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Capucci A. Pill in the Pocket: A Safe and Useful Antiarrhythmic Strategy. JACC Clin Electrophysiol 2022; 8:1521-1522. [PMID: 36543502 DOI: 10.1016/j.jacep.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/14/2022] [Accepted: 11/14/2022] [Indexed: 12/23/2022]
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2
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Ibrahim OA, Belley-Côté EP, Um KJ, Baranchuk A, Benz AP, Dalmia S, Wang CN, Alhazzani W, Conen D, Devereaux PJ, Whitlock RP, Healey JS, McIntyre WF. Single-dose oral anti-arrhythmic drugs for cardioversion of recent-onset atrial fibrillation: a systematic review and network meta-analysis of randomized controlled trials. Europace 2021; 23:1200-1210. [PMID: 33723602 DOI: 10.1093/europace/euab014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/08/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS Single oral dose anti-arrhythmic drugs (AADs) are used to cardiovert recent-onset atrial fibrillation (AF); however, the optimal agent is uncertain. METHODS We performed a systematic review and network meta-analysis of randomized trials testing single oral dose AADs vs. any comparator to cardiovert AF <7 days duration. We searched MEDLINE, Embase, and CENTRAL to April 2020. The primary outcome was successful cardioversion at timepoint nearest 8 h after administration. RESULTS From 12 712 citations, 22 trials (2320 patients) were included. Thirteen trials included patients with some degree of heart failure; 19 included patients with some degree of ischaemic heart disease vs. placebo or rate-control (32% success) at 8 h, flecainide [73%, network odds ratio (OR) 7.6, 95% credible interval (CrI) 4.4-14.0], propafenone (70%, OR 4.6, CrI 2.9-7.3), and pilsicainide (59%, OR 10.0, CrI 1.8-69.0), but not amiodarone (28%, OR 1.0, CrI 0.4-2.8) were superior. Flecainide (OR 7.5, CrI 2.6-24.0) and propafenone (OR 4.5, CrI 1.6-13.0) were superior to amiodarone; propafenone vs. flecainide did not statistically differ (OR 0.6, CrI 0.3-1.1). At longest follow-up, amiodarone was superior to placebo (OR 11.0, CrI 3.2-41.0), flecainide vs. amiodarone (OR 0.79, CrI 0.19-3.1), and propafenone vs. amiodarone (OR 0.36, CrI 0.092-1.4) were not statistically different, and flecainide was superior to propafenone (OR 2.2, CrI 1.1-4.8). Atrial and ventricular tachyarrhythmias, bradyarrhythmias, and hypotension were rare with PO AADs. CONCLUSION Single oral dose Class 1C AADs are effective and safe for cardioversion of recent-onset AF. Flecainide may be superior to propafenone. Amiodarone is a slower acting alternative.
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Affiliation(s)
- Omar A Ibrahim
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - Kevin J Um
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | | | - Alexander P Benz
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - Shreyash Dalmia
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | | | - Waleed Alhazzani
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - David Conen
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - P J Devereaux
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - William F McIntyre
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
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3
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Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, Cox JL, Dorian P, Gladstone DJ, Healey JS, Khairy P, Leblanc K, McMurtry MS, Mitchell LB, Nair GM, Nattel S, Parkash R, Pilote L, Sandhu RK, Sarrazin JF, Sharma M, Skanes AC, Talajic M, Tsang TSM, Verma A, Verma S, Whitlock R, Wyse DG, Macle L. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2020; 36:1847-1948. [PMID: 33191198 DOI: 10.1016/j.cjca.2020.09.001] [Citation(s) in RCA: 312] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/05/2020] [Indexed: 12/20/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Martin Aguilar
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Paul Khairy
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stanley Nattel
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Jean-François Sarrazin
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Mario Talajic
- Montreal Heart Institute, University of Montreal, Montréal, Quebec, Canada
| | - Teresa S M Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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4
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Management of Recent-onset Sustained Atrial Fibrillation: Pharmacologic and Nonpharmacologic Strategies. Clin Ther 2014; 36:1151-9. [DOI: 10.1016/j.clinthera.2014.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 08/04/2014] [Accepted: 08/07/2014] [Indexed: 12/19/2022]
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5
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Vizzardi E, Salghetti F, Bonadei I, Gelsomino S, Lorusso R, D'Aloia A, Curnis A. A new antiarrhythmic drug in the treatment of recent-onset atrial fibrillation: vernakalant. Cardiovasc Ther 2014; 31:e55-62. [PMID: 23398692 DOI: 10.1111/1755-5922.12026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Vernakalant is a new antiarrhythmic agent recently approved in Europe for the rapid cardioversion of recent-onset atrial fibrillation. It works by blocking early-activating K+ atrial channels and frequency-dependent atrial Na+ channels, prolonging atrial refractory periods and rate-dependent slowing atrial conduction, without promoting ventricular arrhythmia. Preclinical and clinical trials showed good toleration of this drug. The main purpose of our review is to describe all the trials that led to the incorporation of vernakalant into the current European atrial fibrillation guidelines.
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Affiliation(s)
- Enrico Vizzardi
- Section of Cardiovascular Diseases, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
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6
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Conde D, Costabel JP, Aragon M, Lambardi F, Klein A, Corrales Barbosa A, Trivi M, Giniger A. Propafenone Versus Vernakalant for Conversion of Recent-Onset Atrial Fibrillation. Cardiovasc Ther 2013; 31:377-80. [DOI: 10.1111/1755-5922.12036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Diego Conde
- Cardiovascular Emergency Care Section; Instituto Cardiovascular de Buenos Aires; Buenos Aires Argentina
| | - Juan Pablo Costabel
- Cardiovascular Emergency Care Section; Instituto Cardiovascular de Buenos Aires; Buenos Aires Argentina
| | - Martin Aragon
- Cardiovascular Emergency Care Section; Instituto Cardiovascular de Buenos Aires; Buenos Aires Argentina
| | - Florencia Lambardi
- Cardiovascular Emergency Care Section; Instituto Cardiovascular de Buenos Aires; Buenos Aires Argentina
| | - Andrés Klein
- Cardiovascular Emergency Care Section; Instituto Cardiovascular de Buenos Aires; Buenos Aires Argentina
| | - Andrea Corrales Barbosa
- Cardiovascular Emergency Care Section; Instituto Cardiovascular de Buenos Aires; Buenos Aires Argentina
| | - Marcelo Trivi
- Clinical Cardiology Service; Instituto Cardiovascular de Buenos Aires; Buenos Aires Argentina
| | - Alberto Giniger
- Electrophysiology Service; Instituto Cardiovascular de Buenos Aires; Buenos Aires Argentina
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7
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Conde D. Is vernakalant better or not compared with other treatments for conversion acute atrial fibrillation? Int J Cardiol 2013; 169:95-6. [DOI: 10.1016/j.ijcard.2013.08.139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Accepted: 08/30/2013] [Indexed: 10/26/2022]
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8
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Conde D. Conversion of recent onset atrial fibrillation: which drug is faster? Am J Emerg Med 2013; 31:1410-1. [DOI: 10.1016/j.ajem.2013.05.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 05/23/2013] [Indexed: 12/01/2022] Open
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Hassan OF, Al Suwaidi J, Salam AM. Anti-Arrhythmic Agents in the Treatment of Atrial Fibrillation. J Atr Fibrillation 2013; 6:864. [PMID: 28496859 DOI: 10.4022/jafib.864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 04/28/2013] [Accepted: 04/29/2013] [Indexed: 11/10/2022]
Abstract
Although atrial fibrillation (AF) is the most common sustained arrhythmia seen during daily cardiovascular physician practice, its management remained a challenge for cardiology physician as there was no single anti-arrhythmic agents proved to be effective in converting atrial fibrillation and kept its effectiveness in maintaining sinus rhythm over long term. Moreover all the anti-arrhythmic agents that are used in treatment of AF were potentially pro-arrhythmic especially in patients with coronary artery disease and structurally abnormal heart. Some of these drugs also have serious non cardiac side effects that limit its long term use in the management of atrial fibrillation. Several new and investigational anti-arrhythmic agents are emerging but data supporting their effectiveness and safety are still limited. In this systematic review we examine the efficacy and safety of these medications supported by the major published randomized trials, meta-analyses and review articles and conclude with a summary of guidelines recommendations.
