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J Am Coll Cardiol, 2003; 41:249-254
© 2003 by the American College of Cardiology Foundation
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CLINICAL STUDY: CARDIAC ELECTROPHYSIOLOGY

Amiodarone and the risk of bradyarrhythmia requiring permanent pacemaker in elderly patients with atrial fibrillation and prior myocardial infarction

Vidal Essebag, MD, MSc, FRCP(C)*,*, Tom Hadjis, MD, MS, FRCP(C)*, Robert W. Platt, PhD{dagger} and Louise Pilote, MD, MPH, PhD{ddagger}

* Department of Cardiology and Division of Clinical Epidemiology, McGill University Health Center, Montreal, Canada
{dagger} Departments of Epidemiology and Biostatistics and of Pediatrics, McGill University Health Center, Montreal, Canada
{ddagger} Department of Internal Medicine and Division of Clinical Epidemiology, McGill University Health Center, Montreal, Canada

Manuscript received May 4, 2002; revised manuscript received July 30, 2002, accepted October 4, 2002.

* Reprint requests and correspondence: Dr. Vidal Essebag, 3600 Parc Avenue #1203, Montreal, Quebec H2X 3R2, Canada.
vidal.essebag{at}mail.mcgill.ca

OBJECTIVES: The aim of this study was to determine whether the use of amiodarone in patients with atrial fibrillation (AF) increases the risk of bradyarrhythmia requiring a permanent pacemaker.

BACKGROUND: Reports of severe bradyarrhythmia during amiodarone therapy are infrequent and limited to studies assessing the therapy’s use in the management of patients with ventricular arrhythmias.

METHODS: A study cohort of 8,770 patients age ≥65 years with a new diagnosis of AF was identified from a provincewide database of Quebec residents with a myocardial infarction (MI) between 1991 and 1999. Using a nested case-control design, 477 cases of bradyarrhythmia requiring a permanent pacemaker were matched (1:4) to 1,908 controls. Multivariable logistic regression was used to estimate the odds ratio (OR) of pacemaker insertion associated with amiodarone use, controlling for baseline risk factors and exposure to sotalol, Class I antiarrhythmic agents, beta-blockers, calcium channel blockers, and digoxin.

RESULTS: Amiodarone use was associated with an increased risk of pacemaker insertion (OR: 2.14, 95% confidence interval [CI]: 1.30 to 3.54). This effect was modified by gender, with a greater risk in women versus men (OR: 3.86, 95% CI: 1.70 to 8.75 vs. OR: 1.52, 95% CI: 0.80 to 2.89). Digoxin was the only other medication associated with an increased risk of pacemaker insertion (OR: 1.78, 95% CI: 1.37 to 2.31).

CONCLUSIONS: This study suggests that the use of amiodarone in elderly patients with AF and a previous MI increases the risk of bradyarrhythmia requiring a permanent pacemaker. The finding of an augmented risk of pacemaker insertion in elderly women receiving amiodarone requires further investigation.

Abbreviations and Acronyms
  AF
  atrial fibrillation
  AMI
  acute myocardial infarction
  AV
  atrioventricular
  CI
  confidence interval
  ICD9
  International Classification of Disease 9
  LV
  left ventricular
  MI
  myocardial infarction
  OR
  odds ratio
  RAMQ
  Regie de l’Assurance Maladie du Quebec
  SA
  sinoatrial




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