Cardioversion of recent-onset atrial fibrillation using intravenous antiarrhythmics: A European perspective

Pharmacological cardioversion using intravenous antiarrhythmic agents is commonly indicated in symptomatic patients with recent-onset atrial fibrillation (AF). Except in hemodynamically unstable patients who require emergency direct current electrical cardioversion, for the majority of hemodynamically stable patients, pharmacological cardioversion represents a valid option and requires the clinician to be familiar with the properties and use of antiarrhythmic agents. The main characteristics of selected intravenous antiarrhythmic agents for conversion of recent-onset AF, the reported success rates, and possible adverse events are discussed. Among intravenous antiarrhythmics, flecainide, propafenone, amiodarone, sotalol, dofetilide, ibutilide, and vernakalant are commonly used. Antazoline, an old antihistaminic agent with antiarrhythmic properties was also reported to give encouraging results in Poland. Intravenous flecainide and propafenone are the only Class I agents still recommended by recent guidelines. Intravenous new Class III agents as dofetilide and ibutilide have high and rapid efficacy in converting AF to sinus rhythm but require strict surveillance with electrocardiogram (ECG) monitoring during and after intravenous administration because of the potential risk of QT prolongation and Torsades de Pointes, which can be prevented and properly managed. Vernakalant, a partial atrial selective was shown to have a high success rate and to be safe in real-life use.

[Prevention of thromboembolic complications during cardioversion and catheter ablation in patients with atrial fibrillation: review of key randomized trials]

This review focuses on the relevance of sinus rhythm control in patients with atrial fibrillation in real-life clinical practice and specific clinical features of patients with this arrhythmia. The authors presented current guidelines on prevention of thromboembolic complications and a review of results from major clinical studies of direct oral anticoagulants. The search for literature and selection of clinical studies for 2009-2020 were performed on websites of the European and Russian Societies of Cardiology, the All-Russian Scientific Society of Arrhythmologists, and in online databases PubMed, EMBASE, eLibrary, and Google Scholar using the key words atrial fibrillation, anticoagulants, ablation, cardioversion, and efficacy and safety.

New-Onset Atrial Fibrillation in Adult Patients After Cardiac Surgery

Purpose of Review

An overview of recent literature regarding pathophysiology, risk factors, prophylaxis, and treatment of new-onset atrial fibrillation (AF) in post-cardiac surgical patients.

Recent Findings

AF is the most frequent adverse event after cardiac surgery with significant associated morbidity, mortality, and financial cost. Its causes are multifactorial, and models to stratify patients into risk categories are progressing but a consistent, evidence-based system has not yet been developed. Pharmacologic and surgical interventions to prevent and treat this complication have been an area of ongoing research and recent societal guidelines reflect this.

Summary

Inconsistencies remain surrounding how to best identify higher-risk AF patients, which interventions should be used to prevent and treat AF, and which patient groups should receive these interventions. The evidence for these available strategies and their place in contemporary guidelines are summarized.

Effect of sotalol on heart rate, QT interval, and atrial fibrillation cycle length in horses with atrial fibrillation

Background

Based on its pharmacokinetic profile and electrophysiological effects in healthy horses, sotalol potentially could be used as a long‐term PO antiarrhythmic drug in horses.

Objectives

To evaluate the effect of sotalol on heart rate (HR), QT interval, atrial fibrillatory rate, and success of cardioversion in horses with naturally occurring chronic atrial fibrillation (AF).

Animals

Twenty‐eight horses referred for transvenous electrical cardioversion of AF were treated with 2 mg/kg sotalol PO q12h for 3 days before cardioversion, and 13 horses underwent the same protocol without sotalol administration.

Methods

Retrospective study. Before and after sotalol or no treatment, the HR was measured at rest and during an exercise test. The QT interval and atrial fibrillation cycle length (AFCL) were measured at rest using tissue Doppler velocity imaging.

Results

In the control group, no significant differences were found between the 2 examinations. In the sotalol group, the HR at rest and during exercise was significantly lower after sotalol treatment, whereas the QT interval and AFCL measured by tissue Doppler increased significantly. Cardioversion to sinus rhythm was achieved in 25/28 horses in the sotalol group and all horses in the control group, but the median number of shocks and energy at cardioversion were significantly lower in the sotalol group.

Conclusions and Clinical Importance

In horses with AF, sotalol administration results in class III antiarrhythmic effects and β‐blocking activity, with moderate HR reduction during exercise.

Management of Atrial Fibrillation Post Bypass Surgery with Intravenous Sotalol: A Case Study

Intravenous sotalol has been available for many years outside of the United States, but has only recently become available in the US. The safety and feasibility of intravenous sotalol for the prevention of recurrent atrial fibrillation following bypass surgery has not been described. The present case study is of a patient with several other co-morbidities undergoing coronary artery bypass graft surgery, who post-operatively developed atrial fibrillation. The patient received intravenous sotalol and was then transitioned to oral sotalol. The patient remained hemodynamically stable, with normal QTc and without further atrial fibrillation or tachyarrhythmias in the post-operative period until discharge. Intravenous sotalol is a reasonable alternative to intravenous amiodarone in the post bypass surgery patient with better tolerability and safety profile.

Intravenous Sotalol - Reintroducing a Forgotten Agent to the Electrophysiology Therapeutic Arsenal

Sotalol is a racemic mixture possessing beta-blocker and class III anti arrhythmic properties. Approved by US food and drug administration (FDA) since 2009 based on its bioequivalence with oral sotalol, clinicians are less familiar with the potential uses of the intravenous form despite its re-launch in United States in 2015. Available literature suggests that intravenous sotalol in recommended doses can be safely administered in adult and pediatric population achieving rapid reliable therapeutic plasma concentration and without additional proarrhythmic effects when compared to its oral form as well as other antiarrhythmic medications. Intravenous sotalol may have potential uses as an alternative agent for highly symptomatic atrial fibrillation post cardiac surgery as well as in life threatening ventricular arrhythmias. As with its oral form, judicious use with close attention to QTc and renal function is warranted. Further studies are needed to better understand the safety, efficacy and different dosing regimens of parenteral sotalol in adults and children.