Atrial fibrillation recurrent

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. 

Lau CP, Chow MS, Tse HF, Tang MO, Fan C. Control of paroxysmal atrial fibrillation recurrence using combined administration of propafenone and quinidine. Am J Cardiol 2000 86 1327-1332. 

Bellandi F, Leoncini M, Maioli M, Gallopin M, Dabizzi RP. Comparing agents for prevention of atrial fibrillation recurrence. Cardiol Rev 2002 19 18-21. 

Shamiss Y, Khaykin Y, Oosthuizen R, Tunney D, Sarak B, Beardsall M, Seabrook C, Frost L, Wulffhart Z, Tsang B, Verma A. Dofetilide is safe and effective in preventing atrial fibrillation recurrences in patients accepted for catheter ablation. Europace 2009 11(11) 1448-55. 

The Heparin in Acute Embolic Stroke Trial (HAEST) was a multicenter, randomized trial of the effect of LMWH (dalteparin 100 lU/kg sc twice daily) or aspirin (160 mg once daily) for the acute treatment of 449 patients with ischemic stroke and atrial fibrillation (AF). The primary outcome was the rate of recurrent stroke within 14 days. No difference in rates of early recurrence (8.5% dalteparin treated vs. 7.5% aspirin treated) or good 3-month functional outcome was found. The frequency of early slCH was 2.7% on dalteparin versus 1.8% on aspirin. 

FIGURE 6-2. Algorithm for the treatment of acute (top portion) paroxysmal supraventricular tachycardia and chronic prevention of recurrences (bottom portion). Note For empiric bridge therapy prior to radiofrequency ablation procedures, calcium channel blockers (or other atrioventricular [AV] nodal blockers) should not be used if the patient has AV reentry with an accessory pathway. (AAD, antiarrhythmic drugs AF, atrial fibrillation AP, accessory pathway AVN, atrioventricular nodal AVNRT, atrioventricular nodal reentrant tachycardia AVRT, atrioventricular reentrant tachycardia DCC, direct-current cardioversion ECG, electrocardiographic monitoring EPS, electrophysiologic studies PRN, as needed VT, ventricular tachycardia.)... 

Immediate-release (IR)-To prolong the time to recurrence of paroxysmal atrial fibrillation/flutter associated with disabling symptoms in patients without structural heart disease. 

Kessler G, Rosenblatt S, Friedman J, Kaphnsky E. Recurrent dilated cardiomyopathy reversed with conversion of atrial fibrillation. Am. Heart J. 1997 133 384-6. 

Rapid loading dose for the management and treatment of CHF control ofventricular rate In patients with atrial fibrillation-, treatment and prevention of recurrent paroxysmal atrial tachycardia PO Initially, 0.5-0.75 mg, additional doses of 0.125-0.375 mg at 6-to8-hr intervals. Range 0.75-1.25 mg. IV 0.6-1 mg. 

Maintenance dosage for CHF control of ventricular rate in patients with atrial fibrillation treatment and prevention of recurrent paroxysmal atrial tachycardia PO, IV... 

Arrhythmias, including prevention of recurrent paroxysmal supraventricular tachycardia and control of ventricular resting rate in chronic atrial fibrillation or flutter (with di-goxin) PO 240-480 mg/day in 3-4 divided doses. 

Low doses (100-200 mg/d) of amiodarone are effective in maintaining normal sinus rhythm in patients with atrial fibrillation. The drug is effective in the prevention of recurrent ventricular tachycardia. It is not associated with an increase in mortality in patients with coronary artery disease or heart failure. In many centers, the implanted cardioverter-defibrillator (ICD) has succeeded drug therapy as the primary treatment modality for ventricular tachycardia, but amiodarone may be used for ventricular tachycardia as adjuvant therapy to decrease the frequency of uncomfortable cardioverter-defibrillator discharges. The drug increases the pacing and defibrillation threshold and these devices require retesting after a maintenance dose has been achieved. 

