Therapy of refractory symptomatic atrial fibrillation and atrial flutter: a staged care approach with new antiarrhythmic drugs

Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115.

One hundred nine patients with recurrent episodes of symptomatic atrial fibrillation or flutter, or both, who had failed one to five previous antiarrhythmic drug trials were treated with propafenone and, subsequently, sotalol if atrial fibrillation recurred. The clinical profile of the study group was as follows: age 63 +/- 13 years, left atrial anteroposterior dimension 4.4 +/- 0.9 cm and left ventricular ejection fraction 57 +/- 14%. Paroxysmal atrial fibrillation occurred in 56 patients (51%) and chronic atrial fibrillation occurred in 53 patients (49%). After loading and dose titration phases were completed, the maintenance doses of drugs were 450 to 900 mg/day for propafenone and 160 to 960 mg/day for sotalol. Life table estimates of the duration of freedom from atrial fibrillation were constructed for each drug trial. The percent of patients free of recurrent symptomatic arrhythmia at 6 months was 39% for propafenone and 50% for sotalol. The cumulative proportion of patients successfully treated with propafenone or sotalol, or both, by 6 months was 55% and remained relatively constant beyond that point. The incidence of intolerable side effects necessitating discontinuation of therapy ranged from 7% to 8%. Thus, despite previous unsuccessful drug trials, a substantial proportion of patients with recurrent symptomatic atrial fibrillation refractory to conventional therapy can be treated successfully and safely with newer antiarrhythmic drugs. Treatment failures tend to occur early in the course of follow-up, permitting easy identification of candidates for alternative therapeutic approaches.

This article has been cited by other articles:

				Writing Committee Members, V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: 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 Europace, September 1, 2006; 8(9): 651 - 745. [Full Text] [PDF]

				V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al. 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 J. Am. Coll. Cardiol., August 15, 2006; 48(4): e149 - e246. [Full Text] [PDF]

				V. Fuster, L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, J.-Y. Le Heuzey, G. N. Kay, J. E. Lowe, et al. 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, August 15, 2006; 114(7): e257 - e354. [Full Text] [PDF]

				G. E. Kochiadakis, N. E. Igoumenidis, M. I. Hamilos, P. G. Tzerakis, N. C. Klapsinos, E. A. Zacharis, and P. E. Vardas Long-term Maintenance of Normal Sinus Rhythm in Patients With Current Symptomatic Atrial Fibrillation: Amiodarone vs Propafenone, Both in Low Doses Chest, February 1, 2004; 125(2): 377 - 383. [Abstract] [Full Text] [PDF]

				E. Bertaglia, D. D'Este, F. Zerbo, F. Zoppo, P. Delise, and P. Pascotto Success of serial external electrical cardioversion of persistent atrial fibrillation in maintaining sinus rhythm. A randomized study Eur. Heart J., October 1, 2002; 23(19): 1522 - 1528. [Abstract] [Full Text] [PDF]

				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) developed in collaboration with the North American Society of Pacing and Electrophysiology Eur. Heart J., October 2, 2001; 22(20): 1852 - 1923. [PDF]

				V. Fuster, L. E. Ryden, R. W. Asinger, D. S. Cannom, H. J. Crijns, R. L. Frye, J. L. Halperin, G. N. Kay, W. W. Klein, S. Levy, et al. 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) Developed in Collaboration With the North American Society of Pacing and Electrophysiology J. Am. Coll. Cardiol., October 1, 2001; 38(4): 1266 - 1266. [Full Text] [PDF]

				C. Ozcan, A. Jahangir, P. A. Friedman, P. J. Patel, T. M. Munger, R. F. Rea, M. A. Lloyd, D. L. Packer, D. O. Hodge, D. L. Hayes, et al. Long-Term Survival after Ablation of the Atrioventricular Node and Implantation of a Permanent Pacemaker in Patients with Atrial Fibrillation N. Engl. J. Med., April 5, 2001; 344(14): 1043 - 1051. [Abstract] [Full Text] [PDF]

				G E Kochiadakis, N E Igoumenidis, M E Marketou, M D Kaleboubas, E N Simantirakis, and P E Vardas Low dose amiodarone and sotalol in the treatment of recurrent, symptomatic atrial fibrillation: a comparative, placebo controlled study Heart, September 1, 2000; 84(3): 251 - 257. [Abstract] [Full Text] [PDF]

