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Pharmakologische Therapie bei Vorhofflimmern – Was leisten moderne Antiarrhythmika wirklich?

Drug therapy in atrial fibrillation – The real value of antiarrhythmic drugs

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Clinical Research in Cardiology Supplements Aims and scope

Zusammenfassung

Trotz zunehmender Verbreitung der direkten Vorhofflimmerablation bleibt für die Mehrzahl der Patienten die medikamentöse Therapie mit Antiarrhythmika die Behandlung der ersten Wahl bei der Rhythmuskontrolle des Vorhofflimmerns. Patienten mit neu aufgetretenem Vorhofflimmern kardiovertieren unter Klasse-IC- bzw. Klasse-III-Antiarrhythmika in ca. 60–70% in den Sinusrhythmus. Ohne Antiarrhythmika liegt die Konversionsrate immerhin auch bei ca. 40%. Bei Patienten mit länger persistierendem Vorhofflimmern ist ein medikamentöser Kardioversionsversuch kaum aussichtsreich, sodass in diesen Fällen eine elektrische Kardioversion empfohlen wird.

Nach erfolgreicher elektrischer oder medikamentöser Kardioversion finden sich trotz Rezidivprophylaxe mit Klasse-I- oder Klasse-III-Antiarrhythmika enttäuschend niedrige Persistenzraten für den Sinusrhythmus (30–40% nach 12 Monaten). Lediglich für Amiodaron lassen sich höhere Erfolgsraten (70% Sinusrhythmus nach 12 Monaten) nachweisen, was aber mit einer höheren Nebenwirkungsrate erkauft werden muss. Ob neue Klasse-III-Antiarrhythmika (wobei vor allem Dofetilide und Dronedarone im Mittelpunkt des Interesses stehen) eine prinzipielle Änderung der bislang unbefriedigenden antiarrhythmischen Therapie bewirken können, scheint noch offen. Neben den Antiarrhythmika im engeren Sinne vermögen jedoch insbesondere Betablocker, aber auch ACE-Hemmer und AT1-Rezeptorantagonisten, möglicherweise sogar OMEGA-3-Fettsäuren und in speziellen Fällen evtl. Glukokortikoide, zur Stabilisierung des Sinusrhythmus beizutragen. Bei der Festlegung der medikamentösen antiarrhythmischen Therapie im Einzelfall ist vom Verhältnis zwischen antiarrhythmischer Effizienz einerseits und den Nebeneffekten, insbesondere Proarrhythmien andererseits auszugehen.

Abstract

Apart from the rising importance of the primary catheter ablation of atrial fibrillation, the use of antiarrhythmic drugs remains first choice for rhythm control in the majority of patients. The cardioversion rate into sinus rhythm in patients with recent- onset atrial fibrillation is about 60 to 70% when antiarrhythmic drugs of class IC or class III are used. Nevertheless cardioversion rate without the use of antiarrhythmic drugs is about 40%. In patients with a long-term atrial fibrillation, cardioversion by means of antiarrhythmic drugs is generally unsuccessful. In those cases, electrical cardioversion is recommended.

After successful electrical or pharmacological cardioversion, we find disappointingly low maintenance rates of sinus rhythm (30 to 40% after 12 months) by using antiarrhythmic drugs of class IC or class III. Only amiodarone is more successful (70% sinus rhythm after 12 months), but patients have to cope with a higher rate of adverse events in exchange. Whether new antiarrhythmic drugs, like especially dofetilide or dronedarone, can bring about essential changes in the until now disappointing antiarrhythmic drug therapy remains to be proved. Also useful for the stabilisation and persistence of sinus rhythm are betablockers, ACE inhibitors and angiotensin receptor antagonists, or perhaps OMEGA-3-fatty acids or in special cases glucocorticoids. In each individual case, the risk of adverse events, especially proarrhythmias, has to be weighed against the antiarrhythmic efficacy of the prescribed antiarrhythmic drug.

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Literatur

  1. ACP/ACC/AHA Task Force Statement (1993) Clinical competence in elective direct current (DC) cardioversion. J Am Coll Cardiol 22:336–339

  2. Alboni P, Botto GL, Baldi N et al (2004) Outpatient treatment of recent-onset atrial fibrillation with the “pill-in-the-pocket” approach. N Engl J Med 351:2384–2391

    Article  PubMed  CAS  Google Scholar 

  3. Arima H, Hart RG, Colman S, Chalmers J, Anderson C, Rodgers A,Woodward M, MacMahon S, Neal B for the PROGRESS collaborative group (2005) Perindopril-based blood pressure-lowering reduces major vascular events in patients with atrial fibrillation and prior stroke or transient ischemic attack. Stroke 36:2164–2169