A 62-year-old woman with paroxysmal atrial fibrillation who had taken amiodarone 300 mg/day had a serum sodium concentration of 120 mmol/1 with a normal serum potassium and a reduced serum osmolality (240 mmol/kg) the urinary sodium concentration was 141 mmol/1 and the urine osmolality 422 mmol/kg (25). There was no evident cause of inappropriate secretion of ADH and within 5 days of withdrawal of amiodarone the serum sodium concentration had risen to 133 mmol/ 1 and rose further to 143 mmol/1 14 days later. There was no rechallenge and no recurrence of hyponatremia during the next 6 months. Another case has been reported (28). 

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,... 

Mr CD, a 75-year-old man, 1.7 m tall, is admitted to hospital very short of breath. He used to work in the docks as a clerk and has smoked 40 cigarettes daily for 30 years and stopped 2 years ago. His previous medical history includes COPD, recurrent infective exacerbations since 1991, no LTOT type 2 diabetes mellitus on insulin 14 IU b.d. for 20 years, retinopathy ischaemic heart disease - coronary artery bypass graft (twice), hypertension myocardial infarction 1986 atrial fibrillation high cholesterol. 

Some of the association between atrial fibrillation and stroke must be coincidental because atrial fibrillation can be caused by coronary and hypertensive heart disease, both of which may be associated with atheromatous disease or primary intracerebral hemorrhage. Although anticoagulation markedly reduces the risk of first or recurrent stroke, this is not necessarily evidence for causality because this treatment may be working in other ways, such as by inhibiting artery-to-artery embolism, although trials of warfarin in secondary prevention of stroke in sinus rhythm have shown no benefit over aspirin (Ch. 24). 

Mitral leaflet prolapse is a common incidental finding. It can be complicated by gross mitral regurgitation, infective endocarditis, atrial fibrillation and left atrial thrombus and thus embolism to the brain. However, there is no excess risk of first or recurrent stroke in patients with uncomplicated mitral leaflet prolapse (Orencia et al. 1995a, b). 

Roy D et al 2000 Amiodarone to prevent recurrence of atrial fibrillation. Canadian Trial of Atrial Fibrillation Investigators. New England Journal of Medicine 342 913-920... 

The use of oral amiodarone in preventing recurrence of atrial fibrillation, for preventing recurrence after cardioversion or for pharmacological cardioversion of atrial fibrillation, has been reviewed (18). There is insufficient evidence to support its use as a first-line drug for... 

Amiodarone, propafenone, and sotalol have also been compared in the prevention of atrial fibrillation in 214 patients with recurrent symptomatic atrial fibrillation. They were randomized to amiodarone 200 mg/day, propafenone 450 mg/day, or sotalol 320 mg/day. There was recurrence of atrial fibrillation in 25 of the 75 patients who took amiodarone compared with the 51 of 75 who took sotalol and 24 of the 64 who took propafenone. There... 

Amiodarone has been reported to cause atrial flutter in 10 patients who had been given it for paroxysmal atrial fibrillation (56). In nine of those the atrial flutter was successfully treated by catheter ablation. However, during a mean follow-up period of 8 months after ablation, atrial fibrillation occurred in two patients who had continued to take amiodarone this was a lower rate of recurrence than in patients in whom atrial flutter was not associated with amiodarone. The authors therefore suggested that in patients with atrial flutter secondary to amiodarone given for atrial fibrillation, catheter ablation allows continuation of amiodarone therapy. 

Kochiadakis GE, Igoumenidis NE, Marketou ME, Kaleboubas MD, Simantirakis EN, Vardas PE. Low dose amiodarone and sotalol in the treatment of recurrent, symptomatic atrial fibrillation a comparative, placebo controlled study. Heart 2000 84(3) 251-7. 

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). 

The co-prescription of sotalol 80 mg bd with terfena-dine 60 mg bd (both drugs that can prolong the QT interval) in a 71-year-old lady with hypertension, atrial fibrillation, and nasal congestion was complicated by recurrent torsade de pointes, causing dizzy spells and confusion after 8 days (412). She was treated with temporary pacing, but her symptoms resolved 72 hours after drug withdrawal. 

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