				V. Kuhlkamp, A. Schirdewan, K. Stangl, M. Homberg, M. Ploch, and O. A. Beck 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., July 1, 2000; 36(1): 139 - 146. [Abstract] [Full Text] [PDF]

				E. Catherwood, W. D. Fitzpatrick, M. L. Greenberg, P. T. Holzberger, D. J. Malenka, B. R. Gerling, and J. D. Birkmeyer Cost-Effectiveness of Cardioversion and Antiarrhythmic Therapy in Nonvalvular Atrial Fibrillation Ann Intern Med, April 20, 1999; 130(8): 625 - 636. [Abstract] [Full Text] [PDF]

				B. N. Singh Review : Sotalol: Current Status and Expanding Indications Journal of Cardiovascular Pharmacology and Therapeutics, January 1, 1999; 4(1): 49 - 65. [Abstract] [PDF]

				M. Valderrabano and B. N. Singh Review : Electrophysiologic and Antiarrhythmic Effects of Propafenone: Focus on Atrial Fibrillation Journal of Cardiovascular Pharmacology and Therapeutics, January 1, 1999; 4(3): 183 - 198. [PDF]

				M. Brignole, L. Gianfranchi, C. Menozzi, P. Alboni, G. Musso, M. G. Bongiorni, M. Gasparini, A. Raviele, G. Lolli, N. Paparella, et al. Prospective, randomized study of atrioventricular ablation and mode-switching, dual chamber pacemaker implantation versus medical therapy in drug-resistant paroxysmal atrial fibrillation: The PAF study Europace, January 1, 1999; 1(1): 15 - 19. [Abstract] [PDF]

				M. K. Chung, R. A. Schweikert, B. L. Wilkoff, M. J. Niebauer, S. L. Pinski, R. G. Trohman, G. A. Kidwell, F. J. Jaeger, V. A. Morant, D. P. Miller, et al. Is hospital admission for initiation of antiarrhythmic therapy with sotalol for atrial arrhythmias required?: yield of in-hospital monitoring and prediction of risk for significant arrhythmia complications J. Am. Coll. Cardiol., July 1, 1998; 32(1): 169 - 176. [Abstract] [Full Text] [PDF]

				C.-T. Tai, S.-A. Chen, C.-E. Chiang, S.-H. Lee, K.-C. Ueng, Z.-C. Wen, J.-L. Huang, Y.-J. Chen, W.-C. Yu, A.-N. Feng, et al. Characterization of Low Right Atrial Isthmus as the Slow Conduction Zone and Pharmacological Target in Typical Atrial Flutter Circulation, October 21, 1997; 96(8): 2601 - 2611. [Abstract] [Full Text]

				M. Brignole, L. Gianfranchi, C. Menozzi, P. Alboni, G. Musso, M. G. Bongiorni, M. Gasparini, A. Raviele, G. Lolli, N. Paparella, et al. Assessment of Atrioventricular Junction Ablation and DDDR Mode-Switching Pacemaker Versus Pharmacological Treatment in Patients With Severely Symptomatic Paroxysmal Atrial Fibrillation : A Randomized Controlled Study Circulation, October 21, 1997; 96(8): 2617 - 2624. [Abstract] [Full Text]

				K. Mori, Y. Hara, T. Saito, Y. Masuda, and H. Nakaya Anticholinergic Effects of Class III Antiarrhythmic Drugs in Guinea Pig Atrial Cells : Different Molecular Mechanisms Circulation, June 1, 1995; 91(11): 2834 - 2843. [Abstract] [Full Text]

				A. Elvan, H. P. Pride, J. N. Eble, and D. P. Zipes Radiofrequency Catheter Ablation of the Atria Reduces Inducibility and Duration of Atrial Fibrillation in Dogs Circulation, April 15, 1995; 91(8): 2235 - 2244. [Abstract] [Full Text]

				P. Turco, P. Guarino, A. Parente, V. Viola, F. Candelmo, G. Bellizzi, A. Foffa, A. Morella, and D. F. Martino Role of Transesophageal Pacing in Recurrent Atrial Fibrillation. Experience with Propafenone Angiology, February 1, 1994; 45(2): 95 - 100. [Abstract] [PDF]

				NEW ANTIARRHYTHMIC AGENTS FOR ATRIAL FIBRILLATION Journal Watch (General), March 20, 1990; 1990(320): 3 - 3. [Full Text]