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Cardiovascular Drugs and Therapy

, Volume 17, Issue 1, pp 31–39 | Cite as

Effects of Amiodarone and Diltiazem on Persistent Atrial Fibrillation Conversion and Recurrence Rates: A Randomized Controlled Study

  • Emmanuel G. Manios
  • Hercules E. Mavrakis
  • Emmanuel M. Kanoupakis
  • Eleftherios M. Kallergis
  • Despina N. Dermitzaki
  • Despina C. Kambouraki
  • Panos E. Vardas
Article

Abstract

Purpose: To assess the effects of amiodarone and diltiazem on atrial fibrillation (AF) induced atrial electrical remodeling and their clinical implications.

Methods: Persistent AF patients were randomly assigned to three treatment groups over a period from 6 weeks before to 6 weeks after internal cardioversion: group A (35 patients, oral diltiazem), group B (34 patients, oral amiodarone) and group C (37 patients, no antiarrhythmic drugs). Several electrophysiological parameters were assessed 5 min and 24 h after cardioversion.

Results: Compared with controls, group B patients had significantly higher conversion rates (83% vs. 100%, p = 0.041) and a higher probability to maintain sinus rhythm (p = 0.037). Patients of group B had longer fibrillatory cycle length intervals than patients of group A and C (180 ± 18 ms vs. 161 ± 17 ms vs. 164 ± 19 ms, p = 0.001) and longer atrial effective refractory periods (211 ± 22 ms vs. 198 ± 16 ms vs. 194 ± 17 ms, p = 0.003) as assessed 5 min after conversion. Post-conversion density of supraventricular ectopics was significantly lower in group B compared to groups A and C (p = 0.001).

Conclusions: Oral amiodarone increases conversion rates, prolongs fibrillatory cycle length and atrial effective refractory period and preserves sinus rhythm after cardioversion in persistent AF patients by suppressing the atrial ectopics that trigger AF.