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Affiliation(s)
- Omar F Hassan
- Department of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation, Qatar
| | - Jassim Al Suwaidi
- Department of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation, Qatar
| | - Amar M Salam
- Department of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation, Qatar
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10
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Abstract
OBJECTIVES Recent-onset (duration ≤ 1 week) atrial fibrillation (AF) has a high rate of spontaneous conversion to sinus rhythm (SR); still anti-arrhythmic drugs (AAD) are given for conversion purposes. We assessed the effect of AADs by reviewing the literature regarding conversion rates of available drugs in a systematic manner. DESIGN PubMed searches were performed using the terms "drug name", "atrial fibrillation", and "clinical study/RCT", and a list of 1302 titles was generated. These titles, including abstracts or complete papers when needed, were reviewed for recent-onset of AF, the use of a control group, and the endpoint of SR within 24 hours. Postoperative and intensive care settings were excluded. RESULTS Five AADs were demonstrated to have an effect, and these were Amiodarone, Ibutilide (only one study and risk of torsade de pointes), Flecainide and Propafenone (only to be used in patients without structural heart disease) and Vernakalant. The time taken for conversion differed markedly; Vernakalant converted after 10 minutes, while Amiodarone converted only after 24 hours; Propafenone and Flecainide had conversion times in-between. CONCLUSIONS For a rapid response in a broad group of patients, Vernakalant appears to be a reasonable first choice, while Flecainide and Propafenone can be used in patients without structural heart disease.
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Affiliation(s)
- Magnus Heldal
- Gardermoen Heart Centre, Skogveien 2, Jessheim, Norway.
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Bash LD, Buono JL, Davies GM, Martin A, Fahrbach K, Phatak H, Avetisyan R, Mwamburi M. Systematic Review and Meta-analysis of the Efficacy of Cardioversion by Vernakalant and Comparators in Patients with Atrial Fibrillation. Cardiovasc Drugs Ther 2012; 26:167-79. [DOI: 10.1007/s10557-012-6374-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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12
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Pisters R, Nieuwlaat R, Prins MH, Le Heuzey JY, Maggioni AP, Camm AJ, Crijns HJGM. Clinical correlates of immediate success and outcome at 1-year follow-up of real-world cardioversion of atrial fibrillation: the Euro Heart Survey. Europace 2012; 14:666-74. [DOI: 10.1093/europace/eur406] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Huezey JY, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS. 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation. Circulation 2011; 123:e269-367. [PMID: 21382897 DOI: 10.1161/cir.0b013e318214876d] [Citation(s) in RCA: 595] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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14
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Huezey JY, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS. 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol 2011; 57:e101-98. [PMID: 21392637 DOI: 10.1016/j.jacc.2010.09.013] [Citation(s) in RCA: 642] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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15
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Camm AJ, Capucci A, Hohnloser SH, Torp-Pedersen C, Van Gelder IC, Mangal B, Beatch G. A randomized active-controlled study comparing the efficacy and safety of vernakalant to amiodarone in recent-onset atrial fibrillation. J Am Coll Cardiol 2011; 57:313-21. [PMID: 21232669 DOI: 10.1016/j.jacc.2010.07.046] [Citation(s) in RCA: 185] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Revised: 06/22/2010] [Accepted: 07/19/2010] [Indexed: 12/23/2022]
Abstract
OBJECTIVES This randomized double-blind study compared the efficacy and safety of intravenous vernakalant and amiodarone for the acute conversion of recent-onset atrial fibrillation (AF). BACKGROUND Intravenous vernakalant has effectively converted recent-onset AF and was well tolerated in placebo-controlled studies. METHODS A total of 254 adult patients with AF (3 to 48 h duration) eligible for cardioversion were enrolled in the study. Patients received either a 10-min infusion of vernakalant (3 mg/kg) followed by a 15-min observation period and a second 10-min infusion (2 mg/kg) if still in AF, plus a sham amiodarone infusion, or a 60-min infusion of amiodarone (5 mg/kg) followed by a maintenance infusion (50 mg) over an additional 60 min, plus a sham vernakalant infusion. RESULTS Conversion from AF to sinus rhythm within the first 90 min (primary end point) was achieved in 60 of 116 (51.7%) vernakalant patients compared with 6 of 116 (5.2%) amiodarone patients (p < 0.0001). Vernakalant resulted in rapid conversion (median time of 11 min in responders) and was associated with a higher rate of symptom relief compared with amiodarone (53.4% of vernakalant patients reported no AF symptoms at 90 min compared with 32.8% of amiodarone patients; p = 0.0012). Serious adverse events or events leading to discontinuation of study drug were uncommon. There were no cases of torsades de pointes, ventricular fibrillation, or polymorphic or sustained ventricular tachycardia. CONCLUSIONS Vernakalant demonstrated efficacy superior to amiodarone for acute conversion of recent-onset AF. Both vernakalant and amiodarone were safe and well tolerated in this study. (A Phase III Superiority Study of Vernakalant vs Amiodarone in Subjects With Recent Onset Atrial Fibrillation [AVRO]; NCT00668759).
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Affiliation(s)
- A John Camm
- St. George's University of London, United Kingdom.
