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Atrial fibrillation: Choosing an antiarrhythmic drug

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Abstract

Atrial fibrillation is the most common arrhythmia encountered in clinical practice. The associated hemodynamic changes can lead to symptoms of palpitations, fatigue, light-headedness, or dyspnea. Extensive research in the use of antiarrhythmic drugs has been performed both to facilitate the conversion of atrial fibrillation to sinus rhythm and to maintain normal sinus rhythm. The relative merits of a rhythm control versus rate control strategy are briefly discussed. Efficacy of the available agents for pharmacologic cardioversion is reviewed in detail. Important drugs for maintenance of sinus rhythm include amiodarone, fiecainide, propafenone, sotalol, and dofetilide. Selection of the appropriate antiarrhythmic drug must be individualized to the clinical situation, with Class IC drugs being first-line agents in the absence of structural heart disease. Regardless of agent selected, appropriate monitoring for development of adverse effects is of utmost importance.

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References and Recommended Reading

  1. Feinberg W, Blackshear JL, Laupacis, et al.: Prevalence, age distribution, and gender of patients with atrial fibrillation: analysis and implications. Arch Intern Med 1995, 155:469- 473.

    Article  PubMed  CAS  Google Scholar 

  2. Nattel S, Li D, Yue L: Basic mechanisms of atrial fibrillation - very new insights into very old ideas. Annu Rev Physiol 2000, 62:51–77.

    Article  PubMed  CAS  Google Scholar 

  3. Haissaguerre M, Jais P, Shah DC, et al.: Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998, 339:659–666.

    Article  PubMed  CAS  Google Scholar 

  4. Wijffels MC, Kirchhof CJ, Dorland R, Allessie MA:Atrial fibrillation begets atrial fibrillation: a study in awake chronically instrumented goats. Circulation 1995, 92:1954–1968.

    PubMed  CAS  Google Scholar 

  5. Fuster V, Ryden LE, Asinger RW, et al.: ACC/AHA/ESC Guidelines for the management of patients with atrial fibrillation. J Am Coll Cardiol 2001, 38:1231–1266.

    Article  PubMed  CAS  Google Scholar 

  6. Go A, Hylek EM, Philips KA, et al.: Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors In Atrial fibrillation study (ATRIA). JAMA 2001, 285:2370–2375.

    Article  PubMed  CAS  Google Scholar 

  7. Kannel WB, Abbott RD, Savage DD, McNamara PM:Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med 1982, 306:1018–1022.

    Article  PubMed  CAS  Google Scholar 

  8. Atrial Fibrillation Investigators: Risk factors for stroke and Efficacy of antithrombotic therapy in atrial fibrillation: analysis of pooled data from five randomized controlled trials. Arch Intern Med 1994, 154:1449–1457.

    Article  Google Scholar 

  9. Hart RG, Pearce LA, McBride R, et al.: Factors associated with ischemic stroke during aspirin therapy in atrial fibrillation: analysis of 2012 participants in the SPAF I-III clinical trials. Stroke 1999, 30:1223–1229.

    PubMed  CAS  Google Scholar 

  10. Wyse DG: Rhythm versus rate control trials in atrial fibrillation. J Cardiovasc Electrophysiol 2003, 14:S35-S39. Consolidated review of the five major randomized controlled trials of rate control versus rhythm control strategies.

    Article  PubMed  Google Scholar 

  11. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators: A comparison of rate control and rhythm control on patients with atrial fibrillation. N Engl J Med 2002, 347:1825–1833.

    Article  Google Scholar 

  12. Dalzell GW, Anderson J, Adgey AA: Factors determining success and energy requirements for cardioversion of atrial fibrillation. Q J Med 1990, 76:903–913.

    PubMed  CAS  Google Scholar 

  13. Gallagher MM, Guo XH, Poloniecki JD, et al.: Initial energy setting, outcome, and efficiency of direct current cardioversion of atrial fibrillation. J Am Coll Cardiol 2001, 38:1498–1504.

    Article  PubMed  CAS  Google Scholar 

  14. Oral H, Souza JJ, Michaud GF, et al.: Facilitating transthoracic cardioversion of atrial fibrillation with ibutilide pretreatment. N Engl J Med 1999, 340:1849–1854.

    Article  PubMed  CAS  Google Scholar 

  15. Capucci A, Villani GO, Aschieri D, et al.: Oral amiodarone increases the Efficacy of direct current cardioversion in restoration of sinus rhythm in patients with chronic atrial fibrillation. Eur Heart J 2000, 21:66–73.

