A comparative study of the efficacy and safety of procainamide versus propafenone versus amiodarone for the conversion of recent-onset atrial fibrillation

The appropriate treatment for the restoration of sinus rhythm in patients with atrial fibrillation (AF) of recent onset is still the subject of controversy. In this prospective, randomized, single-blind, placebo-controlled clinical study, we investigated the effectiveness and safety of procainamide, propafenone, and amiodarone, administered intravenously, for the conversion of recent-onset AF. We enrolled 362 consecutive patients (183 men; age 34 to 86 years; mean 65+/-10) with AF duration of no >48 hours. Of these patients, 89 were given procainamide, 91 propafenone, 92 amiodarone, and 90 placebo. Treatment was considered successful if conversion to sinus rhythm was achieved within the 24-hour study period. Baseline clinical characteristics were similar in the 4 groups. The treatment was successful in 61 of the 89 patients who received procainamide (68.53%; median time 3 hours), 73 of the 91 patients who received propafenone (80.21%; median time 1 hour), 82 of the 92 patients who received amiodarone (89.13%; median time 9 hours), and 55 of the 90 patients who received placebo (61.11%; median time 17 hours; p<0.05 for all medicated groups vs placebo; p<0.05 for amiodarone and propafenone vs procainamide). In conclusion, all 3 medications, when administered intravenously, are effective in the restoration of sinus rhythm in recent-onset AF. Amiodarone and propafenone are more effective whereas procainamide and propafenone are faster.     

Intravenous propafenone in paroxysmal atrial fibrillation: A randomized,placebo-controlled,double-blind,multicenter clinical trial

Background: Pharmacological conversion of paroxysmal atrial fibrillation is frequently necessary. The aim of this study was to compare intravenous propafenone, a class Ic antiar-rhythmic agent, with placebo in paroxysmal atrial fibrillation (AF) of recent onset (<72 h). Patients and methods: We randomly allocated 75 patients, aged 18 to 70 years, with paroxysmal AF to receive intravenous propafenone (2 mg/kg in 15 min followed by 1 mg/kg in 2 h) or the matching placebo. Patients were followed for 3 h. Exclusion criteria were the presence of one of the following: clinical heart failure, recent acute myocardial infarction, hypotension, atrioventricular block, Wolff-Parkinson-White syndrome, or current treatment with antiarrhythmic agents or digitalis. Results: No sign of heart disease was found in 74.7% of the patients. Echocardiographically determined left atrium diameter was similar in the two groups. Conversion to sinus rhythm occurred in 24 of 41 patients allocated to propafenone and in 10 of 34 patients allocated to placebo (odds ratio 3.2, 95% confidence intervals 1.3-7.9;p<0.01). Mean conversion time was 34 ± 29 and 71 ± 55 min, respectively, for propafenone and placebo. Mean heart rate in nonconverters decreased from 146 to 109 beats/min in patients treated with propafenone while it remained virtually unchanged in those treated with placebo. Only minor side effects were noted. Conclusions: Intravenous propafenone is an effective therapeutic option for restoring sinus rhythm in patients with paroxysmal AF of recent onset.     

Long-term efficacy and safety of propafenone and sotalol for the maintenance of sinus rhythm after conversion of recurrent symptomatic atrial fibrillation

This study was performed to evaluate, using a randomized double-blind, placebo-controlled protocol, the long-term efficacy and safety of propafenone and sotalol in maintaining sinus rhythm after conversion of recurrent symptomatic atrial fibrillation (AF). The maintenance of sinus rhythm in patients with recurrent AF has several potential benefits, the most important being a reduced risk of thromboembolic events. Three hundred patients with recurrent AF (> or = 4 episodes in the last year) and AF at enrollment lasting < 48 hours were randomized to receive either propafenone (mean daily dose 13 +/- 1.5 mg/kg; 102 patients), sotalol (mean daily dose 3 +/- 0.4 mg/kg; 106 patients), or placebo (92 patients). After 1-year follow-up, Kaplan-Meier estimates of the proportion of patients remaining in sinus rhythm were comparable between propafenone (63%) and sotalol (73%) and superior to placebo (35%; p = 0.001 vs both drugs). Symptomatic recurrences occurred later with propafenone and sotalol than with placebo. Nine patients (9%) in the propafenone group, 11 (10%) in the sotalol group, and 3 (3%) in the placebo group discontinued therapy due to adverse effects. Malignant nonfatal arrhythmias due to proarrhythmic effects were documented with sotalol only, and occurred < 72 hours from the beginning of therapy in 4 patients (4%). During recurrences, the ventricular rate was significantly reduced in patients taking propafenone and sotalol (p = 0.001 for both drugs vs placebo). The likelihood of remaining in sinus rhythm during follow-up was higher in younger patients with smaller left atrial size and without concomitant heart disease. In patients with recurrent symptomatic AF, propafenone and sotalol are not significantly different from each other and are superior to placebo in maintaining sinus rhythm at 1 year. Recurrences occur later and tend to be less symptomatic with propafenone and sotalol compared with placebo.     