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Abstract
Atrial fibrillation and atrial flutter are common arrhythmias in everyday clinical settings. Pharmacologic cardioversion (CV) is a simple and widely used strategy for the treatment of these arrhythmias, and many drugs are currently available. The choice of drug is strongly influenced by the time elapsed from atrial fibrillation onset and by a patient's clinical subset. Electrical direct-current CV is the treatment of choice in long-lasting forms; nevertheless, some agents also show efficacy in this setting. In addition, promising results come from studies on the efficacy and safety of new antiarrhythmic drugs and from therapeutic approaches that reduce the need for hospitalization and improve quality of life.
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Boriani G, Biffi M, Diemberger I, Domenichini G, Marziali A, Martignani C. Atrial fibrillation: adverse effects of "pill-in-the-pocket" treatment and propafenone-carvedilol interaction. Int J Cardiol 2010; 140:242-3; author reply 243-4. [PMID: 19062111 DOI: 10.1016/j.ijcard.2008.11.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2008] [Accepted: 11/09/2008] [Indexed: 10/21/2022]
Abstract
Propafenone and carvedilol share a common hepatic metabolism involving the oxidative pathway (CYP2D6). Therefore, oral loading with propafenone (as "pill-in-the-pocket" treatment of recent-onset atrial fibrillation) in a patient on concurrent carvedilol treatment may lead to a pharmacokinetic interaction, with high plasma levels of propafenone and potential drug-related adverse effects. In clinical practice, in order to improve the safety of "pill-in-the-pocket" treatment, use of propafenone loading should, in our view, be discouraged in patients on concurrent treatment with carvedilol.
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Boriani G, Biffi M, Branzi A, Magnani B. Pharmacological treatment of atrial fibrillation: a review on prevention of recurrences and control of ventricular response. Arch Gerontol Geriatr 2009; 27:127-39. [PMID: 18653157 DOI: 10.1016/s0167-4943(98)00106-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/1997] [Revised: 04/17/1998] [Accepted: 04/20/1998] [Indexed: 10/18/2022]
Abstract
Atrial fibrillation is the most common sustained arrhythmia, however its treatment remains controversial and problematic. Electrical or pharmacological cardioversion are able to restore sinus rhythm in many patients but maintenance of sinus rhythm requires long term treatment with antiarrrhythmic agents. Today there is major concern regarding the ventricular proarrhythmic effects of antiarrhythmic drugs because they may increase mortality. Even non-cardiac toxicity of these agents must be considered. An alternative strategy based on pharmacological control of ventricular response rate coupled with antithromboembolic prophylaxis can be followed. For rate control digoxin alone has some specific limitations, therefore, use of calcium antagonists (verapamil or diltiazem) or beta-blockers must be considered. At the present time, the relative efficacy and risks of these two alternative strategies in specific patients subgroups remain to be established. Today, non-pharmacological treatments, as atrio-ventricular node ablation are also available. In elderly patients, moreover, advanced age, underlying heart disease, concomitant systemic illnesses and patient compliance to treatments condition our decision making and treatment needs to be individualized. Appropriate knowledge of the advantages, of the limitations and of the costs of every pharmacological or non-pharmacological treatment option is required for deciding in every patient in view of the best risk-benefit and cost-benefit ratio.
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Affiliation(s)
- G Boriani
- Institute of Cardiology, University of Bologna, Policlinico S. Orsola, Via Massarenti 9, 40138 Bologna, Italy
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Reiffel JA. Cardioversion for atrial fibrillation: treatment options and advances. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:1073-84. [PMID: 19659629 DOI: 10.1111/j.1540-8159.2009.02441.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Atrial fibrillation (AF) is associated with significant morbidity and mortality. There are two basic approaches to managing AF: slowing the ventricular rate, while allowing the arrhythmia to continue (the rate-control approach), and restoring and maintaining sinus rhythm (the rhythm-control approach) with antiarrhythmic drugs (AADs) and/or ablation, electrical cardioversion (CV), if needed, or both. Strategy trials comparing rate and rhythm control have found no survival advantage of one approach over the other, but other considerations, such as symptom reduction, often necessitate pursuit of rhythm control. Electrical, or direct current, CV is a widely used and effective method for termination of nonparoxysmal AF, although its success can be affected by patient- and technique-related variables. Pharmacological CV options also exist and are preferable in specific circumstances. Both pharmacological and electrical CV are associated with the risk of proarrhythmia. Many AADs are under development for both CV and maintenance of sinus rhythm. Some are atrioselective, such as vernakalant, and target ion channels in the atria, with little or no effects in the ventricle. Vernakalant, currently under Food and Drug Administration review, appears to offer a safer profile than current CV agents and is likely to expand the role of pharmacological CV. Other new AADs that provide increased efficacy or safety while maintaining normal sinus rhythm may also be better than current drugs; if so, rate-rhythm comparisons will differ from those of previous studies. In conclusion, further trials should clarify the long-term safety profiles of new atrioselective agents and other investigational drugs and define their role in the treatment of AF.
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Affiliation(s)
- James A Reiffel
- Department of Medicine, Division of Cardiology, Section of Electrophysiology, Columbia University, New York, New York 10032, USA.
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20
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Abstract
Acute atrial fibrillation (AF) is the most common cardiac rhythm encountered in clinical practice and is commonly seen in acutely ill patients in critical care. In the latter setting, AF may have two main clinical sequelae: (1) haemodynamic instability and (2) thromboembolism. The approach to the management of AF can broadly be divided into a rate control strategy or a rhythm control strategy, and is largely driven by symptom assessment and functional status. A crucial part of AF management requires the appropriate use of thromboprophylaxis. In patients who are haemodynamically unstable with AF, urgent direct current cardioversion should be considered. Apart from electrical cardioversion, drugs are commonly used, and Class I (flecainide, propafenone) and Class III (amiodarone) antiarrhythmic drugs are more likely to revert AF to sinus rhythm. Beta blockers and rate limiting calcium blockers, as well as digoxin, are often used in controlling heart rate in patients with acute onset AF. The aim of this review article is to provide an overview of the management of AF in the critical care setting.
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Affiliation(s)
- Chee W Khoo
- University Department of Medicine, City Hospital, Birmingham, UK
| | - Gregory Y H Lip
- University Department of Medicine, City Hospital, Birmingham, UK.
