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Rillig A, Eckardt L, Borof K, Camm AJ, Crijns HJGM, Goette A, Breithardt G, Lemoine MD, Metzner A, Rottner L, Schotten U, Vettorazzi E, Wegscheider K, Zapf A, Heidbuchel H, Willems S, Fabritz L, Schnabel RB, Magnussen C, Kirchhof P. Safety and efficacy of long-term sodium channel blocker therapy for early rhythm control: the EAST-AFNET 4 trial. Europace 2024; 26:euae121. [PMID: 38702961 PMCID: PMC11154137 DOI: 10.1093/europace/euae121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/13/2024] [Indexed: 05/06/2024] Open
Abstract
AIMS Clinical concerns exist about the potential proarrhythmic effects of the sodium channel blockers (SCBs) flecainide and propafenone in patients with cardiovascular disease. Sodium channel blockers were used to deliver early rhythm control (ERC) therapy in EAST-AFNET 4. METHODS AND RESULTS We analysed the primary safety outcome (death, stroke, or serious adverse events related to rhythm control therapy) and primary efficacy outcome (cardiovascular death, stroke, and hospitalization for worsening of heart failure (HF) or acute coronary syndrome) during SCB intake for patients with ERC (n = 1395) in EAST-AFNET 4. The protocol discouraged flecainide and propafenone in patients with reduced left ventricular ejection fraction and suggested stopping therapy upon QRS prolongation >25% on therapy. Flecainide or propafenone was given to 689 patients [age 69 (8) years; CHA2DS2-VASc 3.2 (1); 177 with HF; 41 with prior myocardial infarction, coronary artery bypass graft, or percutaneous coronary intervention; 26 with left ventricular hypertrophy >15 mm; median therapy duration 1153 [237, 1828] days]. The primary efficacy outcome occurred less often in patients treated with SCB [3/100 (99/3316) patient-years] than in patients who never received SCB [SCBnever 4.9/100 (150/3083) patient-years, P < 0.001]. There were numerically fewer primary safety outcomes in patients receiving SCB [2.9/100 (96/3359) patient-years] than in SCBnever patients [4.2/100 (135/3220) patient-years, adjusted P = 0.015]. Sinus rhythm at 2 years was similar between groups [SCB 537/610 (88); SCBnever 472/579 (82)]. CONCLUSION Long-term therapy with flecainide or propafenone appeared to be safe in the EAST-AFNET 4 trial to deliver effective ERC therapy, including in selected patients with stable cardiovascular disease such as coronary artery disease and stable HF. Clinical Trial Registration ISRCTN04708680, NCT01288352, EudraCT2010-021258-20, www.easttrial.org.
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Affiliation(s)
- Andreas Rillig
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg–Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
| | - Lars Eckardt
- Atrial Fibrillation Network (AFNET), Mendelstraße 11, 48149 Münster, Germany
- Department of Cardiology II—Electrophysiology, University Hospital Münster, Münster, Germany
| | - Katrin Borof
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg–Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St. George’s University of London, London, UK
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Andreas Goette
- Atrial Fibrillation Network (AFNET), Mendelstraße 11, 48149 Münster, Germany
- St. Vincenz Hospital, Paderborn, Paderborn, Germany
- Working Group of Molecular Electrophysiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Günter Breithardt
- Atrial Fibrillation Network (AFNET), Mendelstraße 11, 48149 Münster, Germany
- Department of Cardiology II—Electrophysiology, University Hospital Münster, Münster, Germany
| | - Marc D Lemoine
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg–Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg–Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
| | - Laura Rottner
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg–Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
| | - Ulrich Schotten
- Department of Physiology, Maastricht University, Maastricht, The Netherlands
| | - Eik Vettorazzi
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg–Eppendorf, Hamburg, Germany
| | - Karl Wegscheider
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
- Atrial Fibrillation Network (AFNET), Mendelstraße 11, 48149 Münster, Germany
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg–Eppendorf, Hamburg, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg–Eppendorf, Hamburg, Germany
| | - Hein Heidbuchel
- Faculty of Medicine and Health Sciences, Department of Cardiology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, Cardiovascular Research, GENCOR, Antwerp University, Antwerp, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Stephan Willems