Restoring Sinus Rhythm in Atrial Fibrillation: Electrical or Pharmacological Cardioversion

Restoration of sinus rhythm represents a desirable endpoint in patients with persistent (nonselfterminating) episode of paroxysmal atrial fibrillation (AF) and in selected patients with chronic AF. The decision whether to cardiovert AF pharmacologically or electrically is unresolved. Pharmacological cardioversion with oral quinidine first used to terminate recent onset AF is no longer used in Europe because its safety has been questioned. Other oral antiarrhythmic agents were used orally in this indication including procaînamide, disopyramide, and oral amiodarone. More recently, oral flecaînide and oral propafenone have been used in recent onset AF. Success rates ranging between 67% and 95% were reported in placebo-controlled studies. Pharmacological cardioversion can also routinely be obtained in hospital practice using intravenous injection of an antiarrhythmic agent. Intravenous digoxin, although commonly used, has shown in controlled studies to be no better than placebo. Intravenous amiodarone in open studies was associated with high success rates. Intravenous flecaînide, intravenous propafenone, and intravenous cibenzoline have been reported to be sucessful in recent onset AF. It is important to keep in mind that pharmacological cardioversion carries the risk of flutter with 1:1 conduction and ventricular proarrhythmia. The safety of pharmacological cardioversion using oral agents should be assessed in a hospital environment before allowing outpatient use. External (transthoracic) electrical cardioversion remains the technique of choice for restoring sinus rhythm in chronic AF. The success rates range from 65% to 90%. A technique of high energy electrical DC (200J or 300J) internal cardioversion has been shown to be useful in patients who failed external conversion. Recently, a technique for low-energy (> 6J) cardioversion of AF using biphasic shocks, electrode catheters positioned in the right atrium (cathode), and the coronary sinus (anode), was found to restore sinus rhythm in 70%-88% of patients. Internal cardioversion is emerging as a therapeutic alternative in selected groups of AF patients, particularly in those who failed external cardioversion.     

Effectiveness of intravenous propafenone for conversion of atrial fibrillation and flutter of recent onset

The efficacy of intravenous propafenone (2 mg/kg) was assessed in 83 consecutive patients: 68 with atrial fibrillation (AF) and 15 with atrial flutter lasting less than 15 days. Conversion to sinus rhythm occurred in 47 patients (57%), including 42 (62%) of those with AF and 5 (33%) of those with atrial flutter (p less than 0.05). The mean time to conversion was 29 +/- 24 minutes. The success rate was strongly affected by arrhythmia duration. Thus, conversion occurred in 40 patients (71%) among the 56 with arrhythmia lasting less than 48 hours but in 7 patients (26%) among the 27 with a longer lasting arrhythmia (p less than 0.0005). Left atrial size (determined echocardiographically in 56 patients) was significantly larger in nonconverters (49 +/- 12 vs 39 +/- 7 mm, p less than 0.0005). In nonconverters the mean ventricular rate decreased from 141 +/- 26 to 104 +/- 22 beats/min (p less than 0.0005). Except for reversible low output state in 3 patients already hemodynamically compromised, no significant side effects were observed. In conclusion, (1) intravenous propafenone allows a quick restoration of sinus rhythm in the majority of patients with AF of recent onset, whereas it seems less effective in atrial flutter; (2) its efficacy is influenced by the duration of the arrhythmia and by left atrial dimensions; (3) the drug allows control of ventricular rate; and (4) its use seems to be safe except in patients with severe cardiac failure.     

