and the modification in it during the first year were evaluated.

RESULTS

During the 3 years long period 1115 patients with atrial fibrillation were admitted (53.9% female, 46.1% male, the mean age was 72.0 +/- 10.4 years), 391 of whom were discharged with sinus rhythm. In 193 cases (49%) a spontaneous cardioversion was observed. 120 electrical (31%) and 78 pharmacological (20%) cardioversions were performed. The electrical form was carried out in 42 cases with acute atrial fibrillation (in 36 of them successfully) and in 100 cases as an elective procedure, in 84 successfully. Pharmacological cardioversion was made in 39 acute cases with the administration of propafenone (in 29 ones successfully) and in 57 elective cases with quinidine + beta-blocker + magnesium (in 49 ones successfully). For the maintenance of sinus rhythm in the 38.8% of cases amiodarone, 24.0% propafenone, 19.9% sotalol, 10.7% beta-blocker, 0.8% quinidine, 0.5% prajmaline was administered, and 5.1% of the patients didn't receive any special treatment. During the one year follow-up from the 391 patients 261 remained on sinus rhythm, in 81 cases (21%) the return of the atrial fibrillation was diagnosed (in 57 of them a successful cardioversion was performed again), 11 patients (3%) died and 38 (9%) were lost for observation. At the time of the one year control 57.8% of patients treated with amiodarone, 61.7% of those treated with propafenone, 67.9% with sotalol and 35.7% with beta-blocker remained on sinus rhythm. The amiodarone was omitted in 17 cases because of its side effects.

CONCLUSIONS

The treatment of the atrial fibrillation has to be performed individually taking into account the guidelines, the comorbidity, the time of the beginning of rhythm disorder, the patients' present other drugs and the former antiarrhythmic therapy. A continuous and consistent follow-up of these patients is crucial.