University of Cincinnati

University of Cincinnati

PRACTICAL APPROACHES TO TREATING ATRIAL FIBRILLATION

These practical approaches to treating atrial fibrillation are the result of a roundtable discussion among five distinguished American arrhythmia experts: Drs. Peter L. Friedman, Charles I. Haffajee, Peter R. Kowey, Douglas L. Packer, and James A. Reiffel. The roundtable discussion was accredited and designed by the University of Cincinnati College of Medicines as an educational activity for a one-hour credit towards the AMA Physician’s Recognition Award.

As a result of the discussion the expert recommendation is as follows for the:

u ACUTE INTERVENTION FOR THE PHARMACOLOGICAL CARDIOVERSION DURING A RELAPSE OF ATRIAL FIBRILLATION

In patients without heart disease, with minimal heart disease or hypertrophic disease, the first and second choices are Class Ic drugs given orally – propafenone being first choice, flecainide second, based on data of their efficacy and their safety profile. I.V. Ibutilide should be considered third choice, as it exerts the risk of a potentially lethal proarrhythmia such as torsade de pointes and therefore strict monitoring is mandatory.

In patients with severe non-ischaemic cardiomyopathy and marked ventricular dysfunction, the first choice agent should be amiodarone due to its effect of controlling the ventricular rate without further depressing ventricular function. I.V. Ibutilide should be used as second choice as it has proven equally effective in patients with high or low ejection fractions. If the arrhythmia does not convert quickly in response to antiarrhythmic agents, the goal is to control ventricular rate with intravenous digitalis.

Class Ic agents should never be used in patients with ischaemic cardiomyopathy. I.V. Ibutilide should be first choice and I.V. Amiodarone second choice in the setting of moderate ischaemic cardiomyopathy and left ventricular function. The third choice, is pharmacologic rate control or, if that fails DC cardioversion.
In patients with severe ischaemic cardiomyopathy complicated by left ventricular dysfunction I.V. Amiodarone is preferable over I.V. Ibutilide. The third choice, is pharmacologic rate control or, if that fails DC cardioversion.

Table 1: Recommendation for the selection of antiarrhythmic drugs for the pharmacologic cardioversion of atrial fibrillation according to heart disease type and severity

Therapy	No structural heart disease	Hypertrophic disease	Non-ischaemic cardiomyopathy		Ischaemic cardiomyopathy
Therapy	No structural heart disease	Hypertrophic disease	Moderate	Severe	Moderate	Severe
1^st choice	Oral Propafenone	Oral Propafenone	Oral Propafenone	Intravenous Amiodarone	Intravenous Ibutilide	Intravenous Amiodarone
2^nd choice	Oral Flecainide	Oral Flecainide	Oral Flecainide	Intravenous Ibutilide	Intravenous Amiodarone	Intravenous Ibutilide
3^rd choice	Intravenous Ibutilide	Intravenous Ibutilide	Intravenous Ibutilide	Pharmacologic ventricular rate control or DC cardioversion	Pharmacologic ventricular rate control or DC cardioversion

[Adopted from: Peter R. Kowey, The Lankenau Hospital and Medical Reseach Center]

u MAINTENANCE OF NORMAL SINUS RHYTHM IN PATIENTS WITH RECURRENT ATRIAL FIBRILLATION

Since atrial fibrillation (AF) by itself is a non-lethal arrhythmia, the choice of prophylactic treatment must be safety driven. For patients that only have few recurrences of AF it could be useful to intervene acutely rather than administer a long-term therapy.
In absence of structural heart disease and mild to moderate left ventricular hypertrophy, Class Ic agents (propafenone, flecainide) are preferable because the proarrhythmic risk is negligible and there is no organ toxicity.
In the setting of severe heart disease, d/l sotalol is first choice and in the presence of ischaemia and severe left ventricular dysfunction amiodarone should be used first line.

Table 2: Recommendation for the selection of antiarrhythmic drugs for maintenance of normal sinus rhythm in recurrent atrial fibrillation according to heart disease type and severity

Therapy	No structural heart disease	Left ventricular hypertrophy (mild-moderate)	ischaemic heart disease	ischaemic heart disease associated to severe ventricular dysfunction
1^st choice	Propafenone	Propafenone	d/l Sotalol	Amiodarone
2^nd choice	Flecainide	Flecainide	Amiodarone
3^rd choice	d/l Sotalol	d/l Sotalol

[Adopted from: James A. Reiffel, College of Physicians and Surgeons of Columbia University]

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