Effectiveness of intravenous propafenone for conversion of recent-onset atrial fibrillation: A placebo-controlled study

To evaluate the efficacy of propafenone in converting recent-onset atrial fibrillation (AF) lasting <7 days, 182 patients were treated intravenously with propafenone (Group 1, n = 98) and with placebo 0.9% saline solution (Group 2, n = 84) in a double blind study. The treatment was continued until sinus rhythm (SR) was restored, but for no more than 24 h. Eighty-nine patients treated with propafenone (90.8%) and 27 patients treated with placebo (32.1%) responded to the treatment and SR was restored (p < 0.0005). The mean time for SR restoration was 2.51± 2.77 h in Group 1, and 17.15± 7.8 h in Group 2 (p < 0.0005). In both groups the patients in whom SR was not restored (nonresponders) had larger left atrial size and longer duration of AF than responders at the onset of the arrhythmia. Nonresponders in Group 1 showed a decrease in mean ventricular rate (MVR) from 143± 16 to 101± 18 (p < 0.0005), while in the nonresponders in Group 2 no reduction of MVR was observed. Two patients whose SR was restored with propafenone had sinus standstill lasting 3.4 and 3.8 s, respectively. Propafenone used intravenously is an effective, quick, and safe drug for treating AF. Moreover, it significantly reduces MVR in nonresponders.     

Long-term maintenance of normal sinus rhythm in patients with current symptomatic atrial fibrillation: amiodarone vs propafenone, both in low doses

STUDY OBJECTIVES: To compare the efficacy and safety of amiodarone and propafenone when used for the prevention of atrial fibrillation (AF) and maintenance of normal sinus rhythm in patients with refractory AF. DESIGN: Prospective, randomized, single-blind trial. SETTING: Tertiary cardiac referral center. PATIENTS: One hundred forty-six consecutive patients (72 men; mean age, 63 +/- 10 years [+/- SD]) with recurrent symptomatic AF. INTERVENTIONS: We studied 146 patients after restoration of sinus rhythm; patients were randomized to amiodarone, 200 mg/d, or propafenone, 450 mg/d. Follow-up clinical evaluations were conducted at the first, second, fourth, and sixth months, and at 3-month intervals thereafter. The proportion of patients relapsing to AF and/or experiencing side effects was calculated for each group using the Kaplan-Meier method. End point of the study was recurrence of AF or occurrence of side effects necessitating discontinuation of medication. Measurements and results: Of 146 patients, 72 received amiodarone and 74 received propafenone. The two groups were clinically similar. Of the 72 patients receiving amiodarone, AF developed in 25 patients, after an average of 9.8 months, compared to 33 of the 74 patients receiving propafenone after an average of 3.8 months. Twelve patients receiving amiodarone and 2 patients receiving propafenone had side effects necessitating withdrawal of medication while still in sinus rhythm. CONCLUSIONS: Amiodarone tends to be more effective than propafenone in maintaining sinus rhythm in patients with AF, but this advantage is offset by a higher incidence of side effects.     

Utility of adjunctive single oral bolus propafenone therapy in patients with atrial defibrillators.

AIMS: Previous studies have demonstrated that ambulatory atrial defibrillation shocks delivered by an implantable cardioverter-defibrillator (ICD) are safe and effective, but poorly tolerated. Separate studies have demonstrated the utility of single oral bolus propafenone for conversion of recent-onset atrial fibrillation (AF); however, most patients were hospitalized, had no structural heart disease, were taking no other antiarrhythmic drugs, and were not exposed to concomitant shock. We hypothesized that a single oral bolus dose of propafenone given early after onset would be a safe and effective adjunct to ICD-based AF therapy and improve overall therapy tolerance. METHODS AND RESULTS: A randomized three-way crossover study design was used to compare three strategies, deployed in the ambulatory setting early after AF episode onset in 35 ICD patients with advanced, drug refractory episodic/persistent syndromes, many of whom had structural heart disease and were taking other antiarrhythmic drugs: (i) single oral bolus propafenone (600 mg), followed by ICD shock if necessary; (ii) single oral bolus placebo, followed by ICD shock if necessary; and (iii) no oral bolus therapy and ICD shock if necessary (no bolus). Antiarrhythmic efficacy, defined by the restoration of sinus rhythm within 24 h, was similar during propafenone (81%) and no-bolus strategies (84%); both were significantly higher than during placebo strategy (62%). Propafenone was well tolerated and not associated with proarrhythmia. Shock use was significantly lower during propafenone strategy (19%) than during no-bolus strategy (55%); this was correlated with improved patient tolerance. CONCLUSION: Adjunctive use of single oral bolus propafenone is safe and effective in patients with an ICD and improves patient tolerance of device-based AF therapy.     