- Asklepios Klinik St. Georg, Klinik für Kardiologie und internistische Intensivmedizin, Hamburg, Germany
| | - Larissa Fabritz
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg–Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
- Atrial Fibrillation Network (AFNET), Mendelstraße 11, 48149 Münster, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg–Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
- Atrial Fibrillation Network (AFNET), Mendelstraße 11, 48149 Münster, Germany
| | - Christina Magnussen
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg–Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg–Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
- Atrial Fibrillation Network (AFNET), Mendelstraße 11, 48149 Münster, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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2
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Pundi K, Fan J, Kabadi S, Din N, Blomström-Lundqvist C, Camm AJ, Kowey P, Singh JP, Rashkin J, Wieloch M, Turakhia MP, Sandhu AT. Dronedarone Versus Sotalol in Antiarrhythmic Drug-Naive Veterans With Atrial Fibrillation. Circ Arrhythm Electrophysiol 2023; 16:456-467. [PMID: 37485722 DOI: 10.1161/circep.123.011893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Sotalol and dronedarone are both used for maintenance of sinus rhythm for patients with atrial fibrillation. However, while sotalol requires initial monitoring for QT prolongation and proarrhythmia, dronedarone does not. These treatments can be used in comparable patients, but their safety and effectiveness have not been compared head to head. Therefore, we retrospectively evaluated the effectiveness and safety using data from a large health care system. METHODS Using Veterans Health Administration data, we identified 11 296 antiarrhythmic drug-naive patients with atrial fibrillation prescribed dronedarone or sotalol in 2012 or later. We excluded patients with prior conduction disease, pacemakers or implantable cardioverter-defibrillators, ventricular arrhythmia, cancer, renal failure, liver disease, or heart failure. We used natural language processing to identify and compare baseline left ventricular ejection fraction between treatment arms. We used 1:1 propensity score matching, based on patient demographics, comorbidities, and medications, and Cox regression to compare strategies. To evaluate residual confounding, we performed falsification analysis with nonplausible outcomes. RESULTS The matched cohort comprised 6212 patients (3106 dronedarone and 3106 sotalol; mean [±SD] age, 71±10 years; 2.5% female; mean [±SD] CHA2DS2-VASC, 2±1.3). The mean (±SD) left ventricular ejection fraction was 55±11 and 58±10 for dronedarone and sotalol users, correspondingly. Dronedarone, compared with sotalol, did not demonstrate a significant association with risk of cardiovascular hospitalization (hazard ratio, 1.03 [95% CI, 0.88-1.21]) or all-cause mortality (hazard ratio, 0.89 [95% CI, 0.68-1.16]). However, dronedarone was associated with significantly lower risk of ventricular proarrhythmic events (hazard ratio, 0.53 [95% CI, 0.38-0.74]) and symptomatic bradycardia (hazard ratio, 0.56 [95% CI, 0.37-0.87]). The primary findings were stable across sensitivity analyses. Falsification analyses were not significant. CONCLUSIONS Dronedarone, compared with sotalol, was associated with a lower risk of ventricular proarrhythmic events and conduction disorders while having no difference in risk of incident cardiovascular hospitalization and mortality. These observational data provide the basis for prospective efficacy and safety trials.
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Affiliation(s)
- Krishna Pundi
- Department of Medicine, Stanford University School of Medicine, CA (K.P., M.P.T., A.T.S.)
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, CA (J.F., N.D., M.P.T., A.T.S.)
| | | | - Natasha Din
- Veterans Affairs Palo Alto Health Care System, CA (J.F., N.D., M.P.T., A.T.S.)
| | - Carina Blomström-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Sweden (C.B.-L.)
| | - A John Camm
- St. George's University of London, United Kingdom (A.J.C.)
| | - Peter Kowey
- Lankenau Heart Institute, Wynnewood, PA (P.K.)
| | | | | | - Mattias Wieloch
- Department of Coagulation Disorders, Skåne University Hospital, Lund University, Malmö, Sweden (M.W.)
- Sanofi, Stockholm, Sweden (M.W.)
| | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, CA (K.P., M.P.T., A.T.S.)
- Veterans Affairs Palo Alto Health Care System, CA (J.F., N.D., M.P.T., A.T.S.)
| | - Alexander T Sandhu
- Department of Medicine, Stanford University School of Medicine, CA (K.P., M.P.T., A.T.S.)
- Veterans Affairs Palo Alto Health Care System, CA (J.F., N.D., M.P.T., A.T.S.)