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21
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Chevalier P, Touboul P. Pharmacotherapy of Atrial Fibrillation. Ann Noninvasive Electrocardiol 2008. [DOI: 10.1111/j.1542-474x.1998.tb00414.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Riccardi A, Lerza R. Controversies in the "pill in the pocket" approach to atrial fibrillation. Intern Emerg Med 2008; 3:187-9. [PMID: 18278444 DOI: 10.1007/s11739-008-0108-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Accepted: 05/07/2007] [Indexed: 11/28/2022]
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Boriani G, Diemberger I, Biffi M, Domenichini G, Martignani C, Valzania C, Branzi A. Electrical cardioversion for persistent atrial fibrillation or atrial flutter in clinical practice: predictors of long-term outcome. Int J Clin Pract 2007; 61:748-56. [PMID: 17493088 DOI: 10.1111/j.1742-1241.2007.01298.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Despite the results of Atrial Fibrillation Follow-up Investigation of Rhythm Management and Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation trials, which favour a general shift in atrial fibrillation (AF) therapeutic approach towards control of ventricular rate, a strategy based on restoration of sinus rhythm could still play a role in selected patients at lower risk of AF recurrence. We explored possible predictors of relapses after external electrical cardioversion among patients with persistent AF or atrial flutter (AFL). We analysed the clinical characteristics and conventional echocardiographic parameters of patients with persistent AF/AFL enrolled in an institutional electrical cardioversion programme. Among 242 patients (AF/AFL, 195/47; mean age 62+/-13 years), sinus rhythm was restored in 215 (89%) and maintained in 73 (34%) at a follow-up of 930 days (median). No baseline clinical/echocardiographic variables predicted acute efficacy of cardioversion at logistic regression analysis. However, two variables predicted long-term AF/AFL recurrence among patients with successful cardioversion at multivariate Cox's proportional hazards analysis: (i) duration of arrhythmia>or=1 year (HR, 2.07; 95% CI, 1.29-3.33) and (ii) presence of previous cardioversion (HR, 1.67; 95% CI, 1.17-2.38). These variables also presented high-positive predictive values (72% and 80% respectively). Whereas the high acute efficacy of electrical cardioversion (approximately 90%) does not appear to be predictable, two simple clinical variables could help identify patients at higher risk of long-term AF/AFL recurrence after successful electrical cardioversion. We think there could be a case for initially attempting external electrical cardioversion to patients who have had AF/AFL for <1 year. In such patients, the chance of long-term success appears to be relatively high.
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Affiliation(s)
- G Boriani
- Institute of Cardiology, University of Bologna, Azienda Ospedaliera S. Orsola-Malpighi, Bologna, Italy.
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation-executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation). Eur Heart J 2007; 27:1979-2030. [PMID: 16885201 DOI: 10.1093/eurheartj/ehl176] [Citation(s) in RCA: 362] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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ACC/AHA/ESC: Guías de Práctica Clínica 2006 para el manejo de pacientes con fibrilación auricular. Versión resumida. Rev Esp Cardiol 2006. [DOI: 10.1157/13096583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Affiliation(s)
- N Sulke
- Cardiology Department, East Sussex Hospitals NHS Trust, Eastbourne, UK.
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Triola BR, Kowey PR. Antiarrhythmic drug therapy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2006; 8:362-70. [PMID: 16939674 DOI: 10.1007/s11936-006-0040-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of antiarrhythmic drugs can be challenging to physicians. They are effective in treating various types of arrhythmias, yet their potential to cause adverse events, in particularly proarrhythmia, can be intimidating. When the decision to use antiarrhythmic therapy has been made, physicians are confronted with several issues: choosing the right drug, preventing complications, and selecting the setting in which the drug is to be given (in-hospital vs outpatient). In determining the best antiarrhythmic agent for each patient, one should have a basic understanding of their mechanisms of action and indications. Once this decision has been made, attention turns to avoiding complications and assessing for efficacy. Clinicians should be aware of the common drug interactions of each antiarrhythmic agent and avoid these whenever possible. In addition, patients need meticulous follow-up, including serial electrocardiograms and assessment for cardiovascular side effects. For several of the antiarrhythmic drugs, this can be accomplished in the outpatient setting in appropriate patients.
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Affiliation(s)
- Brian R Triola
- 558 Medical Office Building East, 100 Lancaster Avenue, Lankenau Hospital, Wynnewood, PA 19096, USA.
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114:e257-354. [PMID: 16908781 DOI: 10.1161/circulationaha.106.177292] [Citation(s) in RCA: 1381] [Impact Index Per Article: 76.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation—Executive Summary. J Am Coll Cardiol 2006; 48:854-906. [PMID: 16904574 DOI: 10.1016/j.jacc.2006.07.009] [Citation(s) in RCA: 717] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Schwartzman D, Harvey MN, Hoyt RH, Koehler JL, Ujhelyi MR, Euler DE. Utility of adjunctive single oral bolus propafenone therapy in patients with atrial defibrillators. ACTA ACUST UNITED AC 2006; 8:211-5. [PMID: 16627442 DOI: 10.1093/europace/euj051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIMS Previous studies have demonstrated that ambulatory atrial defibrillation shocks delivered by an implantable cardioverter-defibrillator (ICD) are safe and effective, but poorly tolerated. Separate studies have demonstrated the utility of single oral bolus propafenone for conversion of recent-onset atrial fibrillation (AF); however, most patients were hospitalized, had no structural heart disease, were taking no other antiarrhythmic drugs, and were not exposed to concomitant shock. We hypothesized that a single oral bolus dose of propafenone given early after onset would be a safe and effective adjunct to ICD-based AF therapy and improve overall therapy tolerance. METHODS AND RESULTS A randomized three-way crossover study design was used to compare three strategies, deployed in the ambulatory setting early after AF episode onset in 35 ICD patients with advanced, drug refractory episodic/persistent syndromes, many of whom had structural heart disease and were taking other antiarrhythmic drugs: (i) single oral bolus propafenone (600 mg), followed by ICD shock if necessary; (ii) single oral bolus placebo, followed by ICD shock if necessary; and (iii) no oral bolus therapy and ICD shock if necessary (no bolus). Antiarrhythmic efficacy, defined by the restoration of sinus rhythm within 24 h, was similar during propafenone (81%) and no-bolus strategies (84%); both were significantly higher than during placebo strategy (62%). Propafenone was well tolerated and not associated with proarrhythmia. Shock use was significantly lower during propafenone strategy (19%) than during no-bolus strategy (55%); this was correlated with improved patient tolerance. CONCLUSION Adjunctive use of single oral bolus propafenone is safe and effective in patients with an ICD and improves patient tolerance of device-based AF therapy.
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Affiliation(s)
- David Schwartzman
- University of Pittsburgh, UPMC Presbyterian, B535 Pittsburgh, PA 15213-2582, USA.
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Abstract
A rhythm control strategy based on a combination of antiarrhythmic drugs and electrical cardioversion(s) has emerged as a viable alternative for treatment of atrial fibrillation, particularly when the arrhythmia is associated with symptoms, which may be poorly tolerated, or with congestive heart failure. Several classes of antiarrhythmic drugs are available to restore sinus rhythm by chemical cardioversion and to help maintain it once it has been achieved. In our discussion, we will detail aspects of their efficacy and safety, and attempt to outline a pragmatic clinical approach to their use. Some newer drugs are currently under investigation and hold promise for improved efficacy and/or more favorable side effect profile and will be mentioned in this article.