A randomized, controlled trial of RSD1235, a novel anti-arrhythmic agent, in the treatment of recent onset atrial fibrillation

OBJECTIVES: The purpose of this study was to determine the efficacy and safety of intravenous RSD1235 in terminating recent onset atrial fibrillation (AF). BACKGROUND: Anti-arrhythmic drugs currently available to terminate AF have limited efficacy and safety. RSD1235 is a novel atrial selective anti-arrhythmic drug. METHODS: This was a phase II, multi-centered, randomized, double-blinded, step-dose, placebo-controlled, parallel group study. Fifty-six patients from 15 U.S. and Canadian sites with AF of 3 to 72 h duration were randomized to one of two RSD1235 dose groups or to placebo. The two RSD1235 groups were RSD-1 (0.5 mg/kg followed by 1 mg/kg) or RSD-2 (2 mg/kg followed by 3 mg/kg), by intravenous infusion over 10 min; a second dose was given only if AF was present. The primary end point was termination of AF during infusion or within 30-min after the last infusion. Secondary end points included the number of patients in sinus rhythm at 0.5, 1, and 24 h post-last infusion and time to conversion to sinus rhythm. RESULTS: The RSD-2 dose showed significant differences over placebo in: 1) termination of AF (61% vs. 5%, p < 0.0005); 2) patients in sinus rhythm at 30 min (56% vs. 5%, p < 0.001); 3) sinus rhythm at 1 h (53% vs. 5%, p = 0.0014); and 4) median time to conversion to SR (14 vs. 162 min, p = 0.016). There were no serious adverse events related to RSD1235. CONCLUSIONS: RSD1235, a new atrial-selective anti-arrhythmic agent, appears to be efficacious and safe for converting recent onset AF to sinus rhythm.     

Is vernakalant better or not compared with other treatments for conversion acute atrial fibrillation?

Vernakalant has proved to be more rapid in converting recent onset AF to sinus rhythm compared to placebo, amiodarone, propafenone and flecainide.     

Comparison of oral loading dose of propafenone and amiodarone for converting recent-onset atrial fibrillation. PARSIFAL Study Group

In patients with recent-onset atrial fibrillation (AF), restoration of sinus rhythm is considered to be the first-line therapeutic option. Although this conversion might be obtained by direct-current shock or intravenous antiarrhythmic drugs, administration of an oral loading dose of class I or III antiarrhythmic drugs is more simple and convenient. This prospective, randomized, multicenter study compares the time to conversion to sinus rhythm obtained with an oral loading dose of propafenone or amiodarone. Patients with recent-onset AF (<2 weeks), without contraindications for the 2 drugs, were randomly assigned to be treated with propafenone (600 mg for the first 24 hours and if necessary a repeated dose of 300 mg for 24 hours) or amiodarone (30 mg/kg for the first 24 hours and if necessary a repeated dose of 15 mg/kg for 24 hours). Exact conversion time during the first 24 hours was determined by Holter monitoring. In each treatment group 43 patients with the same baseline characteristics were included. The median time for restoration of sinus rhythm was shorter (p = 0.05) in the propafenone (2.4 hours) than in the amiodarone (6.9 hours) group. After 24 hours (56% in the propofenone and 47% in the amiodarone group) and 48 hours, the same proportion of patients in the 2 groups recovered sinus rhythm (no serious adverse events were noticed). Thus, oral loading dose of propafenone or amiodarone was safe with a similar conversion rate of recent-onset AF. Propafenone had a faster action.     