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3
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Anderson JL, Knight S, McCubrey RO, May HT, Mason S, Bunch TJ, Min DB, Cutler MJ, Le VT, Muhlestein JB, Knowlton KU. Absent or Mild Coronary Calcium Predicts Low-Risk Stress Test Results and Outcomes in Patients Considered for Flecainide Therapy. J Cardiovasc Pharmacol Ther 2021; 26:648-655. [PMID: 34546822 DOI: 10.1177/10742484211046671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Flecainide is a useful antiarrhythmic for atrial fibrillation (AF). However, because of ventricular proarrhythmia risk, a history of myocardial infarction (MI) or coronary artery disease (CAD) is a flecainide exclusion, and stress testing is used to exclude ischemia. We assessed whether absent/mild coronary artery calcium (CAC) can supplement or avoid the need for stress testing. METHODS We assessed ischemic burden using regadenoson Rb-82 PET/CT in 1372 AF patients ≥50 years old without symptoms or signs of clinical CAD. CAC was determined qualitatively by low dose attenuation computed tomography (CT) (n = 816) or by quantitative CT (n = 556). Ischemic burden and clinical outcomes were compared by CAC burden. RESULTS Patients with CAC absent or mild (n = 766, 57.2%) were younger, more frequently female, and had higher BMI but lower rates of diabetes, hypertension, and dyslipidemia. Average ischemic burden was lower in CAC-absent/mild patients, and CAC-absent/mild patients showed greater coronary flow reserve, had fewer referrals for coronary angiography, and less often had obstructive CAD. Revascularization at 90 days was lower, and the rate of longer-term major adverse cardiovascular events was favorable. CONCLUSIONS An easily administered, inexpensive, low radiation CAC scan can identify a subset of flecainide candidates with a low ischemic burden on PET stress testing that rarely needs coronary angiography/intervention and has favorable outcomes. Absent or mild CAC-burden combined with other clinical information may avoid or complement routine stress testing. However, additional, ideally randomized and multicenter trials are indicated to confirm these findings before replacing stress testing with CAC screening in selecting patients for flecainide therapy in clinical practice.
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Affiliation(s)
- Jeffrey L Anderson
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA.,14434University of Utah, School of Medicine, Salt Lake City, UT, USA
| | - Stacey Knight
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA
| | - Raymond O McCubrey
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA
| | - Heidi T May
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA
| | - Steve Mason
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA
| | - Thomas J Bunch
- 14434University of Utah, School of Medicine, Salt Lake City, UT, USA
| | - David B Min
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA
| | - Michael J Cutler
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA
| | - Viet T Le
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA.,Rocky Mountain University of Health Professionals, Provo, UT, USA
| | - Joseph B Muhlestein
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA.,14434University of Utah, School of Medicine, Salt Lake City, UT, USA
| | - Kirk U Knowlton
- Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA.,14434University of Utah, School of Medicine, Salt Lake City, UT, USA
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4
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Lavalle C, Magnocavallo M, Straito M, Santini L, Forleo GB, Grimaldi M, Badagliacca R, Lanata L, Ricci RP. Flecainide How and When: A Practical Guide in Supraventricular Arrhythmias. J Clin Med 2021; 10:jcm10071456. [PMID: 33918105 PMCID: PMC8036302 DOI: 10.3390/jcm10071456] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/19/2021] [Accepted: 03/29/2021] [Indexed: 11/29/2022] Open
Abstract
Transcatheter ablation was increasingly and successfully used to treat symptomatic drug refractory patients affected by supraventricular arrhythmias. Antiarrhythmic drug treatment still plays a major role in patient management, alone or combined with non-pharmacological therapies. Flecainide is an IC antiarrhythmic drug approved in 1984 from the Food and Drug Administration for the suppression of sustained ventricular tachycardia and later for acute cardioversion of atrial fibrillation and for sinus rhythm maintenance. Currently, flecainide is mostly used for sinus rhythm maintenance in atrial fibrillation (AF) patients without structural cardiomyopathy although recent studies enrolling different patient populations have demonstrated a good effectiveness and safety profile. How should we interpret the results of the CAST after the latest evidence? Is it possible to expand the indications of flecainide, and therefore, its use? This review aims to highlight the main characteristics of flecainide, as well as its optimal clinical use, delineating drug indications and contraindications and appropriate monitoring, based on the most recent evidence.
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Affiliation(s)
- Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Policlinico Umberto I, 00161 Rome, Italy; (M.M.); (M.S.); (R.B.)