    Article  PubMed  CAS  Google Scholar 

  4. Baldi N, Russo VA, Lenti V et al (1993) Relation between plasma levels and efficacy of flecainide and propafenone for treatment of atrial fibrillation of recent onset. New Trends Arrhythmias 9:899–906

    Google Scholar 

  5. Bianconi L, Boccadamo R, Pappalardo A, Gentil C, Pistoles M (1989) Effectiveness of intravenous propafenon for conversion of atrial fibrillation and flutter of recent onset. Am J Cardiol 64:335–338

    Article  PubMed  CAS  Google Scholar 

  6. Brodsky MA, Allen BJ, Walker CJ, Casey TP, Luckett CR, Henry WL (1987) Amiodarone for maintenance of sinus rhythm after conversion of atrial fibrillation in the setting of a dilated left atrium. Am J Cardiol 60:572–575

    Article  PubMed  CAS  Google Scholar 

  7. Cairns JA, Connolly SJ, Roberts R et al (1997) Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarizations: CAMIAT. Canadian American Myocardial Infarction Arrhythmia Trial Investigators. Lancet 349:675–682

    Article  PubMed  CAS  Google Scholar 

  8. Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJG, Damiano RJ, Davies DW, Haines DE, Haissaguerre M, Iesaka Y, Jackman W, Jais P, Kottkamp H, Kuck KH, Lindsay BD, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Natale A, Pappone C, Prystowsky E, Raviele A, Ruskin JN, Shemin RJ (2007) HRA/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. Heart Rhythm 4:816–861

    Article  PubMed  Google Scholar 

  9. Calo L, Bianconi L, Colivicchi F, Lamberti F, Loricchio ML, de Ruvo E, Meo A, Pandozi C, Staibano M, Santini M (2005) N-3 fatty acids for the prevention of atrial fibrillation after coronary artery bypass surgery. A randomized, controlled trial. J Am Coll Cardiol 45:1723–1728

    Article  PubMed  CAS  Google Scholar 

  10. Capucci A, Lenzi T, Boriani G et al (1992) Effectiveness of loading oral flecainide for converting recent-onset atrial fibrillation to sinus rhythm in patients without organic heart disease or with only hypertension. Am J Cardiol 70:69–72

    Article  PubMed  CAS  Google Scholar 

  11. Coplen SE, Antman EM, Berlin JA, Hewitt P, Chalmers TC (1990) Efficacy and safety of quinidine therapy for maintenance of sinus rhythm after cardioversion. A meta-analysis of randomized trials. Circulation 82:1106–1116

    PubMed  CAS  Google Scholar 

  12. Dernellis J, Panaretou M (2004) Relationship between C-reactive protein concentrations during glucocorticoid therapy and recurrent atrial fibrillation. Eur Heart J 25:1100–1107

    Article  PubMed  CAS  Google Scholar 

  13. Fetsch T, Bauer P, Engberding R, Koch HP, Lukl J, Meinertz T, Oeff M, Seipel L, Trappe HJ, Treese N, Breithardt G (2004) Prevention of atrial fibrillation after cardioversion: results of the PAFAC trial. Eur Heart J 25:1385–1394

    Article  PubMed  Google Scholar 

  14. Flaker GC, Blachshear JL, McBride R, Kronmal RA, Halperin JL, Hart RG, SPAF investigators (1992) Antiarrhythmic drug therapy and cardiac mortality in atrial fibrillation. J Am Coll Cardiol 20:527–532

    PubMed  CAS  Google Scholar 

  15. Fuster V, Ryden 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 (2006) ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation-executive summary. Eur Heart J 27:1979–2030

    Article  PubMed  Google Scholar 

  16. Hohnloser S, Zabel H (1992) Shortand long-term efficacy and safety of flecainide acetate for supraventricular arrhythmias. Am J Cardiol 70:3A–10A

    Article  PubMed  CAS  Google Scholar 

  17. Julian DG, Camm AJ, Frangin G et al (1997) Randomised trial of effect of amiodarone on mortality in patients with left-ventricular dysfunction after recent myocardial infarction: EMIAT. European Myocardial Infarct Amiodarone Trial Investigators. Lancet 349:667–674

    Article  PubMed  CAS  Google Scholar 

  18. Juul-Möller S, Edvardsson N, Rehnqvist-Ahlberg N (1990) Sotalol versus quinidine for the maintenance of sinus rhythm after direct current conversion of atrial fibrillation. Circulation 82:1932–1939

    PubMed  Google Scholar 

  19. Karlson BW, Herlitz J, Edvardsson N, Olsson SB (1990) Prophylactic treatment after electroconversion of atrial fibrillation. Clin Cardiol 13:279–286

    Article  PubMed  CAS  Google Scholar 

  20. Kober L, Bloch Thomsen PE, Moller M et al (2000) Effect of dofetilide in patients with recent myocardial infarction and left-ventricular dysfunction: a randomised trial. Lancet 356:2052–2058