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Affiliation(s)
- Peter R Kowey
- Department of Cardiology, Lankenau Hospital, MOBE Suite 558, 100 Lancaster Avenue, Wynnewood, PA 19096, USA.
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Pecini R, Elming H, Pedersen OD, Torp-Pedersen C. New antiarrhythmic agents for atrial fibrillation and atrial flutter. Expert Opin Emerg Drugs 2005; 10:311-22. [PMID: 15934869 DOI: 10.1517/14728214.10.2.311] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia and is a frequent reason for antiarrhythmic therapy. Existing antiarrhythmic drugs have important side effects and presently the therapy to maintain sinus rhythm is not superior to a strategy of controlling excessive heart rate. This review summarises current strategies to improve antiarrhythmic therapy for atrial fibrillation. The most important strategies are: i) to develop drugs without proarrhythmic effects--development of drugs devoid of QT prolonging potential is the main strategy; ii) multiple channel-blocking drugs--inspired by the efficacy of amiodarone, several drugs are being developed that have similar electrophysiological properties as amiodarone, but without the extracardiac side effects; iii) drugs that act exclusively in the atria--the atria contain specific potassium channels, and several drugs that act only on these channels are in development; and iv) antiarrhythmic therapy without effects on ion channels--inhibition of the renin-angiotensin system and steroid therapy has been shown to have some effect in the treatment of atrial fibrillation. Many drugs are in development and the therapeutic scenario for treatment of atrial fibrillation may change quickly.
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Affiliation(s)
- Redi Pecini
- Department of Cardiology, The National Hospital, Copenhagen, Denmark.
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Boriani G, Diemberger I, Biffi M, Martignani C, Branzi A. Pharmacological cardioversion of atrial fibrillation: current management and treatment options. Drugs 2005; 64:2741-62. [PMID: 15563247 DOI: 10.2165/00003495-200464240-00003] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Atrial fibrillation (AF) is the most common form of arrhythmia, carrying high social costs. It is usually first seen by general practitioners or in emergency departments. Despite the availability of consensus guidelines, considerable variations exist in treatment practice, especially outside specialised cardiological settings. Cardioversion to sinus rhythm aims to: (i) restore the atrial contribution to ventricular filling/output; (ii) regularise ventricular rate; and (iii) interrupt atrial remodelling. Cardioversion always requires careful assessment of potential proarrhythmic and thromboembolic risks, and this translates into the need to personalise treatment decisions. Among the many clinical variables that affect strategy selection, time from onset is crucial. In selected patients, pharmacological cardioversion of recent-onset AF can be a safely used, feasible and effective approach, even in internal medicine and emergency departments. In most cases of recent-onset AF, pharmacological cardioversion provides an important--and probably more cost effective--alternative to electrical cardioversion, which can then be employed as a second-line therapy for nonresponders. Class IC agents (flecainide or propafenone), which can be safely used in hospitalised patients with recent-onset AF without left ventricular dysfunction, can provide rapid conversion to sinus rhythm after either intravenous administration or oral loading. Although intravenous amiodarone requires longer conversion times, it is still the standard treatment for patients with heart failure. Ibutilide also provides good conversion rates and could be used for AF patients with left ventricular dysfunction (were it not for high costs). For long-lasting AF most pharmacological treatments have only limited efficacy and electrical cardioversion remains the gold standard in this setting. However, a widely used strategy involves pretreatment with amiodarone in the weeks before planned electrical cardioversion: this provides optimal prophylaxis and can sometimes even restore sinus rhythm. Dofetilide may also be capable of restoring sinus rhythm in up to 25-30% of patients and can be used in patients with heart failure. The potential risk of proarrhythmia increases the need for careful therapeutic decision making and management of pharmacological cardioversion. The results of recent trials (AFFIRM [Atrial Fibrillation Follow-up Investigation of Rhythm Management] and RACE [Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation]) on rate versus rhythm control strategies in the long term have led to a generalised shift in interest towards rate control. Although carefully designed studies are required to better define the role of pharmacological rhythm control in specific AF settings, this alternative option remains a recommendable strategy for many patients, especially those in acute care.
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Affiliation(s)
- Giuseppe Boriani
- Institute of Cardiology, University of Bologna, Azienda Ospedaliera S. Orsola-Malpighi, Bologna, Italy.
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Alboni P, Botto GL, Baldi N, Luzi M, Russo V, Gianfranchi L, Marchi P, Calzolari M, Solano A, Baroffio R, Gaggioli G. Outpatient treatment of recent-onset atrial fibrillation with the "pill-in-the-pocket" approach. N Engl J Med 2004; 351:2384-91. [PMID: 15575054 DOI: 10.1056/nejmoa041233] [Citation(s) in RCA: 283] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In-hospital administration of flecainide and propafenone in a single oral loading dose has been shown to be effective and superior to placebo in terminating atrial fibrillation. We evaluated the feasibility and the safety of self-administered oral loading of flecainide and propafenone in terminating atrial fibrillation of recent onset outside the hospital. METHODS We administered either flecainide or propafenone orally to restore sinus rhythm in 268 patients with mild heart disease or none who came to the emergency room with atrial fibrillation of recent onset that was hemodynamically well tolerated. Of these patients, 58 (22 percent) were excluded from the study because of treatment failure or side effects. Out-of-hospital self-administration of flecainide or propafenone--the "pill-in-the-pocket" approach--after the onset of heart palpitations was evaluated in the remaining 210 patients (mean age [+/-SD], 59+/-11 years). RESULTS During a mean follow-up of 15+/-5 months, 165 patients (79 percent) had a total of 618 episodes of arrhythmia; of those episodes, 569 (92 percent) were treated 36+/-93 minutes after the onset of symptoms. Treatment was successful in 534 episodes (94 percent); the time to resolution of symptoms was 113+/-84 minutes. Among the 165 patients with recurrences, the drug was effective during all the arrhythmic episodes in 139 patients (84 percent). Adverse effects were reported during one or more arrhythmic episodes by 12 patients (7 percent), including atrial flutter at a rapid ventricular rate in 1 patient and noncardiac side effects in 11 patients. The numbers of monthly visits to the emergency room and hospitalizations were significantly lower during follow-up than during the year before the target episode (P<0.001 for both comparisons). CONCLUSIONS In a selected, risk-stratified population of patients with recurrent atrial fibrillation, pill-in-the-pocket treatment is feasible and safe, with a high rate of compliance by patients, a low rate of adverse events, and a marked reduction in emergency room visits and hospital admissions.
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Affiliation(s)
- Paolo Alboni
- Division of Cardiology, Ospedale Civile, Cento, Italy.