    Article  PubMed  CAS  Google Scholar 

  16. DeSimone A, Stabile G, Vitale DF, et al.: Pretreatment with verapamil in patients with persistent or chronic atrial fibrillation who underwent electrical cardioversion. J Am Coll Cardiol 1999, 34:810 -814.

    Article  CAS  Google Scholar 

  17. Madrid AH, Bueno MG, Rebollo JM, et al.: Use of irbesartan to maintain sinus rhythm in patients with long-standing persistent atrial fibrillation: a prospective and randomized study. Circulation 2002, 106:331–336.

    Article  PubMed  CAS  Google Scholar 

  18. Boriani G, Diemberger I, Bif. M, et al.: Pharmacologic cardioversion of atrial fibrillation: current management and treatment options. Drugs 2004, 64:2741–2762. A current, comprehensive review of the use of antiarrhythmic drugs in pharmacologic cardioversion.

    Article  PubMed  CAS  Google Scholar 

  19. Echt DS, Liebson PR, Mitchell LB, et al.: Mortality and morbidity in patients receiving encainide, fiecainide, or placebo. The cardiac arrhythmia suppression trial. N Engl J Med 1991, 324:781–788.

    Article  PubMed  CAS  Google Scholar 

  20. Capucci A, Villani GO, Piepoli MF, Aschieri D: The role of oral IC antiarrhythmic drugs in terminating atrial fibrillation. Curr Opin Cardiol 1999, 14:4–8.

    Article  PubMed  CAS  Google Scholar 

  21. Alboni P, Botto G, Baldi N, et al.: Outpatient treatment of recent onset atrial fibrillation with the "pill-in-the-pocket" approach. N Engl J Med 2004, 351:2384–2391.

    Article  PubMed  CAS  Google Scholar 

  22. Volgman AS, Carberry PA, Stambler BS, et al.: Conversion Efficacy and safety of intravenous ibutilide compared with intravenous procainamide in patients with atrial flutter or fibrillation. J Am Coll Cardiol 1998, 31:1414–1419.

    Article  PubMed  CAS  Google Scholar 

  23. Borgeat A, Goy JJ, Maendly R, et al.: Flecainide versus quinidine for conversion of atrial fibrillation to sinus rhythm. Am J Cardiol 1986, 58:496–498.

    Article  PubMed  CAS  Google Scholar 

  24. Reisinger J, Gatterer E, Heinze G, et al.: Prospective comparison of fiecainide versus sotalol for immediate cardioversion of atrial fibrillation. Am J Cardiol 1998, 81:1450–1454.

    Article  PubMed  CAS  Google Scholar 

  25. Hohnloser SH, Woosley RL: Sotalol. N Engl J Med 1994, 331:31–38.

    Article  PubMed  CAS  Google Scholar 

  26. Falk RH, Pollak A, Singh SN, Friedrich T, for the Intravenous Dofetilide Investigators: Intravenous dofetilide, a class III antiarrhythmic agent, for the termination of sustained atrial fibrillation or flutter. J Am Coll Cardiol 1997, 29:385–390.

    Article  PubMed  CAS  Google Scholar 

  27. Chevalier P, Durand-Dubief A, Burri H, et al.: Amiodarone versus placebo and classic drugs for cardioversion of recent onset atrial fibrillation: a meta-analysis. J Am Coll Cardiol 2003, 41:255–262.

    Article  PubMed  CAS  Google Scholar 

  28. Murray KT: Ibutilide. Circulation 1998, 97:493–497.

    PubMed  CAS  Google Scholar 

  29. Stambler BS, Wood MA, Ellenbogen KA, et al.: Efficacy and safety of repeated intravenous doses of ibutilide for rapid conversion of atrial flutter or fibrillation. Circulation 1996, 94:1613–1621.

    PubMed  CAS  Google Scholar 

  30. Vos MA, Golitsyn SR, Stangl K, et al.: Superiority of ibutilide over sotalol in converting atrial flutter and atrial fibrillation. The Ibutilide/Sotalol Comparator Study Group. Heart 1998, 79:568–575.

    PubMed  CAS  Google Scholar 

  31. Hersi A, Wyse DG: Management of atrial fibrillation. Curr Probl Cardiol 2005, 30:175–234. Very current and thorough review of AF management, including both pharmacologic and nonpharmacologic therapies.

    Article  PubMed  CAS  Google Scholar 

  32. Ehrlich JR and Hohnloser S: Pharmacologic cardioversion of atrial fibrillation. In Atrial Fibrillation. Edited by Kowey P, Naccarelli G. New York: Marcel Dekker; 2005:181–194. This text is a current and comprehensive review of all aspects of AF, including epidemiology, pathophysiology, management strategies, antiarrhythmic drugs, and nonpharmacologic therapies.

