One-year treatment persistence and potential adverse events among patients with atrial fibrillation treated with amiodarone or sotalol: a retrospective claims database analysis

Comparative Safety and Effectiveness of Sotalol Versus Dronedarone After Catheter Ablation for Atrial Fibrillation

Background Atrial tachyarrhythmias are common after atrial fibrillation ablation, so adjunctive antiarrhythmic drug therapy is often used. Data on the effectiveness and safety of dronedarone and sotalol after AF ablation are limited. Here, we compared health outcomes of ablated patients treated with dronedarone versus sotalol. Methods and Results A comparative analysis of propensity score-matched retrospective cohorts was performed using IBM MarketScan Research Databases. Patients treated with dronedarone after atrial fibrillation ablation were matched 1:1 to patients treated with sotalol between January 1, 2013 and March 31, 2018. Outcomes of interest included cardiovascular hospitalization, proarrhythmia, repeat ablation, and cardioversion. This study was exempt from institutional review board review. Among 30 696 patients who underwent atrial fibrillation ablation, 2086 were treated with dronedarone and 3665 with sotalol after ablation. Propensity-score matching resulted in 1815 patients receiving dronedarone matched 1:1 to patients receiving sotalol. Risk of cardiovascular hospitalization was lower with dronedarone versus sotalol at 3 months (adjusted hazard ratio [aHR], 0.77 [95% CI, 0.61-0.97]), 6 months (aHR, 0.76 [95% CI, 0.63-0.93]), and 12 months after ablation (aHR, 0.70 [95% CI, 0.66-0.93]). Risk of repeat ablation and cardioversion generally did not differ between the 2 groups. A lower risk of proarrhythmia was associated with dronedarone versus sotalol at 3 months (aHR, 0.76 [95% CI, 0.64-0.90]), 6 months (aHR, 0.80 [95% CI, 0.70-0.93]), and 12 months (aHR, 0.83 [95% CI, 0.73-0.94]) after ablation. Conclusions These data suggest that dronedarone may be a more effective and safer alternative after ablation than sotalol.

US Antiarrhythmic Drug Treatment for Patients With Atrial Fibrillation: An Insurance Claims-Based Report

Background

Current American Heart Association/American College of Cardiology/Heart Rhythm Society guidelines and European Society of Cardiology guidelines recommend antiarrhythmic drugs (AADs) for maintenance of sinus rhythm in patients with atrial fibrillation. We assessed the concordance between healthcare provider real‐world practice and current guidelines with respect to first‐line AAD rhythm management.

Methods and Results

Administrative claims data from the deidentified Optum Clinformatics Data Mart database were used. Patients were included if they were initiated on an AAD in 2015 to 2016, had 1 year of continuous data availability before their first AAD pharmacy claim, and had a diagnosis for atrial fibrillation within that period. Concordance was assessed by comparing the AAD initiated by the healthcare provider against guideline recommendations for first‐line treatment, given the presence of heart failure, coronary artery disease, both, or neither (as determined by International Classification of Diseases, Ninth Revision and Tenth Revision [ICD‐9 and ICD‐10] codes). Concordance was also assessed by provider type using Medicare taxonomy codes. For the 15 445 patients included, 51% of healthcare providers initiated AAD treatments with amiodarone, 18% flecainide, 15% sotalol, 8% dronedarone, 5% propafenone, and 2% dofetilide. The overall rate of guideline concordance was 61%, with differences by provider type: 67% for electrophysiologists, 61% for cardiologists, and 60% for others (internal medicine, etc).

Conclusions

There continues to be a sizable gap in concordance between practice and guidelines in first‐line rhythm management of patients with atrial fibrillation. Further research is needed to identify possible explanations for non–guideline‐recommended use of AADs, in addition to enhanced AAD educational strategies for practitioners.