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Nichol G, Huszti E, Rokosh J, Dumbrell A, McGowan J, Becker L. Impact of informed consent requirements on cardiac arrest research in the United States: exception from consent or from research? Resuscitation 2004; 62:3-23. [PMID: 15246579 DOI: 10.1016/j.resuscitation.2004.02.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2003] [Revised: 02/11/2004] [Accepted: 02/11/2004] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Research in patients with life-threatening illness such as cardiac arrest is challenging since they can not consent. The Food and Drug Administration addressed research under emergency conditions by publishing new criteria for exception from informed consent in 1996. We systematically reviewed randomized trials over a 10-year period to assess the impact of these regulations. METHODS Case-control study of published trials for cardiac arrest (cases) and atrial fibrillation (controls.) Studies were identified by using structured searches of MEDLINE and EMBASE from 1992 to 2002. Included were studies using random allocation in humans with cardiac arrest or atrial fibrillation prior to enrollment. Excluded were duplicate publications. Number of American trials, foreign trials and proportion of trials of American origin were compared by using regression analysis. Changes in cardiac arrest versus atrial fibrillation trials were calculated as risk differences. RESULTS Of 4982 identified cardiac arrest studies, 57 (1.1%) were randomized trials. The number of American cardiac arrest trials decreased by 15% (95% CI: 8, 22%) annually (P = 0.05). The proportion of cardiac arrest trials of American origin decreased by 16% (95% CI: 10, 22%) annually (P = 0.006). Of 5596 identified atrial fibrillation studies, 197 trials (3.5%) were randomized trials. The risk difference between cardiac arrest versus atrial fibrillation trials being of American origin decreased significantly (annual difference -5.8% (95% CI: -10, -0.1%), P = 0.03). INTERPRETATION Fewer American cardiac arrest trials were published during the last decade, when federal consent requirements changed. Regulatory requirements for clinical trials may inhibit improvements in care and threaten public health.
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Affiliation(s)
- G Nichol
- Clinical Epidemiology Program and Department of Medicine, University of Ottawa, ON, Canada.
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Abstract
In the post-AFFIRM era, treatment of AF has become the treatment of symptoms. In some patients, this will be simple rate control, but there remain a significant cohort of patients in whom rate control alone does not give acceptable symptom relief. In this group, antiarrhythmic therapy still has a role, and the AFFIRM trial indicates that this therapeutic strategy is without significant deleterious effect on mortality. The choice of antiarrhythmic agent must be individualized according to underlying cardiac pathologies and comorbidities, however. Most recently, the introduction of dofetilide has widened the therapeutic options in patients with severe heart disease, and the Canadian Trial of Atrial Fibrillation indicated the superior efficacy of amiodarone at low doses. The release/ development of newer Class III antiarrhythmic agents may offer hope for the benefits of amiodarone without the serious adverse effects with long-term therapy.
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Affiliation(s)
- Robert A VerNooy
- Electrophysiology Laboratory, Cardiovascular Division, Department of Medicine, University of Virginia Health System, Private Clinics Building, Room 5610, Hospital Drive, Charlottesville, VA 22908-0158, USA
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Nichol G, McAlister F, Pham B, Laupacis A, Shea B, Green M, Tang A, Wells G. Meta-analysis of randomised controlled trials of the effectiveness of antiarrhythmic agents at promoting sinus rhythm in patients with atrial fibrillation. Heart 2002; 87:535-43. [PMID: 12010934 PMCID: PMC1767130 DOI: 10.1136/heart.87.6.535] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To conduct a meta-analysis of randomised controlled trials to estimate the effectiveness of antiarrhythmic drugs at promoting sinus rhythm in patients with atrial fibrillation. DESIGN Articles were identified by using a comprehensive search of English language papers indexed in Medline from 1966 to August 2001. For the outcomes of sinus rhythm and death, a random effects model was used to model repeated assessments within a study at different time points. SETTING Emergency departments and ambulatory clinics. PATIENTS Patients with atrial fibrillation. INTERVENTIONS Antiarrhythmic agents grouped according to their Vaughan-Williams class. MAIN OUTCOME MEASURES Sinus rhythm and mortality. RESULTS 91 articles met a priori criteria for inclusion in the analysis. Median duration of follow up was one day (range 0.04-1096, mean (SD) 46 (136) days). The median proportion of patients in sinus rhythm at follow up was 55% (range 0-100%) and 32% (range 0-90%) receiving active treatment and placebo, respectively. Median survival was 99% (range 55-100%) and 99% (range 55-100%). Compared with placebo, the following drug classes were associated with increased sinus rhythm at follow up: IA (treatment difference 21.5%, 95% confidence interval (CI) 16.3% to 26.8%); IC (treatment difference 33.1%, 95% CI 23.3% to 42.9%); and III (treatment difference 17.4%, 95% CI 11.5% to 23.3%). Class IC drugs were associated with increased sinus rhythm at follow up compared with class IV drugs (treatment difference 43.2%, 95% CI 11.5% to 75.0%). There was no significant difference in mortality between any drug classes. CONCLUSIONS Class IA, IC, and III drugs are associated with increased sinus rhythm at follow up compared with placebo. It is unclear whether any antiarrhythmic drug class is associated with increased or decreased mortality.
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Affiliation(s)
- G Nichol
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada.
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Boriani G, Martignani C, Biffi M, Capucci A, Branzi A. Oral loading with propafenone for conversion of recent-onset atrial fibrillation: a review on in-hospital treatment. Drugs 2002; 62:415-23. [PMID: 11827557 DOI: 10.2165/00003495-200262030-00001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Atrial fibrillation (AF) is a very common arrhythmia. In order to treat acute AF rapidly, effective drug regimens are required. Propafenone is a class IC antiarrhythmic agent that is suitable for oral loading as it reaches peak plasma concentrations within 2 to 4 hours of administration. The use of propafenone loading in patients with AF must be based on appropriate patient selection in view of the negative inotropic effect and the potential proarrhythmic effects of the drug. A series of controlled trials in patients with recent-onset AF without heart failure who were hospitalised with enforced bed rest has shown that orally loaded propafenone (450 to 600 mg as single dose) exerts a relatively quick effect (within 3 to 4 hours) and a high rate of efficacy (72 to 78% within 8 hours). A potentially harmful effect of class IC agents is the risk of transforming AF into atrial flutter (3.5 to 5% of patients). However, atrial flutter with 1 : 1 atrioventricular response was observed in only two of 709 patients receiving propafenone (0.3% incidence). Nevertheless, the potential negative inotropic effect of propafenone demands careful patient selection, with systematic exclusion of patients with left ventricular dysfunction or congestive heart failure. Oral loading with propafenone can be considered as an episodic treatment in patients with AF recurrences, as has been proposed for other drugs in the past. However, the safety of oral loading with propafenone as an outpatient treatment in appropriately selected patients has to be assessed by appropriately designed prospective studies.
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Affiliation(s)
- Giuseppe Boriani
- Institute of Cardiology, University of Bologna, Policlinico S. Orsola, Via Massarenti 9, 40138 Bologna, Italy.