    Google Scholar 

  33. Roy D, Talajic M, Dorian P, et al.: Amiodarone to prevent recurrence of atrial fibrillation. Canadian Trial of Atrial Fibrillation Investigators. N Engl J Med 2000, 342:913–920.

    Article  PubMed  CAS  Google Scholar 

  34. Singh BN, Singh SN, Reda DJ, et al.: Amiodarone versus sotalol for atrial fibrillation. New Engl J Med 2005, 352:1861–1872.

    Article  PubMed  CAS  Google Scholar 

  35. Singh S, Zoble RG, Yellen L, et al.: 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 2000, 102:2385–2390.

    PubMed  CAS  Google Scholar 

  36. Greenbaum RA, Campbell TJ, Channer KS, et al.: Conversion of atrial fibrillation and maintenance of sinus rhythm by dofetilide. The EMERALD (European and Australian Multicenter Evaluative Research on Atrial Fibrillation Dofetilide) Study [abstract]. Circulation 1998, 98:1633.

    Google Scholar 

  37. Chimienti M, Cullen MT, Casadei, G: Safety of long-term fiecainide and propafenone in the management of patients with symptomatic paroxysmal atrial fibrillation: report from the fiecainide and propafenone Italian Study Investigators. Am J Cardiol 1996, 77:60A-65A.

    Article  PubMed  CAS  Google Scholar 

  38. Echt DS, Liebson PR, Mitchell LB, et al.: Mortality and morbidity in patients receiving encainide, fiecainide, or placebo. The Cardiac Arrhythmia Suppression Trial. N Engl J Med 1991, 324:781–788.

    Article  PubMed  CAS  Google Scholar 

  39. Prichett EL, Page RL, Carlson M, et al.: Rythmol Atrial Fibrillation Trial (RAFT) Investigators: Efficacy and safety of sustained-release propafenone (propafenone SR) for patients with atrial fibrillation. Am J Cardiol 2003, 92:941–946.

    Article  CAS  Google Scholar 

  40. Meinertz T, Gregory YH, Fedrico L, et al.: Efficacy and safety of propafenone sustained release in the prophylaxis of symptomatic paroxysmal atrial fibrillation (The European Rythmol/Rytmonorm Atrial Fibrillation Trial [ERAFT] Study). Am J Cardiol 2002, 90:1300–1306.

    Article  PubMed  CAS  Google Scholar 

  41. Benditt DG, Williams JH, Jin J, et al.: Maintenance of sinus rhythm with oral d,l-sotalol therapy in patients with symptomatic atrial fibrillation and/or atrial flutter. d,l-Sotalol Atrial Fibrillation/Flutter Study Group. Am J Cardiol 1999, 84:270–277.

    Article  PubMed  CAS  Google Scholar 

  42. Wanless RS, Anderson K, Joy M, Joseph SP: Multicenter comparative study of the Efficacy and safety of sotalol in the prophylactic treatment of patients with paroxysmal supraventricular tachyarrhythmias. Am Heart J 1997, 133:441–446.

    Article  PubMed  CAS  Google Scholar 

  43. Fuster V, Ryden LE, Asinger RW, et al.: ACC/AHA/ESC Guidelines for the management of patients with atrial fibrillation: executive summary. Circulation 2001, 104:2118–2150.

    PubMed  CAS  Google Scholar 

  44. Reiffel JA: Maintenance of normal sinus rhythm with antiarrhythmic drugs. In Atrial Fibrillation. Edited by Kowey P, Naccarelli G. New York: Marcel Dekker; 2005:195–217.

    Google Scholar 

  45. Reiffel JA: Inpatient versus outpatient antiarrhythmic drug initiation: safety and cost-effectiveness issues. Curr Opin Cardiol 2000, 15:7–11.

    Article  PubMed  CAS  Google Scholar 

  46. Marcus FI: Risks of initiating therapy with sotalol for treatment of atrial fibrillation. J Am Coll Cardiol 1998, 32:177–180.

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Division of Cardiovascular Diseases, Main Line Health Heart Center, Lankenau Hospital, 100 Lancaster Avenue, MOB East, Suite 558, 19096, Wynnewood, PA, USA

    Todd Rudo MD

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  1. Todd Rudo MD
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  2. Peter Kowey MD
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Correspondence to Todd Rudo MD.

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Rudo, T., Kowey, P. Atrial fibrillation: Choosing an antiarrhythmic drug. Curr Cardiol Rep 8, 370–376 (2006). https://doi.org/10.1007/s11886-006-0077-z

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