atrial fibrillation remodeling recurrence diltiazem amiodarone 

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References

  1. 1.
    Morillo C, Klein G, Jones DL, Guiraurdon CM. Chronic rapid atrial pacing: Structural, functional, and electrophysiological characteristics of a new model of sustained atrial fibrillation. Circulation 1995;91:1588-1595.Google Scholar
  2. 2.
    Wijffels MCEF, Kirchoff CJ, Dorland R, Allessie MA. Atrial fibrillation begets atrial fibrillation. A study in awake chronically instrumented goats. Circulation 1995;92:1954-1968.Google Scholar
  3. 3.
    Goette A, Honeycutt C, Langberg JJ. Electrical remodeling in atrial fibrillation. Time course and mechanisms. Circulation 1996;94:2968-2974.Google Scholar
  4. 4.
    Daoud EG, Bogun F, Goyal R, et al. Effect of AF on atrial refractoriness in humans. Circulation 1996;94:1600-1606.Google Scholar
  5. 5.
    Wijffels MC, Kirchhof CJ, Dorland R, Power J, Allessie MA. Electrical remodeling due to atrial fibrillation in chronically instrumented conscious goats: Roles of neurohumoral changes, ischemia, atrial stretch, and high rate of electrical activation. Circulation 1997;96:3710-3720.Google Scholar
  6. 6.
    Gaspo R, Bosch RF, Talajic M, Nattel S. Functional mechanisms underlying tachycardia-induced sustained atrial fibrillation in a chronic dog model. Circulation 1997;96:4027-4035.Google Scholar
  7. 7.
    Bosch R, Zeng X, Grammer J, Popovic K, Mewis C, Kuhlkamp V. Ionic mechanisms of electrical remodeling in human atrial fibrillation. Cardiovasc Res 1999;44:121-131.Google Scholar
  8. 8.
    Lai LP, Su MJ, Lin JL, et al. Down regulation of L-type calcium channel and sarcoplasmic reticular Ca2+-ATPase mRNAinhumanatrial fibrillation without significant change in themRNAof ryanodine receptor, calsequestrin and phospholamban. J Am Coll Cardiol 1999;33:1231-1237.Google Scholar
  9. 9.
    Fareh S, Villemaire C, Nattel S. Importance of refractoriness heterogeneity in the enhanced vulnerability to atrial fibrillation induction caused by tachycardia-induced atrial electrical remodeling. Circulation 1998;98:2202-2209.Google Scholar
  10. 10.
    Allessie MA. Atrial electrophysiological remodeling: Another vicious circle? J Cardiovasc Electrophysiol 1998;9:1378-1393.Google Scholar
  11. 11.
    Nattel S. Atrial electrophysiological remodeling caused by rapid atrial activation: Underlying mechanisms and clinical relevance to atrial fibrillation. Cardiovasc Res 1999;42:298-308.Google Scholar
  12. 12.
    Yu W, Lee SH, Tai CT, et al. Reversal of atrial electrical remodeling following cardioversion of long-standing atrial fibrillation in man. Cardiovasc Res 1999;42:470-476.Google Scholar
  13. 13.
    Lee SH LF, Yu WC, Cheng JJ, et al. Regional differences in the recovery course of tachycardia induced changes of atrial electrophysiological properties. Circulation 1999;99:1255-1264.Google Scholar
  14. 14.
    Manios E, Kanoupakis E, Chlouverakis G, Kaleboubas M, Mavrakis H, Vardas P. Changes in atrial electrical properties following cardioversion of chronic atrial fibrillation: Relation with recurrence. Cardiovasc Res 2000;47:244-253.Google Scholar
  15. 15.
    Tieleman RG, De Langen C, Van Gelder IC, et al. Verapamil reduces tachycardia-induced electrical remodeling of the atria. Circulation 1997;95:1945-1953.Google Scholar
  16. 16.
    Daoud EG, Knight BP, Weiss R, et al. Effect of Verapamil and procainamide on atrial fibrillation-induced electrical remodeling in humans. Circulation 1997;96:1542-1550.Google Scholar
  17. 17.
    Tieleman RG, Van Gelder IC, Crijns HJ, et al. Early recurrences of atrial fibrillation after electrical cardioversion: A result of fibrillation-induced electrical remodeling of the atria? J Am Coll Cardiol 1998;31:167-173.Google Scholar
  18. 18.
    De Simone 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.Google Scholar
  19. 19.
    Botto GL, Belotti G, Romano M, et al. Verapamil pretreatment before electrical cardioversion of persistent atrial fibrillation: The VERAF study. Eur Heart J 2001;22:329 (abstr).Google Scholar
  20. 20.
    Van Noord T, Van Gelder IC, Tieleman RG, et al. VERDICT: The verapamil versus digoxin cardioversion trial: A randomized study on the role of calcium lowering for maintenance of sinus rhythm after cardioversion of persistent atrial fibrillation. J Cardiovasc Electrophysiol 2001;12:766-769.Google Scholar
  21. 21.
