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CLINICAL RESEARCH: HEART RHYTHM DISORDERS

Verapamil Versus Digoxin and Acute Versus Routine Serial Cardioversion for the Improvement of Rhythm Control for Persistent Atrial Fibrillation

Martin E.W. Hemels, MD^_*, Trudeke Van Noord, MD^_*, Harry J.G.M. Crijns, MD, Dirk J. Van Veldhuisen, MD, FACC^_*, Nic J.G.M. Veeger, MSc, Hans A. Bosker, MD, Ans C. P. Wiesfeld, MD^_*, Maarten P. Van den Berg, MD^_*, Adelita V. Ranchor, PhD^|| and Isabelle C. Van Gelder, MD^_*,_*

^_* Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
University Hospital, Maastricht, the Netherlands
Trial Coordination Center, Groningen, the Netherlands
Rijnstate Hospital, Arnhem, the Netherlands
^|| Northern Center for Health Care Research, Groningen, the Netherlands

Manuscript received January 25, 2006; revised manuscript received April 10, 2006, accepted May 2, 2006.

^_* Reprint requests and correspondence: Dr. Isabelle C. Van Gelder, Department of Cardiology, Thoraxcenter, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands. (Email: I.C.van.Gelder{at}thorax.umcg.nl).

OBJECTIVES: The VERDICT (Verapamil Versus Digoxin and Acute Versus Routine Serial Cardioversion Trial) is a prospective, randomized study to investigate whether: 1) acutely repeated serial electrical cardioversions (ECVs) after a relapse of atrial fibrillation (AF); and 2) prevention of intracellular calcium overload by verapamil, decrease intractability of AF.

BACKGROUND: Rhythm control is desirable in patients suffering from symptomatic AF.

METHODS: A total of 144 patients with persistent AF were included. Seventy-four (51%) patients were randomized to the acute (within 24 h) and 70 (49%) patients to the routine serial ECVs, and 74 (51%) patients to verapamil and 70 (49%) patients to digoxin for rate control before ECV and continued during follow-up (2 x 2 factorial design). Class III antiarrhythmic drugs were used after a relapse of AF. Follow-up was 18 months.

RESULTS: At baseline, there were no significant differences between the groups, except for beta-blocker use in the verapamil versus digoxin group (38% vs. 60%, respectively, p = 0.01). At follow-up, no difference in the occurrence of permanent AF between the acute and the routine cardioversion groups was observed (32% [95% confidence intervals (CI)] 22 to 44) vs. 31% [95% CI 21 to 44], respectively, p = NS), and also no difference between the verapamil- and the digoxin-randomized patients (28% [95% CI 19 to 40] vs. 36% [95% CI 25 to 48] respectively, p = NS). Multivariate Cox regression analysis revealed that lone digoxin use was the only significant predictor of failure of rhythm control treatment (hazard ratio 2.2 [95% CI 1.1 to 4.4], p = 0.02).

CONCLUSIONS: An acute serial cardioversion strategy does not improve long-term rhythm control in comparison with a routine serial cardioversion strategy. Furthermore, verapamil has no beneficial effect in a serial cardioversion strategy.

Abbreviations and Acronyms   AF = atrial fibrillation   CI = confidence interval   ECV = electrical cardioversion   INR = international normalized ratio   IRAF = immediate reinitiation of atrial fibrillation   LV = left ventricle/ventricular   NYHA = New York Heart Association   SR = sinus rhythm

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