Time to Cardioversion of Recurrent Atrial Arrhythmias After Catheter Ablation of Atrial Fibrillation and Long‐Term Clinical Outcome

Introduction: It is unclear whether early restoration of sinus rhythm in patients with persistent atrial arrhythmias after catheter ablation of atrial fibrillation (AF) facilitates reverse atrial remodeling and promotes long‐term maintenance of sinus rhythm. The purpose of this study was to determine the relationship between the time to restoration of sinus rhythm after a recurrence of an atrial arrhythmia and long‐term maintenance of sinus rhythm after radiofrequency catheter ablation of AF. Methods and Results: Radiofrequency catheter ablation was performed in 384 consecutive patients (age 60 ± 9 years) for paroxysmal (215 patients) or persistent AF (169 patients). Transthoracic cardioversion was performed in all 93 patients (24%) who presented with a persistent atrial arrhythmia: AF (n = 74) or atrial flutter (n = 19) at a mean of 51 ± 53 days from the recurrence of atrial arrhythmia and 88 ± 72 days from the ablation procedure. At a mean of 16 ± 10 months after the ablation procedure, 25 of 93 patients (27%) who underwent cardioversion were in sinus rhythm without antiarrhythmic therapy. Among the 46 patients who underwent cardioversion at ≤30 days after the recurrence, 23 (50%) were in sinus rhythm without antiarrhythmic therapy. On multivariate analysis of clinical variables, time to cardioversion within 30 days after the onset of atrial arrhythmia was the only independent predictor of maintenance of sinus rhythm in the absence of antiarrhythmic drug therapy after a single ablation procedure (OR 22.5; 95% CI 4.87–103.88, P < 0.001). Conclusion: Freedom from AF/flutter is achieved in approximately 50% of patients who undergo cardioversion within 30 days of a persistent atrial arrhythmia after catheter ablation of AF.     

Outpatient treatment of recurrent atrial fibrillation with the "pill-in-the-pocket" approach: practical aspects]

In patients with not very frequent episodes of atrial fibrillation (AF), highly symptomatic for palpitation, hemodynamically well tolerated but long enough to require emergency room (ER) intervention, the best outpatient treatment appears to be the "pill-in-the-pocket" approach. In several studies, in-hospital administration of flecainide or propafenone in a single oral loading dose has been shown to be effective and superior to placebo in terminating recent-onset AF. Recently, a multicenter Italian study has been carried out to evaluate the feasibility and the safety of self-administered oral loading of flecainide or propafenone in terminating AF of recent onset outside the hospital. Either flecainide or propafenone were administered orally to restore sinus rhythm in 268 patients with mild heart disease or none, who came to the ER with AF of recent onset that was hemodynamically well tolerated. Of these patients, 21% were excluded from the study because of treatment failure or side effects. During a mean follow-up of 15 months, 94% of the arrhythmic episodes were interrupted by the oral loading of flecainide or propafenone; the mean time to resolution of symptoms was about 2 hours. Adverse effects were reported during one or more arrhythmic episodes by 7% of the patients, including atrial flutter at a rapid ventricular rate in 1 patient. The numbers of monthly visits to the ER and hospitalizations were 90% lower during follow-up than the year before enrollment. These results show that in a selected, risk-stratified population of patients with recurrent AF, the "pill-in-the-pocket" treatment is feasible and safe, with a high rate of compliance by patients, a low rate of adverse effects, and a marked reduction in ER visits. Some recommendations on the practical use of this type of treatment are given.     

Effect of candesartan and various inflammatory markers on maintenance of sinus rhythm after electrical cardioversion for atrial fibrillation

Inflammatory markers, their relation to maintenance of sinus rhythm after electrical cardioversion for atrial fibrillation (AF), and the effect of candesartan were investigated in a double-blind placebo-controlled study (CAPRAF). One hundred seventy-one patients with persistent AF were randomly assigned to receive candesartan 8 mg/day or placebo for 3 to 6 weeks before and candesartan 16 mg/day or placebo for 6 months after electrical cardioversion. Serum levels of high-sensitivity C-reactive protein (hs-CRP), tumor necrosis factor-alpha, interleukin-6, P-selectin, E-selectin, CD-40 ligand, and vascular cell adhesion molecule-1 were measured at baseline and end of study. Compared with patients with a relapse of AF, patients still in sinus rhythm at 6 months after cardioversion (n = 40) had lower baseline hs-CRP and E-selectin levels: median 2.36 mg/L (25th, 75th percentiles 1.28, 4.09) versus 3.44 mg/L (25th, 75th percentiles 1.66, 6.05, p = 0.031) and 32 ng/ml (25th, 75th percentiles 23, 42) versus 37 ng/ml (25th, 75th percentiles 28, 51, p = 0.042), respectively. Neither sustained sinus rhythm for 6 months nor treatment with candesartan had an impact on measured concentrations of markers of inflammation. In conclusion, low hs-CRP and E-selectin at baseline were associated with maintenance of sinus rhythm after electrical cardioversion.     