    Villani GQ, Piepoli MF, Terracciano C, Capucci A. Effects of diltiazem pretreatment on direct-current cardioversion in patients with persistent atrial fibrillation: A single-blind, randomized, controlled study. Am Heart J 2000;140:437-443.Google Scholar
  22. 22.
    Tieleman RG, Gosselink AT, Crijns HJGM, et al. Efficacy safety and determinants of conversion of atrial fibrillation and flutter with oral amiodarone. Am J Cardiol 1997;79:53-57.Google Scholar
  23. 23.
    Kerin NZ, Faitel K, Naini M. The efficacy of intravenous amiodarone for the conversion of chronic atrial fibrillation. Arch Intern Med 1996;156:49-53.Google Scholar
  24. 24.
    Gosselink AT, Crijns HJGM, van Gelder IC, et al. Low dose amiodarone for maintenance of sinus rhythm after conversion of atrial fibrillation or flutter. JAMA 1992;267:3289-3293.Google Scholar
  25. 25.
    Capucci A, Villani GQ, Aschieri D, Rosi A, Piepoli MF. 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.Google Scholar
  26. 26.
    Vardas P, Kochiadakis G, Igoumenidis N, Tsatsakis A, Simantirakis E, Chlouverakis G. Amiodarone as a first choice drug for restoring sinus rhythm in patients with atrial fibrillation. Chest 2000;117:1538-1545.Google Scholar
  27. 27.
    Gaita F, Riccardi R, Calo L, et al. Atrial mapping and radiofrequency catheter ablation in patients with idiopathic atrial fibrillation. Electrophysiological findings and ablation results. Circulation 1998;97:2136-2145.Google Scholar
  28. 28.
    Josephson M. Clinical Cardiac Electrophysiology: Techniques and Interpretations, 2nd ed. Philadelphia: Lea & Febiger, 1993:22-70.Google Scholar
  29. 29.
    Lee SH, Yu WC, Cheng JJ, et al. effect of verapamil on long term tachycardia induced atrial electrical remodeling. Circulation 2000;101:200-206.Google Scholar
  30. 30.
    Fareh S, Benardeau A, Natel S. Differential efficacy of L-type and T-type calcium channel blockers in preventing tachycardia induced atrial remodeling in dogs. Cardiovasc Res 2001;49:762-770.Google Scholar
  31. 31.
    Pandozi C, Bianconi L, Calo L, et al. Postcardioversion atrial electrophysiologic changes induced by oral verapamil in patients with persistent atrial fibrillation. J Am Coll Cardiol 2000;36:2234-2241.Google Scholar
  32. 32.
    Kurita Y, Mitamura H, Shiroshita-Takeshita A, et al. Daily oral verapamil before but not after rapid atrial excitation prevents electrical remodeling. Cardiovasc Res 2002;54:447-455.Google Scholar
  33. 33.
    Villani GQ, Piepoli MF, Marrazzo N, Capucci A. Electrophysiologic effect of amiodarone pre-treatment in persistent atrial fibrillation patients. J Am Coll Cardiol 2001;37:1A (abstr).Google Scholar
  34. 34.
    Asano Y, Saito J, Matsumoto K, et al. On the mechanism of termination and perpetuation of atrial fibrillation. Am J Cardiol 1992;69:1033-1038.Google Scholar
  35. 35.
    Haissaguerre M, Jais P, Shah DC, et al. A focal source of atrial fibrillation treated by discrete radiofrequency ablation. Circulation 1997;95:572-576.Google Scholar
  36. 36.
    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.Google Scholar
  37. 37.
    Chen S-A, Hsieh M-S, Tai CT, et al. Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins: Electrophysiological characteristics, pharmacological responses and effects of radiofrequency ablation. Circulation 1999;100:1879-1886.Google Scholar
  38. 38.
    Waktare JEP, Hnatkova K, Sopher M, et al. The role of atrial ectopics in initiating paroxysms of atrial fibrillation. Eur Heart J 2001;22:333-339.Google Scholar
  39. 39.
    Manios E, Kanoupakis E, Mavrakis H, Kallergis E, Dermitzaki D, Vardas P. Sinus pacemaker function after cardioversion of chronic atrial fibrillation: Is sinus node remodeling related with recurrence? J Cardiovasc Electrophysiol 2001;12:800-806.Google Scholar
  40. 40.
    Sharpe MD, Dobkowski WB, Murkin JM, Klein G, Yee R. Propofol has no direct effect on sinoatrial node function or on normal atrioventricular and accessory pathway conduction inWolff-Parkinson-White syndrome during alfentanil/midazolam anesthesia. Anesthesiology 1995;82:888-895.Google Scholar

Copyright information

© Kluwer Academic Publishers 2003

Authors and Affiliations

  • Emmanuel G. Manios
    • 1
  • Hercules E. Mavrakis
    • 1
  • Emmanuel M. Kanoupakis
    • 1
  • Eleftherios M. Kallergis
    • 1
  • Despina N. Dermitzaki
    • 1
  • Despina C. Kambouraki
    • 1
  • Panos E. Vardas
    • 1
  1. 1.Department of CardiologyUniversity Hospital of HeraklionCreteGreece

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