Antiarrhythmic drug use in patients <65 years with atrial fibrillation and without structural heart disease

Little is known in clinical practice about antiarrhythmic drug (AAD) use in patients with atrial fibrillation (AF) (particularly younger ones) who do not have structural heart disease. Using the MarketScan database, we identified patients <65 years without known coronary artery disease or heart failure who had an AAD prescription claim (class Ic drug, amiodarone, sotalol, or dronedarone) after their first AF encounter. A multinomial logistic regression model was created to assess factors associated with using each available AAD compared with using class Ic drugs before and after dronedarone was marketed in the United States. Additionally, we used the Kaplan-Meier method to determine the rates of change in AAD use and discontinuation during the year after AAD initiation. Of 8,562 patients with AF, 35% received class Ic drugs, 34% amiodarone, 24% sotalol, and 7% dronedarone. The median patient age was 56 (interquartile range 49 to 61), and 34% were women. Both before and after dronedarone was marketed, there was a statistically significant lower likelihood of class Ic drug use versus other AAD use with increasing age, inpatient index AF encounter, and previous or concomitant anticoagulation therapy. During the 1 year after AAD initiation, the AAD change rate was 14% for class Ic drugs, 8% for amiodarone, 17% for sotalol, and 18% for dronedarone (p <0.001); the AAD discontinuation rate was 40% for class Ic drugs, 52% for amiodarone, 40% for sotalol, and 69% for dronedarone (p <0.001). In conclusion, we found extensive use of amiodarone that may be inconsistent with guideline recommendations and unexpectedly high rates of AAD discontinuation.

The efficacy and tolerability of commonly used agents to prevent recurrence of atrial fibrillation after successful cardioversion

A number of therapeutic strategies exist for the restoration and maintenance of sinus rhythm in patients presenting with atrial fibrillation. The acute success rate with electrical cardioversion is high. However, many patients relapse into atrial fibrillation. A major challenge faced by those who care for patients with atrial fibrillation is the long-term maintenance of sinus rhythm whilst avoiding treatment-related adverse effects. This review examines the efficacy and tolerability of conventional anti-arrhythmic drugs for the secondary prevention of atrial fibrillation in the post-cardioversion period.

Use of antiarrhythmic drug therapy and clinical outcomes in older patients with concomitant atrial fibrillation and coronary artery disease

AIMS

Atrial fibrillation (AF) and coronary artery disease (CAD) are common in older patients. We aimed to describe the use of antiarrhythmic drug (AAD) therapy and clinical outcomes in these patients.

METHODS AND RESULTS

We analysed AAD therapy and outcomes in 1738 older patients (age ≥65) with AF and CAD in the Duke Databank for cardiovascular disease. The primary outcomes were mortality and rehospitalization at 1 and 5 years. Overall, 35% of patients received an AAD at baseline, 43% were female and 85% were white. Prior myocardial infarction (MI, 31%) and heart failure (41%) were common. Amiodarone was the most common AAD (21%), followed by pure Class III agents (sotalol 6.3%, dofetilide 2.2%). Persistence of AAD was low (35% at 1 year). After adjustment, baseline AAD use was not associated with 1-year mortality [adjusted hazard ratio (HR) 1.23, 95% confidence interval (CI) 0.94-1.60] or cardiovascular mortality (adjusted HR 1.27, 95% CI 0.90-1.80). However, AAD use was associated with increased all-cause rehospitalization (adjusted HR 1.20, 95% CI 1.03-1.39) and cardiovascular rehospitalization (adjusted HR 1.20, 95% CI 1.01-1.43) at 1 year. This association did not persist at 5 years; however, these patients were at very high risk of death (55% for those >75 and on AAD) and all-cause rehospitalization (87% for those >75 and on AAD) at 5 years.

CONCLUSIONS

In older patients with AF and CAD, antiarrhythmic therapy was associated with increased rehospitalization at 1 year. Overall, these patients are at high risk of longer-term hospitalization and death. Safer, better-tolerated, and more effective therapies for symptom control in this high-risk population are warranted.

Clinical characteristics, management, and control of permanent vs. nonpermanent atrial fibrillation: insights from the RealiseAF survey

Background

Atrial fibrillation can be categorized into nonpermanent and permanent atrial fibrillation. There is less information on permanent than on nonpermanent atrial fibrillation patients. This analysis aimed to describe the characteristics and current management, including the proportion of patients with successful atrial fibrillation control, of these atrial fibrillation subsets in a large, geographically diverse contemporary sample.