- Correspondence: ; Tel.: +39-335-376-901
| | - Michele Magnocavallo
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Policlinico Umberto I, 00161 Rome, Italy; (M.M.); (M.S.); (R.B.)
| | - Martina Straito
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Policlinico Umberto I, 00161 Rome, Italy; (M.M.); (M.S.); (R.B.)
| | - Luca Santini
- Department of Cardiology, Ospedale GB Grassi, 00121 Ostia, Italy;
| | | | - Massimo Grimaldi
- Department of Cardiology, Ospedale Generale Regionale F. Miulli, Acquaviva delle Fonti, 70021 Bari, Italy;
| | - Roberto Badagliacca
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Policlinico Umberto I, 00161 Rome, Italy; (M.M.); (M.S.); (R.B.)
| | - Luigi Lanata
- Medical Affairs Department, Dompé Farmaceutici SpA, 20057 Milan, Italy;
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5
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Goehring EL, Bohn RL, Pezzullo J, Tave AK, Jones JK, Bozzi S, Tamayo RCSG, Sicignano N, Naccarelli GV. Outcomes Associated with Dronedarone Use in Patients with Atrial Fibrillation. Am J Cardiol 2020; 135:77-83. [PMID: 32861738 DOI: 10.1016/j.amjcard.2020.08.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/09/2020] [Accepted: 08/11/2020] [Indexed: 12/20/2022]
Abstract
The antiarrhythmic drug dronedarone was designed to reduce the extra-cardiac adverse effects associated with amiodarone use in treatment of patients with atrial fibrillation / atrial flutter (AF/AFL). This epidemiological study used a retrospective cohort design to compare risk of cardiovascular-related hospitalizations and death in AF/AFL patients treated with dronedarone versus other antiarrhythmic drugs (AADs). AF/AFL patients with incident dronedarone fills were matched by propensity score (PS) to incident users of other AADs. The primary study outcome was hospitalization for cardiovascular (CV) causes within 24 months after the first study drug fill. A secondary composite outcome comprised hospitalization for CV causes or all-cause mortality during follow-up. In the AF/AFL patient cohort meeting eligibility criteria, 6,964 incident users of dronedarone and 25 607 incident users of other AADs were identified. The PS-matched cohort comprised 6,349 Dronedarone users (91.2% of all eligible) and 12,698 other AAD users. Dronedarone patients had a significantly lower risk of hospitalization for a CV event compared to Other AAD users (hazard ratio = 0.87; 95% confidence interval = 0.79 to 0.96). This was consistent with results for the composite outcome (hazard ratio=0.86; 95% confidence interval = 0.78 to 0.95). In conclusion, AF/AFL patients initiated on dronedarone versus other AADs had significantly lower risk of CV hospitalizations as well as the composite CV hospitalization / death from any cause.
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Affiliation(s)
| | | | - John Pezzullo
- Georgetown University, Washington, District of Columbia
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6
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Echt DS, Ruskin JN. Use of Flecainide for the Treatment of Atrial Fibrillation. Am J Cardiol 2020; 125:1123-1133. [PMID: 32044037 DOI: 10.1016/j.amjcard.2019.12.041] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/16/2019] [Accepted: 12/18/2019] [Indexed: 01/26/2023]
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with substantial morbidity and impairment of quality of life. Restoration and maintenance of normal sinus rhythm is a desirable goal for many patients with AF; however, this strategy is limited by the relatively small number of antiarrhythmic drugs (AADs) available for AF rhythm control. Although it is recommended in current medical guidelines as first-line therapy for patients without structural heart disease, the use of flecainide has been curtailed since the completion of the Cardiac Arrhythmia Suppression Trial. In clinical trials and real-world use, flecainide has proven to be more effective than other AADs for the acute termination of recent onset AF. Flecainide is also moderately effective and, with the exception of amiodarone, equivalent to other AADs for the chronic suppression of paroxysmal and persistent AF. In patients without structural heart disease, flecainide has been demonstrated to be safe and well tolerated relative to other AADs. Despite this favorable profile, flecainide is underutilized, likely due to a perceived risk of ventricular proarrhythmia, a concern that has not been borne out in patients without underlying structural heart disease. Guidelines for administration and use of flecainide are summarized in this review.
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Affiliation(s)
| | - Jeremy N Ruskin
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts.