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Fuster V, Rydén LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, Halperin JL, Kay GN, Klein WW, Lévy S, McNamara RL, Prystowsky EN, Wann LS, Wyse DG, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC, Klein WW, Alonso-Garcia A, Blomström-Lundqvist C, de Backer G, Flather M, Hradec J, Oto A, Parkhomenko A, Silber S, Torbicki A. ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation)Developed in Collaboration With the North American Society of Pacing and Electrophysiology. Circulation 2001. [DOI: 10.1161/circ.104.17.2118] [Citation(s) in RCA: 557] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Fuster V, Rydén LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, Halperin JL, Kay GN, Klein WW, Lévy S, McNamara RL, Prystowsky EN, Wann LS, Wyse DG, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC, Klein WW, Alonso-Garcia A, Blomström-Lundqvist C, De Backer G, Flather M, Hradec J, Oto A, Parkhomenko A, Silber S, Torbicki A. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary. A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation): developed in Collaboration With the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol 2001; 38:1231-66. [PMID: 11583910 DOI: 10.1016/s0735-1097(01)01587-x] [Citation(s) in RCA: 486] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Fuster V, Rydén LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, Halperin JL, Kay G, Klein WW, Lévy S, McNamara RL, Prystowsky EN, Wann L, Wyse D, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC, Klein WW, Alonso-Garcia A, Blomström-Lundqvist C, De Backer G, Flather M, Hradec J, Oto A, Parkhomenko A, Silber S, Torbicki A. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation31This document was approved by the American College of Cardiology Board of Trustees in August 2001, the American Heart Association Science Advisory and Coordinating Committee in August 2001, and the European Society of Cardiology Board and Committee for Practice Guidelines and Policy Conferences in August 2001.32When citing this document, the American College of Cardiology, the American Heart Association, and the European Society of Cardiology would appreciate the following citation format: Fuster V, Rydén LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, Halperin JL, Kay GN, Klein WW, Lévy S, McNamara RL, Prystowsky EN, Wann LS, Wyse DG. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol 2001;38:XX-XX.33This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org), the American Heart Association (www.americanheart.org), the European Society of Cardiology (www.escardio.org), and the North American Society of Pacing and Electrophysiology (www.naspe.org). Single reprints of this document (the complete Guidelines) to be published in the mid-October issue of the European Heart Journal are available by calling +44.207.424.4200 or +44.207.424.4389, faxing +44.207.424.4433, or writing Harcourt Publishers Ltd, European Heart Journal, ESC Guidelines – Reprints, 32 Jamestown Road, London, NW1 7BY, United Kingdom. Single reprints of the shorter version (Executive Summary and Summary of Recommendations) published in the October issue of the Journal of the American College of Cardiology and the October issue of Circulation, are available for $5.00 each by calling 800-253-4636 (US only) or by writing the Resource Center, American College of Cardiology, 9111 Old Georgetown Road, Bethesda, Maryland 20814. To purchase bulk reprints specify version and reprint number (Executive Summary 71-0208; full text 71-0209) up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 214-706-1466, fax 214-691-6342; or E-mail: pubauth@heart.org. J Am Coll Cardiol 2001. [DOI: 10.1016/s0735-1097(01)01586-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Slavik RS, Tisdale JE, Borzak S. Pharmacologic conversion of atrial fibrillation: a systematic review of available evidence. Prog Cardiovasc Dis 2001; 44:121-52. [PMID: 11568824 DOI: 10.1053/pcad.2001.26966] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This report reviews the efficacy of currently available antiarrhythmic agents for conversion of atrial fibrilation (AF) to normal sinus rhythm (NSR). A systematic search of literature in the English language was done on computerized databases, such as MEDLINE, EMBASE, and Current Contents, in reference lists, by manual searching, and in contact with expert informants. Published studies involving humans that described the use of antiarrhythmic therapy for conversion of AF to NSR were considered and only studies that examined the use of agents currently available in the United States were included. Studies exclusively describing antiarrhythmic therapy for conversion of postsurgical AF were excluded. The methodology and results of each trial were assessed and attempts were made to acquire additional information from investigators when needed. Assessment of methodological quality was incorporated into a levels-of-evidence scheme. Eighty-eight trials were included, of which 34 (39%) included a placebo group (level I data). We found in recent-onset AF of less than 7 days, intravenous (i.v.) procainamide, high-dose i.v. or high-dose combination i.v. and oral amiodarone, oral quinidine, oral flecainide, oral propafenone, and high-dose oral amiodarone are more effective than placebo for converting AF to NSR. In recent-onset AF of less than 90 days, i.v. ibutilide is more effective than placebo and i.v. procainamide. In chronic AF, oral dofetilide converts AF to NSR within 72 hours, and oral propafenone and amiodarone are effective after 30 days of therapy. We conclude than for conversion of recent-onset AF of less than 7 days, procainamide may be considered a preferred i.v. agent and propafenone a preferred oral agent. For conversion of recent-onset AF of longer duration (less than 90 days), i.v. ibutilide may be considered a preferred agent. For patients with chronic AF and left ventricular dysfunction, direct current cardioversion is the preferred conversion method. Larger, well-designed randomized controlled trials with clinically important endpoints in specific populations of AF patients are needed.
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Affiliation(s)
- R S Slavik
- Clinical Services Unit-Pharmaceutical Sciences, Vancouver Hospital and Health Sciences Center, University of British Columbia, Vancouver, BC, Canada
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Khan IA. Single oral loading dose of propafenone for pharmacological cardioversion of recent-onset atrial fibrillation. J Am Coll Cardiol 2001; 37:542-7. [PMID: 11216976 DOI: 10.1016/s0735-1097(00)01116-5] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The efficacy and safety of the single dose oral loading regimen of propafenone for pharmacological cardioversion of recent-onset atrial fibrillation (AFib) was evaluated by analyzing the trials on the subject identified through a comprehensive literature search. Most of the trials used a single dose of 600 mg for oral loading. The success rates ranged from 56% to 83%, depending on the duration of AFib and follow-up after drug administration. The conversion time ranged from 110 +/- 59 to 287 +/- 352 min, depending on the duration of observation after drug administration. The single dose oral loading regimen of propafenone was significantly more efficacious than placebo in the first 8 h after administration but not at 24 h. Compared with the intravenous regimen, the oral regimen resulted in fewer conversions in the first 2 h, but both regimens were equally efficacious afterward. The oral propafenone regimen was as efficacious as the single dose oral loading regimen of flecainide but was superior to those of quinidine and amiodarone. The adverse effects reported were transient arrhythmia, reversible QRS-complex widening, transient hypotension and mild noncardiac side effects. The transient arrhythmias were chiefly at the time of conversion and included appearance of atrial flutter, bradycardia, pauses and junctional rhythm. No life-threatening proarrhythmic adverse effects were reported. The single oral loading dose of propafenone appears to be highly effective for conversion of recent-onset AFib, with a relatively rapid effect within 2 to 3 h and freedom from serious adverse effects.