Stunning of the left atrium after pharmacological cardioversion of atrial fibrillation

INTRODUCTION: Stunning of the left atrium and atrial appendage is a well known but not fully clarified phenomenon observed during the cardioversion of atrial fibrillation regardless of the cardioversion method attempted. AIM: To assess the effects of propafenone and amiodarone on left atrium and left atrial appendage contractility. METHODS: Forty patients with paroxysmal atrial fibrillation (20 females, 20 males), aged 60-83 (mean 72.0+/-10.1) years, were enrolled into the study. Half of these patients had sinus rhythm restored by the administration of oral propafenone (150-300 mg) and the remaining 20 patients were treated with intravenous amiodarone (150-450 mg). The control group consisted of 20 patients (10 females, 10 males) aged 52-78 (mean 61.2+/-9.3) years with sinus rhythm and no history of atrial fibrillation. All the patients had a transthoracic (TTE) and transesophageal (TEE) echocardiography performed while still in the AF, before drug administration and 1 hour after sinus rhythm restoration. RESULTS: All haemodynamic parameters of the left atrium measured after the sinus rhythm restoration were significantly worse when compared with the control group. Left atrial fractional shortening and total atrial fraction were significantly lower after propafenone than amiodarone (8.6+/-3.6% vs 11.7+/-5.5%, p<0.05; and LA FC 16.2+/-5.3% vs 23.3 (+/-6.3)% respectively, p<0.05). Doppler echocardiographic parameters included in the analysis such as mitral flow and superior left pulmonary vein flow were significantly lower in the sinus rhythm restoration group than in the control group. Among them the end-diastolic mitral flow velocity amplitude and flow velocity integral as well as the maximum pulmonary retrograde velocity were significantly worse in the group treated with propafenone than in patients receiving amiodarone. All the atrial appendage Doppler velocity parameters were significantly reduced after the sinus rhythm restoration in both groups. In the patients treated with propafenone, values of these parameters were significantly decreased compared with the patients receiving amiodarone. CONCLUSIONS: Successful pharmacological cardioversion of atrial fibrillation causes the left atrium and left atrial appendage contractility impairment similar to that observed with other methods of the sinus rhythm restoration. Following the AF cardioversion the level of left atrial stunning is higher in the patients treated with propafenone than in subjects receiving amiodarone.     

The efficacy of azimilide in the treatment of atrial fibrillation in the presence of left ventricular systolic dysfunction: results from the Azimilide Postinfarct Survival Evaluation (ALIVE) trial

OBJECTIVES: The purpose of this study was to assess the effect of oral azimilide dihydrochloride (AZ) 100 mg versus placebo on the onset, termination, and prevalence of atrial fibrillation (AF) in a subpopulation of patients in the Azimilide Postinfarct Survival Evaluation (ALIVE) trial. BACKGROUND: Previous clinical trials have demonstrated the antiarrhythmic effects of AZ in patients with AF. Azimilide was investigated for its effects on mortality in patients with depressed left ventricular (LV) function after recent myocardial infarction (MI) and in a subpopulation of patients with AF. METHODS: A total of 3,381 post-MI patients with depressed LV function were enrolled in this randomized, placebo-controlled, double-blind study of AZ 100 mg on all-cause mortality. A total of 93 patients had AF on the baseline 12-lead electrocardiogram (ECG). An additional 27 patients developed AF after initially being in sinus rhythm at randomization. These patients were identified through 12-lead ECGs obtained during routine visits at week 2, months 1, 4, 8, and 12. RESULTS: Patients with AF at baseline had a higher mortality than those without AF (p = 0.0006). Among AF patients, there was no difference in mortality between AZ patients and placebo patients (p = 0.82). Fewer AZ patients developed AF than placebo patients (p = 0.04). More AZ patients than placebo patients converted to sinus rhythm, but this difference did not achieve statistical significance (p = 0.076). Over one-year follow-up, more AZ patients were in sinus rhythm than placebo patients (p = 0.04). CONCLUSIONS: Azimilide was safe and effective AF therapy in patients with depressed LV function after an MI.     

Acute pharmacologic conversion of atrial fibrillation and flutter: the role of flecainide, propafenone, and verapamil.