Methods and Results

Data from RealiseAF, an international, observational, cross-sectional survey of 10,491 patients with atrial fibrillation, were used to characterize permanent atrial fibrillation (N = 4869) and nonpermanent atrial fibrillation (N = 5622) patients. Permanent atrial fibrillation patients were older, had a longer time since atrial fibrillation diagnosis, a higher symptom burden, and were more likely to be physically inactive. They also had a higher mean (SD) CHADS₂ score (2.2 [1.3] vs. 1.7 [1.3], p<0.001), and a higher frequency of CHADS₂ score ≥2 (67.3% vs. 53.0%, p<0.001) and comorbidities, most notably heart failure. Physicians indicated using a rate-control strategy in 84.2% of permanent atrial fibrillation patients (vs. 27.5% in nonpermanent atrial fibrillation). Only 50.2% (N = 2262/4508) of permanent atrial fibrillation patients were controlled. These patients had a longer time since atrial fibrillation diagnosis, a lower symptom burden, less obesity and physical inactivity, less severe heart failure, and fewer hospitalizations for acute heart failure than uncontrolled permanent atrial fibrillation patients, but with more arrhythmic events. The most frequent causes of hospitalization in the last 12 months were acute heart failure and stroke.

Conclusion

Permanent atrial fibrillation is a high-risk subset of atrial fibrillation, representing half of all atrial fibrillation patients, yet rate control is only achieved in around half. Since control is associated with lower symptom burden and heart failure, adequate rate control is an important target for improving the management of permanent atrial fibrillation patients.

Frequency of inappropriate medication prescription in hospitalized elderly patients in Italy

Background

Older people often need comprehensive treatment, including many medications, and polypharmacy is common. The aims of this cross-sectional investigation were to examine the potentially inappropriate medication during the hospitalization and to identify the factors that may influence such inappropriateness among elderly in Italy.

Methods

A sample of 605 individuals aged 65 years and older admitted in non-academic public acute care hospitals was randomly selected. Prescription of inappropriate medications were evaluated during the period from the day of admission to a randomly preselected day (index day). Beers Criteria were used to evaluate appropriateness.

Results

At least one potentially inappropriate medication prescription from the day of hospital admission to the index day has been observed in 188 patients (31.1%), and respectively 84.1% and 15.9% of them had received one or two inappropriate medications. A total of 15 medications was prescribed inappropriately to these 188 patients, for 215 times with a total of 1143 doses. The multivariate logistic regression analysis revealed that the significant predictors for having at least one potentially inappropriate medication prescription during the hospitalization were: patients having an elementary education level, a lower pre-admission performance-based measure of basic activities of daily living, having received an inappropriate drug before the hospitalization, a hospital stay in the general and in the specialties surgical wards, a longer length of hospital stay from the admission to the index day, and having received a higher number of drugs from the day of the hospital admission to the index day. The most prevalent inappropriate medications administered were ketorolac (27.4%), amiodarone (19.1%), and clonidine (11.2%).

Conclusions

This study supports the need for clinical guidelines implementation to assist physicians in choosing the most appropriate drugs for the elderly and for effective education of all physicians.

Advances in the management of atrial fibrillation

Atrial fibrillation (AF) is the most common arrhythmia worldwide, increasing in incidence with the aging population. Substantial morbidity and mortality accompany its diagnosis. Management should focus on rate and rhythm management, on reducing thromboembolic risk, and also potentially on targeting the mechanisms responsible for its perpetuation. Current antiarrhythmic therapy has only modest efficacy and substantial side effects, and anticoagulation regimes are cumbersome and require regular monitoring. Novel anticoagulants and antiarrhythmics hold the promise of improved efficacy and safety. This review covers current therapy for AF, major advances in pharmacological management and future directions for therapy.

Do the benefits of anti-arrhythmic drugs outweigh the associated risks? A tale of treatment goals in atrial fibrillation

Atrial fibrillation (AF) is the most common cardiac rhythm disorder and places a substantial burden on the US healthcare system. Unfortunately, there is no consensus as to whether patients should be treated with a primary rate- or rhythm-control strategy. The use of anti-arrhythmic drugs in the treatment of AF is discussed in the broader context of AF disease-management strategies with a focus on rhythm control. Outside of rhythm/ECG, AF treatment targets and cardiovascular outcomes are highlighted.