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June 24, 1992, Vol 267, No. 24 >
ARTICLE | June 24, 1992

Evolving Strategies for the Management of Atrial Fibrillation: Title and subTitle BreakThe Role of Amiodarone FREE

N. A. Mark Estes, III, MD
[+] Author Affiliations

Reprint requests to New England Medical Center Hospitals, Box 197, 750 Washington St, Boston, MA 02111 (Dr Estes).


JAMA. 1992;267(24):3332-3333. doi:10.1001/jama.1992.03480240094042
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Article
References

Management strategies for the most common sustained cardiac arrhythmia,1,2 atrial fibrillation, have undergone considerable evolution over the last several years. The objectives of therapy are to slow ventricular rate and restore and maintain sinus rhythm. Prevention of symptoms and reduction in the risk of complications such as stroke are therapeutic goals with agents that slow atrioventricular nodal conduction, antiarrhythmic agents, and anticoagulants.

The utility of digoxin for rate control has been questioned with recent studies suggesting that this former mainstay of therapy may now play a subsidiary role.3 β-Blockers and calcium channel blockers are now frequently used for slowing ventricular response. Concerns regarding the safety of quinidine have been raised by a recent meta-analysis showing an increased mortality in patients randomized to quinidine therapy or placebo for atrial fibrillation,4 although there are many limitations to this retrospective analysis. These safety concerns have been extended with recent observations

