Menoufia Medical Journal

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 32  |  Issue : 3  |  Page : 851--854

Pharmacological conversion of recent-onset atrial fibrillation: a randomized study of propafenone and amiodarone


Abdallah M Kamal, Naglaa F Ahmed, George S Kamil 
 Department of Cardiology, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt

Correspondence Address:
George S Kamil
Shobra Masr, Cairo
Egypt

Abstract

Aim The aim of this study was to compare the efficacy and rapidity of recent-onset atrial fibrillation (AF) conversion by oral propafenone versus an intravenous infusion of amiodarone. Background Amiodarone and propafenone are the most widely used drugs in Egypt for the pharmacological cardioversion of AF. Patients and methods Fifty patients with recent-onset AF – within less than 48 h – were investigated. The patients were divided randomly into two groups: the first group (group A) included 25 patients in whom amiodarone was administered and the second group (group B) included 25 patients in whom propafenone was administered. Results 88% of patients in group A were converted successfully into sinus rhythm compared with 84% of patients in group B (receiving propafenone). The time elapsed between the onset of drug administration to conversion of AF into sinus rhythm in group A was 9 h: 7 min ± 5 h: 04 min, whereas that of group B was 3 h: 9 min ± 1 h: 54 min, with P value 0.001 (highly significant). Conclusion Intravenous infusion of amiodarone as well as oral propafonone can be used successfully in cardioversion of AF into sinus rhythm. Intravenous infusions of amiodarone and oral propafonone are not only highly effective but also well-tolerated drugs in the management of recent-onset AF. Time needed for conversion of AF into sinus rhythm using oral propafenone is significantly shorter than that needed by amiodarone.



How to cite this article:
Kamal AM, Ahmed NF, Kamil GS. Pharmacological conversion of recent-onset atrial fibrillation: a randomized study of propafenone and amiodarone.Menoufia Med J 2019;32:851-854


How to cite this URL:
Kamal AM, Ahmed NF, Kamil GS. Pharmacological conversion of recent-onset atrial fibrillation: a randomized study of propafenone and amiodarone. Menoufia Med J [serial online] 2019 [cited 2019 Dec 5 ];32:851-854
Available from: http://www.mmj.eg.net/text.asp?2019/32/3/851/268843


Full Text



 Introduction



Atrial fibrillation (AF) is a supraventricular tachyarrhythmia characterized by uncoordinated atrial activation, with consequent deterioration of atrial mechanical function [1]. It is the most common sustained cardiac rhythm disturbance. Although it is often associated with heart disease, AF occurs in many patients with without associated clinical etiology [2]. In one series, AF was present in 34.5% of patients hospitalized with a cardiac rhythm disturbance [3]. AF can be isolated or associated with other arrhythmias [4].

During AF, three factors can affect hemodynamic function: loss of synchronous atrial mechanical activity, irregularity of ventricular response, and inappropriately rapid heart rate [5].

The complications of AF include adverse symptoms (most, but not all, patients feel unwell with AF), besides palpitations, stroke, and heart failure [6].

The major issues in the management of patients with AF are related to the arrhythmia itself and the prevention of thromboembolism. In patients with persistent AF, there are fundamentally two ways to manage the dysrhythmia: to restore and maintain sinus rhythm or to allow AF to continue and ensure that the ventricular rate is controlled [7].

 Patient and Methods



The present study was carried out on 50 patients who presented with recent-onset AF within less than 48 h (with no contraindication to pharmacological conversion) to the Cardiology Department of Menoufia University Hospital.

The patients were divided randomly into two groups: both the first group (group A) and the second group (group B) included 25 patients; the numbers of male patients were 15 and 17 in group A and group B, respectively. The mean ages of the population were about 54 and 50 years in group A and group B, respectively, and the mean weight of both groups was about 80 kg.

The random sampling method was used.

Patients included in this study should have had recent-onset AF within less than 48 h.