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Affiliation(s)
- I A Khan
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska 68131-2044, USA.
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Anguera Camós I, Brugada Terradellas P. [New perspectives in the nonpharmacological treatment of atrial fibrillation]. Med Clin (Barc) 2000; 114:25-30. [PMID: 10782458 DOI: 10.1016/s0025-7753(00)71177-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Blanc JJ, Voinov C, Maarek M. Comparison of oral loading dose of propafenone and amiodarone for converting recent-onset atrial fibrillation. PARSIFAL Study Group. Am J Cardiol 1999; 84:1029-32. [PMID: 10569658 DOI: 10.1016/s0002-9149(99)00493-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In patients with recent-onset atrial fibrillation (AF), restoration of sinus rhythm is considered to be the first-line therapeutic option. Although this conversion might be obtained by direct-current shock or intravenous antiarrhythmic drugs, administration of an oral loading dose of class I or III antiarrhythmic drugs is more simple and convenient. This prospective, randomized, multicenter study compares the time to conversion to sinus rhythm obtained with an oral loading dose of propafenone or amiodarone. Patients with recent-onset AF (<2 weeks), without contraindications for the 2 drugs, were randomly assigned to be treated with propafenone (600 mg for the first 24 hours and if necessary a repeated dose of 300 mg for 24 hours) or amiodarone (30 mg/kg for the first 24 hours and if necessary a repeated dose of 15 mg/kg for 24 hours). Exact conversion time during the first 24 hours was determined by Holter monitoring. In each treatment group 43 patients with the same baseline characteristics were included. The median time for restoration of sinus rhythm was shorter (p = 0.05) in the propafenone (2.4 hours) than in the amiodarone (6.9 hours) group. After 24 hours (56% in the propofenone and 47% in the amiodarone group) and 48 hours, the same proportion of patients in the 2 groups recovered sinus rhythm (no serious adverse events were noticed). Thus, oral loading dose of propafenone or amiodarone was safe with a similar conversion rate of recent-onset AF. Propafenone had a faster action.
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Affiliation(s)
- J J Blanc
- Department of Cardiology Brest University Hospital, France
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Ergene U, Ergene O, Fowler J, Kinay O, Cete Y, Oktay C, Nazli C. Must antidysrhythmic agents be given to all patients with new-onset atrial fibrillation? Am J Emerg Med 1999; 17:659-62. [PMID: 10597083 DOI: 10.1016/s0735-6757(99)90153-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We investigated the spontaneous conversion rate of new-onset atrial fibrillation (AF) in emergency department patients and the recurrence rate of AF during a 1 month follow-up period. Sixty-six consecutive hemodynamically stable patients presenting to a university hospital emergency department with new-onset atrial fibrillation (less than 72 hours duration) comprised the study population. Patients were initially monitored for 8 hours and observed for spontaneous conversion of AF to sinus rhythm. If conversion did not occur in the first 8 hours, an oral loading dose (600 mg) of propafenone was given, and patients were observed for an additional 8 hours. All patients were reevaluated at 24 hours and at 1 month. The spontaneous conversion rate in patients presenting within 6 hours of AF onset during the initial 8-hour observation period was 71%. The spontaneous conversion rate for all patients during the initial observation period was 53%. The conversion rates between patients presenting "early" (less than 6 hours) and "late" (7-72 hours) were significantly different (P < 0.001). Many patients with new-onset AF, especially those with atrial fibrillation duration less than 6 hours, may need observation only, rather than immediate intervention, to treat their dysrhythmia.
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Affiliation(s)
- U Ergene
- Department of Emergency Medicine, Dokuz Eylul University Medical Center, Izmir, Turkey
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Biffi M, Boriani G, Bronzetti G, Capucci A, Branzi A, Magnani B. Electrophysiological effects of flecainide and propafenone on atrial fibrillation cycle and relation with arrhythmia termination. Heart 1999; 82:176-82. [PMID: 10409531 PMCID: PMC1729125 DOI: 10.1136/hrt.82.2.176] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES (1) To investigate the electrophysiological effects of flecainide and propafenone during atrial fibrillation, and their relation to arrhythmia termination; (2) to investigate the effects of isoprenaline on atrial fibrillation in basal conditions and during treatment with class 1C drugs to evaluate the role of adrenergic stimulation on proarrhythmic events occurring during this treatment. DESIGN Prospective, single centre study. SETTING University hospital. METHODS 10 patients with lone paroxysmal atrial fibrillation underwent an electrophysiological study. The dynamic behaviour of MFF (the mean of 100 consecutive atrial fibrillation intervals) was evaluated at two atrial sites after induction of atrial fibrillation either at baseline or after class 1C drug administration (flecainide or propafenone 2 mg/kg). The effects of isoprenaline on MFF and RR interval were also investigated both under basal conditions and during class 1C drug treatment. RESULTS After induction of atrial fibrillation, mean (SD) MFF shortened with time, and was further shortened by isoprenaline infusion (177 (22) v 162 (16) v 144 (11) ms, p < 0.05). The administration of class 1C drugs reversed this trend and significantly increased the MFF to an average of 295 (49) ms, leading to conversion to sinus rhythm within 10 minutes in all patients. Atrial fibrillation was then reinduced on class 1C drugs: isoprenaline shortened the MFF and RR interval with a trend to AV synchronisation (223 (43) v 269 (49) ms for the MFF, 347 (55) v 509 (92) ms for the RR, p < 0.05); 1:1 sustained AV conduction occurred in two patients, at 187 and 222 beats/min respectively. One of these patients underwent electrical cardioversion because of haemodynamic collapse. CONCLUSIONS Class 1C drugs are effective at restoring sinus rhythm by increasing the MFF to a much greater extent than observed in self terminating atrial fibrillation episodes, and reversing the spontaneous atrial fibrillation behaviour (progressive shortening of MFF and self perpetuation of atrial fibrillation). MFF prolongation with 1:1 conduction at fast ventricular rates may lead to synchronisation during adrenergic stimulation, with a very short ventricular cycle; hence it is advisable to keep the patients at rest after acute class 1C drug loading or to consider pharmacological modulation of AV conduction for patients who are prone to a fast ventricular response.
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Affiliation(s)
- M Biffi
- Institute of Cardiovascular Diseases, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
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Valderrábano M, Singh BN. Electrophysiologic and Antiarrhythmic Effects of Propafenone: Focus on Atrial Fibrillation. J Cardiovasc Pharmacol Ther 1999; 4:183-198. [PMID: 10684540 DOI: 10.1177/107424849900400308] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- M Valderrábano
- Veterans Affairs Medical Center of West Los Angeles, Los Angeles, California, USA
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