REFERENCES

1 +
Brand FN, Abbott RD, Kannel WB, Wolf PA.  Characteristics and prognosis of lone atrial fibrillation: 30-year follow-up in the Framingham Study. JAMA . 1985;; 254:3449-3453.
2 +
Kopecky SL, Gersh BI, McGoon MD, et al.  The natural history of lone atrial fibrillation: a population-based study over three decades. N Engl J Med . 1987;; 317:669-674.
3 +
Falk RH, Leavitt J.  Digoxin for atrial fibrillation: a drug whose time has gone. Ann Intern Med . 1991;;114:573-575.
4 +
Coplen SE, Antman EM, Berlin JA, Hewitt P, Chalmers TC.  Efficacy and safety of quinidine therapy for maintenance of sinus rhythm after cardioversion. Circulation . 1990;;82:1106-1116.
5 +
Flaker GC, Blackshear JL, McBride R, et al.  Cardiac mortality during antiarrhythmic drug therapy in the Stroke Prevention in Atrial Fibrillation (SPAF) Study. Circulation . 1992;;19:227A.
6 +
Anderson JL, Gilbert EM, Alpert B, et al.  Prevention of symptomatic recurrences of paroxysmal atrial fibrillation in patients initially tolerating antiarrhythmic therapy: a multicenter double-blind crossover study of flecainide and placebo with transtelephonic monitoring. Circulation . 1989;;80:1559-1570.
7 +
Cardiac Arrhythmia Suppression Trial (CAST) Investigators.  Randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med . 1989;;321:406-412.
8 +
Reimold SC, Friedman PL, Cantillon CO, Antman EM.  A randomized comparison of propafenone versus sotalol for treatment of refractory atrial fibrillation. J Am Coll Cardiol . 1992;;19:62.
9 +
Brugada P, deSwart H, Smeets J, Wellens HJ.  Transcoronary chemical ablation of atrioventricular conduction. Circulation . 1990;;81:757-761.
10 +
Scheinman MM, Morady F, Hess DS, et al.  Catheter ablation of the atrioventricular junction: a report of the precutaneous mapping and ablation registry. Circulation . 1984;;70:1024-1029.
11 +
Langberg J, Chin MC, Rosenquist M, et al.  Catheter ablation of the atrioventricular junction with radiofrequency energy. Circulation . 1989;;80:1527-1535.
12 +
Cox JL, Boineau JP, Schuessler RB, et al.  Successful surgical treatment of atrial fibrillation. JAMA . 1991;;226:1976-1980.
13 +
Guiraadon GM, Camphell CS, Jones DL, et al.  Combined sinoatrial node atrioventricular node isolation: a surgical alternative to His bundle ablation in patients with atrial fibrillation. Circulation . 1985;;72:220.
14 +
Rosenbaum MB, Chiale PA, Halpern MS, et al.  Clinical efficacy of amiodarone as an antiarrhythmic agent. Am J Cardiol . 1976;;38:934-944.
15 +
Ward DE, Camm AJ, Spurrell RAJ.  Clinical antiarrhythmic effects of amiodarone in patients with resistant paroxysmal tachycardias. Br Heart J . 1980;;44:91-95.
16 +
Yee KG, Heger JJ, Prystowsky EN, Miles WM, Zipes DP.  Predictors of clinical efficacy for amiodarone in supraventricular tachyarrhythmias. Circulation . 1984;;20 ( (suppl 2) ):II-438.
17 +
Hohnloser SH, Meinertz T, Dammbacher T, et al.  Electrocardiographic and antiarrhythmic effects of intravenous amiodarone: results of a prospective, placebo-controlled study. Am Heart J . 1991;;21:89-95.