Efficacy and safety of intravenous flecainide (2 mg/kg body weight in 10 minutes), verapamil (10 mg in 1 minute), and propafenone (2 mg/kg body weight in 10 minutes) were investigated in 90 consecutive patients with atrial fibrillation (AF) or flutter (AFL). In the first 40 patients, flecainide and verapamil were evaluated; in the second 50 patients, flecainide and propafenone were compared, both in a single-blind randomized study design. The primary end point was sinus rhythm occurring within 1 hour after start of infusion. Sinus rhythm was attained in 32 of 37 patients (86%) with AF treated with flecainide and in 11 of 20 patients (55%) with AF treated with propafenone. In recent onset AF (less than or equal to 24 hours) conversion rates were 24 of 25 patients (96%) in the flecainide group and 8 of 14 patients (57%) in the propafenone group (p less than 0.05). Conversion of AFL occurred in only 1 of 8 patients (13%) in the flecainide-treated patients and in 2 of 5 patients (40%) treated with propafenone (difference not significant). Verapamil was almost ineffective, since only 1 of 20 patients (5%) responded within 1 hour. Time to conversion was 21 +/- 17 minutes in the flecainide group and 16 +/- 10 minutes in the propafenone group. QRS widening occurred in flecainide-treated patients (83 +/- 15 to 99 +/- 20 msec; p less than 0.001), but not after propafenone (83 +/- 11 to 86 +/- 12 msec). Significantly higher plasma levels were found in patients with conversion within 1 hour using propafenone.(ABSTRACT TRUNCATED AT 250 WORDS)     

Efficacy of intravenous propafenone in acute atrial fibrillation complicating open-heart surgery.

Early postoperative atrial fibrillation (AF) is a frequent complication of major cardiovascular surgery. To assess the effectiveness of intravenous propafenone in this setting, we studied 50 patients who developed AF within 48 hours after open-heart surgery. Intravenous propafenone (2 mg/kg in 10 minutes) was administered 15 minutes after the onset of the arrhythmia. Sinus rhythm was restored in 35 patients (70%) after a mean time of 22 +/- 6 minutes after the beginning of the infusion. The conversion was obtained in 28 of 32 patients (88%) who had a coronary artery bypass graft and in 7 of 18 patients (39%) who had valvular or septal surgery (p less than 0.01). In those whose arrhythmia did not convert to sinus rhythm, the ventricular rate was reduced from 142 +/- 14 beats/min to 108 +/- 9 beats/min (p less than 0.01). In patients whose arrhythmia was converted to sinus rhythm, mean cardiac index increased from a mean baseline value of 2.7 +/- 0.4 L/min/m2 to 3.4 +/- 0.1 L/min/m2 (p less than 0.05), while it remained virtually unchanged in those whose arrhythmia did not convert. No significant side effects were observed. We conclude that intravenous propafenone is effective in converting to sinus rhythm the majority of patients with AF complicating open-heart surgery. Heart rate was reduced in those who did not convert to sinus rhythm and no side effects nor hemodynamic deterioration were observed in any case.     

Differential sensitivity of the RV6:RV5 voltage ratio by pathogenesis of left ventricular hypertrophy and diagnostic cutpoint

To evaluate the efficacy of propafenone for suppression of recurrent paroxysmal symptomatic atrial fibrillation (AF), patients with frequent episodes of AF entered an open-label, dose-ranging study to determine the maximal tolerated dose of propafenone and were subsequently randomized to alternate between propafenone and placebo every month for 4 months. Patients recorded each episode of AF in a diary and recorded a simultaneous electrocardiographic rhythm strip by means of a transtelephonic recorder and transmitter to validate the presence of AF. Eighteen patients were eligible for study. During dose ranging, 4 patients withdrew due to inadequate drug efficacy or poor compliance, 2 withdrew due to intolerable side effects and 1 died. The mean dose of propafenone at the end of dose ranging was 644 +/- 189 mg/day. During the crossover study, the percentage of days with an attack of AF was significantly reduced by propafenone compared with placebo (27 +/- 34 vs 51 +/- 34%, p less than 0.01). The rate of early crossover or withdrawal from the crossover study was 13.6% with propafenone and 45% with placebo (p = 0.056). Five patients went on to receive long-term propafenone and 4 continued treatment with suppression of AF for 12 to 21 months. During the crossover study there were 29 reported minor side effects with propafenone and 11 with placebo.