Patients with uncontrolled congestive heart failure, acute myocardial infarction within the previous 7 days, previous electrocardiographic documentation of atrioventricular block or sick sinus syndrome, patients on antiarrhythmic drugs at the time of admission, patients with a previous thromboembolic episode or stroke, presence of left atrial thrombus, patients with known hepatic or renal impairment, patients with advanced bronchopulmonary disease, thyroid dysfunction, pregnancy, and hemodynamic instability (baseline systolic blood pressure ≤90 mmHg), and patients with a history of hypersensitivity to any of the study medications were all excluded.

Conversion to sinus rhythm was verified by 24 h monitoring. The results of therapy were assessed over 24 h after the drug intake. No other rate control drugs were used in any of the randomization groups.

No lab results were considered in this study.

Patients were included in this study after obtaining their consent and after approval from the Ethics Committee of Faculty of Medicine at Menoufia University.

Statistical analysis

All collected data were tabulated and analyzed by the appropriate statistical tests using SPSS, version 17.0 (Chicago, SPSS Inc.).

Categorical data were described as numbers (percentage) and analyzed using the χ2-test. Continuous data were described as mean ± SD and analyzed using the standard t-test.

Significance was defined as a P value less than 0.05.

 Results



The present study was carried out on 50 patients who presented with recent-onset AF within less than 48 h (with no contraindication to pharmacological conversion). The mean age of the study population was about 52 years, and the numbers of male patients were 15 and 17 in group A and group B, respectively.

Patients included in this study were classified into two groups: the first group (group A) included 25 patients who were assigned randomly to intravenous amiodarone (300 mg intravenously over 1 h, followed by 20 mg/kg in the next 24 h after the diagnosis of AF of recent onset). The second group (group B) included 25 patients with the diagnosis of AF of recent onset who were assigned randomly to single oral doses of propafenone (600 mg oral dose once).

In group A, 22 (88%) patients were converted successfully into sinus rhythm compared with 21 (84%) patients in group B. The difference between both groups was statistically insignificant [Table 1].{Table 1}

The time elapsed between drug administration to conversion of AF into sinus rhythm in group A was 9 h: 7 min ± 5 h: 4 min, whereas that of group B was 3 h: 9 min ± 1 h: 54 min (P = 0.001), a difference that was statistically highly significant [Table 2].{Table 2}

In group A, four patients were converted into sinus rhythm in up to 3 h, three patients were converted in more than 3 to up to 6 h, 10 patients were converted in more than 6 to up to 12 h, and five patients were converted in more than 12 to up to 24 h.

In group B, 11 patients were converted into sinus rhythm in up to 3 h, six patients were converted in more than 3 to up to 6 h, three patients were converted in more than 6 to up to 12 h, and one patient was converted in more than 12 to up to 24 h.

There was a highly significant difference between both groups (P = 0.001) [Table 3].{Table 3}

 Discussion



AF is the most common sustained arrhythmia affecting humans. It is an electrical disturbance that leads to rapid, disorganized, and asynchronous contraction of the atrial muscle [1]. In clinical practice, it accounts for approximately one-third of hospitalizations for cardiac rhythm disturbances. The incidence of AF increased from less than 0.1% per year in those younger than 40 years old to exceed 1.5% per year in women and 2% per year in men older than 80 years [3].

The initiation of AF in many patients may be caused by rapidly firing foci, typically in the pulmonary vein(s) in the left atrium, although other atrial sites including the superior vena cava, ligament of Marshall, crista terminalis, coronary sinus, and left posterior free wall, have also been identified [8]. Many patients have idiopathic, or lone, AF. There are three major types of therapy: (a) restoration and maintenance of sinus rhythm, (b) ventricular rate control, and (c) prevention of thromboembolism. One or more of these may be indicated in a particular patient [9].

The decision to attempt to maintain sinus rhythm rather than use ventricular rate control should be individualized to each patient on the basis of analysis of the risk–benefit ratio for that individual [10].