    Article  PubMed  CAS  Google Scholar 

  21. Kühlkamp V, Schirdewan A, Stangl K et al (2000) Use of metoprolol CR/XL to maintain sinus rhythm after conversion from persistent atrial fibrillation: a randomized, double-blind, placebo-controlled study. J Am Coll Cardiol 36:139–146

    Article  PubMed  Google Scholar 

  22. Patten M, Maas R, Bauer P, Lüderitz B, Sonntag F, Dluzniewski M, Hatala R, Opolski G, Müller HW, Meinertz T (2004) Suppression of paroxysmal atrial tachyarrhythmias – results of the SOPAT trial. Eur Heart J 25:1395–1404

    Article  PubMed  Google Scholar 

  23. Reisinger J, Gatterer E, Lang W, Vanicek T, Eisserer G, Bachleitner T, Niemeth C, Aicher F, Grander W, Heinze G, Kühn P, Siostrzonek P (2004) Flecainide versus ibutilide for immediate cardioversion of atrial fibrillation of recent onset. Eur Heart J 25:1318–1324

    Article  PubMed  CAS  Google Scholar 

  24. Roy D, Talajic M, Dorian P et al (2000) Amiodarone to prevent recurrence of atrial fibrillation. N Engl J Med 342:913–920

    Article  PubMed  CAS  Google Scholar 

  25. Singh BN, Singh SN, Reda DJ, Tang XC, Lopez B, Harris CL, Fletcher RD, Sharma SC, Atwood JE, Jacobson AK, Lewis HD, Raisch DW, Ezekowitz MD for the Sotalol Amiodarone Atrial Fibrillation Efficacy Trial (SAFE-T) Investigators (2005) Amiodarone versus Sotalol for Atrial Fibrillation. N Engl J Med 352:1861–1872

    Article  PubMed  CAS  Google Scholar 

  26. Singh BN (2007) Dronedarone for maintenance of sinus rhythm in atrial fibrillation or flutter. N Engl J Med 357:987–999

    Article  PubMed  CAS  Google Scholar 

  27. Singh S, Zoble RG, Yellen L et al (2000) Efficacy and safety of oral dofetilide in converting to and maintaining sinus rhythm in patients with chronic atrial fibrillation or atrial flutter: the symptomatic atrial fibrillation investigative research on dofetilide (SAFIRE-D) study. Circulation 102:2385–2390

    PubMed  CAS  Google Scholar 

  28. Spenke S, Ullmann HM, Vetter S, Volkmann H (1997) Geringe Erfolgsrate medikamentöser Kardioversionsversuche bei länger persistierendem Vorhofflimmern. Z Kardiol 86(Suppl 3):93

    Google Scholar 

  29. Suttorp MJ, Kingma JH, Jessurun ER et al (1990) The value of class IC antiarrhythmic drugs for acute conversion of paroxysmal atrial fibrillation or flutter to sinus rhythm. J Am Coll Cardiol 16:1722–1727

    Article  PubMed  CAS  Google Scholar 

  30. Vardas PE, Kochiadakis GE, Igoumenidis NE et al (2000) Amiodarone as a first-choice drug for restoring sinus rhythm in patients with atrial fibrillation: a randomized, controlled study. Chest 117:1538–1545

    Article  PubMed  CAS  Google Scholar 

  31. Vermes E, Tardif JC, Bourassa MG, Racine N, Levesque S, White M, Guerra PG, Ducharme A (2003) Enalapril decreases the incidence of atrial fibrillation in patients with left ventricular dysfunction. Insight from the studies of left ventricular dysfunction (SOLVD) trials. Circulation 107:2926–2931

    Article  PubMed  Google Scholar 

  32. Wachtel K, Lehto M, Gerdts E, Olsen MH, Hornestam B, Dahlöf B, Ibsen H, Julius S, Kjeldsen SE, Lindholm LH, Nieminen MS, Devereux RB (2005) Angiotensin II receptor blockade reduces new-onset atrial fibrillation and subsequent stroke compared to atenolol. The losartan intervention for end point reduction in hypertension (LIFE) study. J Am Coll Cardiol 45:712–719

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Ärztlicher Direktor, Erzgebirgsklinikum Annaberg, Klinik für Innere Medizin/Kardiologie, Chemnitzer Straße 15, 09456, Annaberg-Buchholz, Germany

    H. Volkmann, L. Richter & C. Bergmann

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  1. H. Volkmann
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Correspondence to H. Volkmann.

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Volkmann, H., Richter, L. & Bergmann, C. Pharmakologische Therapie bei Vorhofflimmern – Was leisten moderne Antiarrhythmika wirklich?. Clin Res Cardiol Suppl 3, 101–106 (2008). https://doi.org/10.1007/s11789-008-0034-z

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  • DOI: https://doi.org/10.1007/s11789-008-0034-z

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