18 +
Guarnieri T, Tomaselli G, Griffith LS, Brinker J.  The interaction of antiarrhythmic drugs and the energy for cardioversion of chronic atrial fibrillation. PACE Pacing Clin Electrophysiol . 1991;;14:1007-1012.
19 +
Crijns HJ, Van Gelder IC, Van Gilst WH, Hillige H, Gosselink AM, Lie KI.  Serial antiarrhythmic drug treatment to maintain sinus rhythm after electrical cardioversion for chronic atrial fibrillation or atrial flutter. Am J Cardiol . 1991;;68:335-341.
20 +
McAlister HF, Luke RA, Whitlock RM, Smith WM.  Intravenous amiodarone bolus versus oral quinidine for atrial flutter and fibrillation after cardiac operations. J Thorac Caridovasc Surg . 1990;;99:911-918.
21 +
Noc M, Stajer D, Horvat M.  Intravenous amiodarone versus verapamil for acute conversion of paroxysmal atrial fibrillation to sinus rhythm. Am J Cardiol . 1990;;65: 679-680.
22 +
Kopelman HA, Horowitz LN.  Efficacy and toxicity of amiodarone for the treatment of supraventricular tachyarrhythmias. Prog Cardiovasc Dis . 1989;;31:355-366.
23 +
Greenspan AM.  Hypertrophic cardiomyopathy and atrial fibrillation: a change of perspective. J Am Coll Cardiol . 1990;;15:1286-1287.
24 +
Bauernfeind RA, Welch WJ.  New hope in atrial fibrillation. J Am Coll Cardiol . 1990;;15:708-709.
25 +
Tuzcu EM, Gilbo J, Masterson M, Maloney JD.  The usefulness of amiodarone in management of refractory supraventricular tachyarrhythmias. Cleve Clin J Med . 1989;;56:238-242.
26 +
Mostow ND, Vrobel TR, Noon D, Ralatal L.  Rapid control of refractory atrial tachyarrhythmias with high-dose oral amiodarone. Am Heart J . 1990;;120:1356-1363.
27 +
Feld GK, Nademanee K, Stevenson W, Weiss I, Klitzner T, Singh BN.  Clinical and electrophysiologic effects of amiodarone in patients with atrial fibrillation complicating the Wolff-Parkinson-White syndrome. Am Heart J . 1988;;115:102-107.
28 +
Kowey PR, Friehling TD, Marinachak RA, Sulpizi AM, Stohler JL.  Safety and efficacy of amiodarone: the low-dose perspective. Chest . 1988;;93:54-59.
29 +
Gosselink ATM, Crijns HJGM, Van Gelder IC, Hillige H, Wiesfeld ACP, Lie KI.  Low-dose amiodarone for maintenance of sinus rhythm after cardioversion of atrial fibrillation or flutter. JAMA . 1992;;267:3289-3293.
30 +
Mason JW, Amiodarone Toxicity Study Group.  Toxicity of amiodarone. Circulation . 1985;;72:272.
31 +
The Boston Area Anticoagulation Trial for Atrial Fibrillation.  The effect of low dose warfarin on the risks of stroke in nonrheumatic atrial fibrillation. N Engl J Med . 1990;;323:1505-1511.
32 +
Stroke Prevention in Atrial Fibrillation Study Investigators.  Final results. Circulation . 1991;;84:527-538.
33 +
Cairns JA, Connolly SJ.  Nonrheumatic atrial fibrillation: risk of stroke and role of antithrombotic therapy. Circulation . 1991;;84:469-480.
34 +
Stroke Prevention in Atrial Fibrillation Investigators.  Predictors of thromboembolism in atrial fibrillation, I: clinical features of patients at risk. Ann Intern Med . 1992;;116:1-12.

