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Clinical Bottom Lines: 1. Up to 1/2 of all patients spontaneously convert to sinus rhythm within the first 12 to 24 hrs of trial entry 2. Flecainide is the most effective antiarrhythmic agent and can be given orally (300 mg po as single dose) 3. Clonidine (0.075 mg po initially & repeat at 2 hrs if required), an antihypertensive agent, has shown promising preliminary results. Also effective for rate control. 4. Digoxin appears no better than placebo for conversion, and is slow to attain rate control |
Appraised by: S Sauvé, April 26th 1993
Comments:
1. Flecainide administration requires monitoring since can convert AF to flutter with 1:1 conduction
2. Results with Clonidine have yet to be duplicated, and it is unknown how clonidine would fare against traditional antiarrhythmic agents
___________________________________________________________________________________________
REFERENCES:
[1] Falk RH et al. Digoxin for converting recent-onset atrial fibrillation to sinus rhythm. Ann Int Med 1987;106:503-506.
[2] Roth A et al. Clonidine for patients with rapid atrial fibrillation. Ann Int Med 1992;116:388-390.
[3] Toivonen LK et al. (intravenous pirmenol) Br Heart J 1986;55:176-180.
[4] Cowan JC et al. (amiodarone and digoxin) J cardiovasc Pharmacol 1986;8:252-256.
[5] Negrini M et al. (amiodarone and quinidine) G Ital Cardiol 1990;20(3):207-214.
[6] Bertini G et al. (propafenone and amiodarone) J Emerg Med 1990;8:15-20.
[7] Noc M et al. (amiodarone and verapamil) Am J Cardiol 1990;65:679-680.
[8] Tommasso C et al. (verapamil) Arch Intern Med 1983;143:877-881.
[9] Waxman HL et al. (verapamil) Annals Internal Medicine 1981;94(1):1-6.
[10] Aronow WS et al. (verapamil) Clin Pharmacol Ther 1979;26:578-583.
[11] Platia EV et al. (esmolol, verapamil, digoxin, placebo) Circulation 1987;76(supp IV):529[abstract 2068]
[12] Platia EV et al. (esmolol vs verapamil) Am J Cardiol 1989;63:925-929.
[13] Suttorp MJ et al. (flecainide vs verapamil) Am J Cardiol 1989;63:693-696.
[14] Donovan KD et al. (flecainide) Am J Cardiol 1991;67:137-141.
[15] Borgeat A et al. (flecainide vs quinidine) Am J Cardiol 1986;58:496-498.
[16] Capucci A et al. (propafenone or flecainide) JACC 1993;21(2):171A abstract.
[17] Kondili A et al. (verapamil, flecainide and propafenone) Wien Klin Wochenschr 1990;102:510-513.
[18] Suttorp MJ et al. (propafenone vs flecainide) J Am Coll Cardiol 1990;16:1722-1727.
[19] Capucci A et al. (flecainide) Am J cardiol 1992;70:69-72.
[20] Villani GQ et al. (flecainide) G Ital cardiol 1990;20:564-568.
[21] Campbell TJ et al. (sotalol vs disopyramide) Br Heart J 1985;54:86-90.
The Evidence: SUMMARY TABLE of trial results. Proportion of patients remaining in AF at various times from onset therapy for each drug.
|
drug |
time (hrs) from onset therapy |
|||||||||
|
|
.5 |
1 |
2 |
3 |
4 |
6 |
8 |
12 |
18 |
24 |
|
placebo |
1.0 |
.85 |
|
.87 |
.89 |
.65 |
.72 |
|
.56 |
.72 |
|
|
1.0 |
.86 |
|
.71 |
|
|
.52 |
|
|
|
|
|
1.0 |
.89 |
|
|
|
|
|
|
|
|
|
quinidine |
|
|
|
|
|
|
|
|
|
.40 |
|
|
|
|
|
|
|
|
|
|
|
.31 |
|
disopyram . |
|
|
|
|
|
|
|
.15 |
|
|
|
flecainide |
|
.30 |
|
.44 |
|
.33 |
.20 |
|
|
.33 |
|
|
|
.43 |
|
.32 |
|
|
.09 |
|
|
.05 |
|
|
|
.50 |
|
|
|
|
|
|
|
.05 |
|
|
|
.24 |
|
|
|
|
|
|
|
|
|
propafeno. |
|
.75 |
.19 |
.51 |
|
|
.26 |
|
|
|
|
|
|
.48 |
|
|
|
|
|
|
|
|
|
esmolol |
|
.67 |
|
|
|
|
|
|
|
|
|
|
|
.52 |
|
|
|
|
|
|
|
|
|
sotalol |
|
|
|
|
|
|
|
.14 |
|
|
|
amiodarone |
|
|
.75 |
.84 |
.28 |
|
.63 |
|
|
.17 |
|
|
|
|
|
.29 |
|
|
|
|
|
.11 |
|
|
|
|
|
|
|
|
|
|
|
.30 |
|
verapamil |
.71 |
.95 |
|
.93 |
|
|
|
|
|
|
|
|
.85 |
.92 |
|
|
|
|
|
|
|
|
|
|
.93 |
.86 |
|
|
|
|
|
|
|
|
|
|
|
.80 |
|
|
|
|
|
|
|
|
|
clonidine |
|
|
|
|
.33 |
|
|
|
|
|
|
digoxin |
|
.85 |
|
|
.69 |
|
|
|
.50 |
.25 |
|
pirmenol |
|
.40 |
|
|
|
|
|
|
|
|
nb: results in bold are for oral administration of drug.
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