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7
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Kipp R, Askari M, Fan J, Field ME, Turakhia MP. Real-World Comparison of Classes IC and III Antiarrhythmic Drugs as an Initial Rhythm Control Strategy in Newly Diagnosed Atrial Fibrillation. JACC Clin Electrophysiol 2019; 5:231-241. [DOI: 10.1016/j.jacep.2018.08.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 08/23/2018] [Indexed: 11/29/2022]
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8
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Naccarelli GV. Antiarrhythmic Drugs for Atrial Fibrillation in the Real World. JACC Clin Electrophysiol 2019; 5:242-244. [DOI: 10.1016/j.jacep.2018.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 10/19/2018] [Accepted: 10/22/2018] [Indexed: 11/17/2022]
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9
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Maan A, Zhang Z, Qin Z, Wang Y, Dudley S, Dabhadakar K, Refaat M, Mansour M, Ruskin JN, Heist EK. Impact of treatment crossovers on clinical outcomes in the rate and rhythm control strategies for atrial fibrillation: Insights from the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trial. Pacing Clin Electrophysiol 2017; 40:770-778. [PMID: 28543286 DOI: 10.1111/pace.13112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 04/10/2017] [Accepted: 04/13/2017] [Indexed: 11/27/2022]
Abstract
We investigated the rates and reasons for crossover to alternative treatment strategies and its impact on mortality in patients who were enrolled in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. Over a mean follow-up period of 3.5 years, 842 patients underwent crossover to the alternative treatment arms in AFFIRM. The rate of crossover from rhythm to rate control (594/2,033, 29.2%) was more frequent than the rate of crossover from rate to rhythm control (248/2,027, 12.2%, P < 0.0001). The leading reasons for crossover from rhythm to rate control were failure to achieve or maintain sinus rhythm (272/594, 45.8%) and intolerable adverse effects (122/594, 20.5%). In comparison, the major reasons for crossover from rate to rhythm control were failure to control atrial fibrillation symptoms (159/248, 64.1%) and intolerable adverse effects (9/248, 3.6%). This difference in crossover pattern was statistically significant (P < 0.0001). There was a significantly decreased risk of all-cause mortality (adjusted HR: 0.61, 95% CI: 0.48-0.78, P < 0.0001) and cardiac mortality (adjusted hazard ratio [HR]: 0.61, 95% confidence interval [CI]: 0.43-0.88, P = 0.008) in the subgroup of patients who crossed over from rhythm to rate control as compared to those who continued in rhythm control. There was a nonsignificant trend toward decreased all-cause (adjusted HR: 0.76, 95% CI: 0.53-1.10, P = 0.14) and cardiac mortality (adjusted HR: 0.70, 95% CI: 0.42-1.18, P = 0.18) in patients who crossed over from rate to rhythm control as compared to those who continued rate control.
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Affiliation(s)
- Abhishek Maan
- Division of Cardiology, The Warren Alpert School of Brown University, Providence, RI
| | - Zheng Zhang
- Brown University School of Public Health, Providence, RI
| | - Ziling Qin
- Brown University School of Public Health, Providence, RI
| | - Yanbing Wang
- Brown University School of Public Health, Providence, RI
| | - Samuel Dudley
- Division of Cardiology, The Warren Alpert School of Brown University, Providence, RI
| | - Kaustubh Dabhadakar
- Division of Cardiology, The Warren Alpert School of Brown University, Providence, RI
| | - Marwan Refaat
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Moussa Mansour
- Cardiac Arrhythmia Service and Heart Center, Massachusetts General Hospital, Boston, MA
| | - Jeremy N Ruskin
- Cardiac Arrhythmia Service and Heart Center, Massachusetts General Hospital, Boston, MA
| | - E Kevin Heist
- Cardiac Arrhythmia Service and Heart Center, Massachusetts General Hospital, Boston, MA
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10
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Abstract
Dronedarone is the newest antiarrhythmic drug approved for the maintenance of sinus rhythm in patients with nonpermanent atrial fibrillation (AF). It is a multi-channel blocker with diverse electrophysiologic properties. Dronedarone decreases the incidence of AF recurrence and the ventricular rate during recurrence. Dronedarone decreases rates of cardiovascular hospitalizations in patients with paroxysmal and persistent AF. Dronedarone increases mortality in patients with permanent AF and those with moderate-severe heart failure, and should thus be avoided in these populations. Dronedarone is less effective than amiodarone but also has less toxicity. Direct comparison with other antiarrhythmic drugs is not available.
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Affiliation(s)
- Rafik Tadros
- Department of Medicine, Université de Montréal and Montreal Heart Institute, 5000 Rue Belanger, Montreal, Québec H1T 1C8, Canada
| | - Stanley Nattel
- Department of Medicine, Université de Montréal and Montreal Heart Institute, 5000 Rue Belanger, Montreal, Québec H1T 1C8, Canada
| | - Jason G Andrade
- Department of Medicine, Université de Montréal and Montreal Heart Institute, 5000 Rue Belanger, Montreal, Québec H1T 1C8, Canada; Heart Rhythm Services, Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada.
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