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1 +
Brand FN, Abbott RD, Kannel WB, Wolf PA.  Characteristics and prognosis of lone atrial fibrillation: 30-year follow-up in the Framingham Study. JAMA . 1985;; 254:3449-3453.
2 +
Kopecky SL, Gersh BI, McGoon MD, et al.  The natural history of lone atrial fibrillation: a population-based study over three decades. N Engl J Med . 1987;; 317:669-674.
3 +
Falk RH, Leavitt J.  Digoxin for atrial fibrillation: a drug whose time has gone. Ann Intern Med . 1991;;114:573-575.
4 +
Coplen SE, Antman EM, Berlin JA, Hewitt P, Chalmers TC.  Efficacy and safety of quinidine therapy for maintenance of sinus rhythm after cardioversion. Circulation . 1990;;82:1106-1116.
5 +
Flaker GC, Blackshear JL, McBride R, et al.  Cardiac mortality during antiarrhythmic drug therapy in the Stroke Prevention in Atrial Fibrillation (SPAF) Study. Circulation . 1992;;19:227A.
6 +
Anderson JL, Gilbert EM, Alpert B, et al.  Prevention of symptomatic recurrences of paroxysmal atrial fibrillation in patients initially tolerating antiarrhythmic therapy: a multicenter double-blind crossover study of flecainide and placebo with transtelephonic monitoring. Circulation . 1989;;80:1559-1570.
7 +
Cardiac Arrhythmia Suppression Trial (CAST) Investigators.  Randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med . 1989;;321:406-412.
8 +
Reimold SC, Friedman PL, Cantillon CO, Antman EM.  A randomized comparison of propafenone versus sotalol for treatment of refractory atrial fibrillation. J Am Coll Cardiol . 1992;;19:62.
9 +
Brugada P, deSwart H, Smeets J, Wellens HJ.  Transcoronary chemical ablation of atrioventricular conduction. Circulation . 1990;;81:757-761.
10 +
Scheinman MM, Morady F, Hess DS, et al.  Catheter ablation of the atrioventricular junction: a report of the precutaneous mapping and ablation registry. Circulation . 1984;;70:1024-1029.
11 +
Langberg J, Chin MC, Rosenquist M, et al.  Catheter ablation of the atrioventricular junction with radiofrequency energy. Circulation . 1989;;80:1527-1535.
12 +
Cox JL, Boineau JP, Schuessler RB, et al.  Successful surgical treatment of atrial fibrillation. JAMA . 1991;;226:1976-1980.
13 +
Guiraadon GM, Camphell CS, Jones DL, et al.  Combined sinoatrial node atrioventricular node isolation: a surgical alternative to His bundle ablation in patients with atrial fibrillation. Circulation . 1985;;72:220.
14 +
Rosenbaum MB, Chiale PA, Halpern MS, et al.  Clinical efficacy of amiodarone as an antiarrhythmic agent. Am J Cardiol . 1976;;38:934-944.
15 +
Ward DE, Camm AJ, Spurrell RAJ.  Clinical antiarrhythmic effects of amiodarone in patients with resistant paroxysmal tachycardias. Br Heart J . 1980;;44:91-95.
16 +
Yee KG, Heger JJ, Prystowsky EN, Miles WM, Zipes DP.  Predictors of clinical efficacy for amiodarone in supraventricular tachyarrhythmias. Circulation . 1984;;20 ( (suppl 2) ):II-438.
17 +
Hohnloser SH, Meinertz T, Dammbacher T, et al.  Electrocardiographic and antiarrhythmic effects of intravenous amiodarone: results of a prospective, placebo-controlled study. Am Heart J . 1991;;21:89-95.
18 +
Guarnieri T, Tomaselli G, Griffith LS, Brinker J.  The interaction of antiarrhythmic drugs and the energy for cardioversion of chronic atrial fibrillation. PACE Pacing Clin Electrophysiol . 1991;;14:1007-1012.
19 +
Crijns HJ, Van Gelder IC, Van Gilst WH, Hillige H, Gosselink AM, Lie KI.  Serial antiarrhythmic drug treatment to maintain sinus rhythm after electrical cardioversion for chronic atrial fibrillation or atrial flutter. Am J Cardiol . 1991;;68:335-341.
20 +
McAlister HF, Luke RA, Whitlock RM, Smith WM.  Intravenous amiodarone bolus versus oral quinidine for atrial flutter and fibrillation after cardiac operations. J Thorac Caridovasc Surg . 1990;;99:911-918.
21 +
Noc M, Stajer D, Horvat M.  Intravenous amiodarone versus verapamil for acute conversion of paroxysmal atrial fibrillation to sinus rhythm. Am J Cardiol . 1990;;65: 679-680.
22 +
Kopelman HA, Horowitz LN.  Efficacy and toxicity of amiodarone for the treatment of supraventricular tachyarrhythmias. Prog Cardiovasc Dis . 1989;;31:355-366.
23 +
Greenspan AM.  Hypertrophic cardiomyopathy and atrial fibrillation: a change of perspective. J Am Coll Cardiol . 1990;;15:1286-1287.
24 +
Bauernfeind RA, Welch WJ.  New hope in atrial fibrillation. J Am Coll Cardiol . 1990;;15:708-709.
25 +
Tuzcu EM, Gilbo J, Masterson M, Maloney JD.  The usefulness of amiodarone in management of refractory supraventricular tachyarrhythmias. Cleve Clin J Med . 1989;;56:238-242.
26 +
Mostow ND, Vrobel TR, Noon D, Ralatal L.  Rapid control of refractory atrial tachyarrhythmias with high-dose oral amiodarone. Am Heart J . 1990;;120:1356-1363.
27 +
Feld GK, Nademanee K, Stevenson W, Weiss I, Klitzner T, Singh BN.  Clinical and electrophysiologic effects of amiodarone in patients with atrial fibrillation complicating the Wolff-Parkinson-White syndrome. Am Heart J . 1988;;115:102-107.
28 +
Kowey PR, Friehling TD, Marinachak RA, Sulpizi AM, Stohler JL.  Safety and efficacy of amiodarone: the low-dose perspective. Chest . 1988;;93:54-59.
29 +
Gosselink ATM, Crijns HJGM, Van Gelder IC, Hillige H, Wiesfeld ACP, Lie KI.  Low-dose amiodarone for maintenance of sinus rhythm after cardioversion of atrial fibrillation or flutter. JAMA . 1992;;267:3289-3293.
30 +
Mason JW, Amiodarone Toxicity Study Group.  Toxicity of amiodarone. Circulation . 1985;;72:272.
31 +
The Boston Area Anticoagulation Trial for Atrial Fibrillation.  The effect of low dose warfarin on the risks of stroke in nonrheumatic atrial fibrillation. N Engl J Med . 1990;;323:1505-1511.
32 +
Stroke Prevention in Atrial Fibrillation Study Investigators.  Final results. Circulation . 1991;;84:527-538.
33 +
Cairns JA, Connolly SJ.  Nonrheumatic atrial fibrillation: risk of stroke and role of antithrombotic therapy. Circulation . 1991;;84:469-480.
34 +
Stroke Prevention in Atrial Fibrillation Investigators.  Predictors of thromboembolism in atrial fibrillation, I: clinical features of patients at risk. Ann Intern Med . 1992;;116:1-12.

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