Atrial fibrillation persistent

Atrial fibrillation is classified as paroxysmal, persistent, or permanent (Fig. 6-4).23 Patients with paroxysmal AF have episodes that start suddenly and spontaneously, last minutes... 

FIGURE 6-5. Decision algorithm for ventricular rate control using intravenous drug therapy for patients presenting with the first detected episode or an episode of persistent atrial fibrillation that is hemody-namically stable. 

Unlabeled Uses Control of hemodynamicallystableventriculartachycardia, control of rapid ventricular rate due to accessory pathway conduction in preexcited atrial arrhythmias, conversion of atrial fibrillation to normal sinus rhythm, in cardiac arrest with persistent ventricular tachycardia or ventricular fibrillation, paroxysmal supraventricular tachycardia, polymorphic ventricular tachycardia or wide complex tachycardia of uncertain origin, prevention of postoperative atrial fibrillation... 

Dronedarone doubled the interval between episodes of atrial fibrillation recurrence in patients with paroxysmal or persistent atrial fibrillation. It is the first antiarrhythmic drug to demonstrate a reduction in mortality or hospitalization in patients with atrial fibrillation. 

Intravenous vernakalant is effective in converting recent-onset atrial fibrillation to normal sinus rhythm in 50% of patients. Approval has been recommended for this purpose. The drug is undergoing clinical trials for maintenance of normal sinus rhythm in patients with paroxysmal or persistent atrial fibrillation. 

Van Gelder IC, et al, A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002 347(23) 1834-1840,... 

Madrid AH, Bueno MG, Rebollo JM, Marin I, Pena G, Bernal E, Rodriguez A, Cano L, Cano JM, Cabeza P, Moro C. Use of irbesartan to maintain sinus rhythm in patients with long-lasting persistent atrial fibrillation a prospective and randomized study. Circulation 2002 106 331-336. 

Brundel B, Ausma J, Gelder I, et al. 2002a. Activation of proteolysis by calpains and structural changes in human paroxysmal and persistent atrial fibrillation. Cardiovasc Res 54 380-389. 

Mr Jones is subsequently transferred to the cardiology ward where his continuing atrial fibrillation is later confirmed as persistent atrial fibrillation. As the ward clinical pharmacist, you are responsible for daily review of drug charts and advice to medical and nursing staff on all aspects of drug treatment for patients on the ward. 

Rhythm control is not recommended as first line treatment in older people with persistent AF and all patients with permanent AF, as rate control would be the preferred treatment. If a patient requires rhythm control, referral to a specialist is recommended rather than commencing in primary care. At least one meta-analysis has shown that, in people with atrial fibrillation at moderate to high risk of stroke, survival rates were similar for rate control or rhythm control. 

Cardioversion is an option in patients with persistent atrial fibrillation and has an initial success rate of 70 - 90% in selected people. Success is more likely in recent-onset AF and in younger people. 

Paroxysmal atrial fibrillation carries the same stroke risk as persistent atrial fibrillation (Lip and Hee 2001 Saxonhouse and Curtis 2003) and should be treated similarly. There is no evidence that conversion to sinus rhythm followed by pharmacotherapy to try to maintain such rhythm is superior to rate control in terms of mortality and stroke risk (Segal et al. 2001 Blackshear and Safford 2003 Hart et al. 2003). 

Cardiac glycosides such as digoxin are commonly used to treat uncomphcated atrial fibrillation. In those in whom digi-tahs is not completely effective or in whom s)mptoms (for example bouts of palpitation) persist despite adequate digitalization, a calcium antagonist, such as verapamil or diltia-zem, can be added, or amiodarone used as an alternative. 

Of 85 patients with persistent atrial fibrillation after balloon mitral valvotomy given amiodarone (600 mg/day for 2 weeks and 200 mg/day thereafter), 33 converted to sinus rhythm (29). Of the other 52 patients, who underwent DC cardioversion at 6 weeks, 41 converted to sinus rhythm. Six patients had adverse effects attributable to amiodarone. Five had mild gastrointestinal symptoms, such as abdominal discomfort and nausea. One developed hypothyroidism after 3 months, which resolved when the dosage of amiodarone was reduced to 100 mg/day. 

Qf 136 patients with atrial fibrillation treated with either amiodarone (n = 96) or propafenone (n = 40), 15 developed subsequent persistent atrial flutter, nine of those taking amiodarone and six of those taking propafenone (58). In all cases radiofrequency ablation was effective. It is not clear to what extent these cases of atrial flutter were due to the drugs, although the frequency of atrial flutter in previous studies with propafenone has been similar. Atrial enlargement was significantly related to the occurrence of persistent atrial flutter in these patients. 

Kapoor A, Kumar S, Singh RK, Pandey CM, Sinha N. Management of persistent atrial fibrillation following balloon mitral valvotomy safety and efficacy of low-dose amiodarone. J Heart Valve Dis 2002 ll(6) 802-9. 

Kosior D, Karpinski G, Wretowski D, Stolaiz P, Stawicki S, Rabczenko D, Torbicki A, Opolski G. Sequential prophylactic antiarrhythmic therapy for maintenance of sinus rhythm after cardioversion of persistent atrial fibrillation—one year follow-up. Kardiol Pol 2002 56 361-7. 

Tai CT, Chiang CE, Lee SH, Chen YJ, Yu WC, Feng AN, Ding YA, Chang MS, Chen SA. Persistent atrial flutter in patients treated for atrial fibrillation with amiodarone and propafenone electrophysiologic characteristics, radiofrequency catheter ablation, and risk prediction. J Cardiovasc Electrophysiol 1999 10(9) 1180-7. 

In a comparison of oral aprindine and propafenone in 32 patients (25 men and 7 women, aged 43-82) with paroxysmal or persistent atrial fibrillation, aprindine was effective in five of 29 and propafenone in six of 28 adverse effects were not reported (6). 

There has been a multicenter, randomized, placebo-controUed, double-blind comparison of aprindine and digoxin in the prevention of atrial fibrillation and its recurrence in 141 patients with symptomatic paroxysmal or persistent atrial fibrillation who had converted to sinus rhythm (7). They were randomized in equal numbers to aprindine 40 mg/day, digoxin 0.25 mg/day, or placebo and followed every 2 weeks for 6 months. After 6 months the Kaplan-Meier estimates of the numbers of patients who had no recurrences with aprindine, digoxin, and placebo were 33, 29, and 22% respectively. The rates of adverse events were similar in the three groups. This suggests that aprindine has a very small beneficial effect in preventing relapse of sjmptomatic atrial fibrillation after conversion to sinus rhythm. Furthermore, recurrence occurred later with aprindine than with placebo or digoxin (about 60% recurrence at 115 days compared with 30 days). 

A second fundamental question concerns the role of resynchronization therapy in patients with persistent atrial fibrillation (AF). Atrial fibrillation is common in advanced heart failure (35), but patients with persistent atrial fibrillation were excluded from the majority of randomized clinical trials of resynchronization. Nevertheless, the most recent guidelines classify AF with QRS duration >120 msec to be a Class Ha indication for CRT implantation (1). Three multicenter randomized trials of resynchronization therapy have... 

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