Several antiarrhythmic agents are effective for restoring and maintaining sinus rhythm. The selection of a particular drug depends on many factors including the presence and type of underlying heart disease, concomitant illnesses, and renal or hepatic dysfunction. Radiofrequency catheter ablation is being used more frequently to cure AF in patients failing drug therapy [11].

Both amiodarone and propafenone have relatively equal efficacy, with success rates ranging from 58 to 95%. Amiodarone has been administered (intravenously and orally) for the treatment of AF and the conversion rates ranged from 41 to 100% within the first 24 h after administration, and were found to be relatively well tolerated [12],[13]. Propafenone has the advantage of acting rapidly and its efficacy in converting AF of recent onset to sinus rhythm has been documented [14].

In our study, we investigated the efficacy of two commonly used antiarrhythmic drugs: oral propafenone versus intravenous infusion of amiodarone. We investigated 50 patients who had recent-onset AF within less than 48 h. The patients were divided randomly into two groups: the first group included 25 patients in whom amiodarone was administered, whereas the second group included 25 patients in whom propafenone was administered.

We excluded patients with uncontrolled congestive heart failure, acute myocardial infarction within 7 days, and patients with pervious electrocardiographic documentation of atrioventricular block or sick sinus syndrome. In addition, patients on antiarrhythmic drugs at the time of admission and patients with previous thromboembolic episode or stroke were excluded. Patients with known hepatic or renal impairment, patients with advanced bronchopulmonary disease, pregnancy, hemodynamic instability (baseline systolic blood pressure ≤90), and patients with hypersensitivity to the study medications were also excluded.

The diagnosis of AF was established on the basis of 12-lead ECG criteria (absence of P waves, presence of irregular atrial electrical activity, and irregular RR intervals). Medical history and physical examination were obtained in every patient.

Conversion to sinus rhythm was verified by 24 h monitoring, and documented with 12-lead ECG. The results of therapy were assessed over 24 h after the drug intake. No other rate control drugs were used in any of the randomization groups. The primary endpoint of the study was conversion rate at 24 h after drug intake.

In our study, the success rate of conversion with amiodarone was 88%, which is in agreement with Belle et al. [15], who also obtained similar conversion rates (87.5%), and Cotter and colleagues, who reported a conversion rate with amiodarone up to 92%.

However, the success rate of conversion with propafenone was 84%, which is also in agreement with Kosior and colleagues [16],[17], who also reported a similar conversion rate (83%).

These results were also similar to those obtained by Kochiadakis et al. [18], who reported success rates of 89.13 and 80.21% with amiodarone and propafenone, respectively.

In our study, we found that the mean time needed for conversion of AF into sinus rhythm in the amiodarone group was 9 h: 7 min ± 5 h: 4 min. This is in agreement with Kochiadakis, et al. [18], who reported a mean conversion time of 9 h. Belle et al. [15] also reported that the highest conversion rates with amiodarone were between 6 and 12 h.

This was significantly longer than the mean time needed by propafenone, which was 3 h: 9 min ± 1 h: 54 min This is in agreement with Kochiadakis et al. [18], who reported a mean conversion time of 1 h. Belle et al. [15] also reported that the highest conversion rates with propafenone were between 3 and 6 h.

Being able to convert AF into sinus rhythm in a shorter time, propafenone permits shorter hospital stay. In addition, it alleviates much of the patient's stress and anxiety related to prolonged hospitalization. However, amiodarone, which is administered by an intravenous infusion, requires special equipment such as infusion pumps or syringe pumps in addition to skilled personnel; these problems are not associated with propafenone, which is an orally administered drug.

 Conclusion



From the present study, we came to the following conclusions:

Intravenous infusion of amiodarone as well as oral propafonone can be used successfully in cardioversion of AF into sinus rhythm.

Intravenous infusions of amiodarone and oral propafonone are not only highly effective but also well-tolerated drugs in the management of recent-onset AF.

Time needed for conversion of AF into sinus rhythm using oral propafenone is significantly shorter than time needed by amiodarone to convert AF into sinus rhythm.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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