Pharmacological Cardioversion after Pre-Treatment with Antiarrythmic Drugs Prior to Electrical Cardioversion in Persistent Atrial Fibrillation: Impact on Maintenance of Sinus Rhythm.

Amine El Amrani,Miguel Angel Arias,Josep M Alegret,Pilar Valdovinos,Victor Bazan,Xavier Viñolas

doi:10.3390/jcm10051029

Abstract

Background: Antiarrhythmic drugs (AADs) are frequently initiated in patients with persistent atrial fibrillation (AF) prior to electrical cardioversion (ECV), achieving pharmacological cardioversion (PCV) in some cases. Little is known about the mode of cardioversion and the effect of the type of AAD used in the maintenance of sinus rhythm (SR). Methods: From three national surveys of patients with persistent AF referred for ECV, we selected those who were pre-treated with AADs (amiodarone or group Ic AADs). We analyzed the effect of the type of cardioversion (pharmacological vs. electrical) and the AAD used in the maintenance of SR at three months. Results: Among the 665 patients selected, 151 had a successful PCV prior to the planned ECV. In the remaining 514 patients, 460 had a successful ECV. A successful PCV was related to a higher rate of SR maintenance than a successful ECV (77.9% vs. 57.5%; p < 0.0001). After a successful PCV, the maintenance of SR was identical in those patients treated with amiodarone and those treated with group Ic AADs (77.4% vs. 77.5%; p = 0.99), whereas after a successful ECV, amiodarone was clearly superior to group Ic AADs (61.3% vs. 43.0%; p = 0.001). Considering patients with successful PCV and ECV together, PCV was an independent factor related to the maintenance of SR. Conclusions: In patients with persistent AF, successful PCV selects a subgroup with a high probability of maintenance of SR. With regard to drugs, amiodarone was superior to group Ic AADs in patients with ECV, whereas in PCV, no differences were observed.

Highlights

In patient candidates for rhythm control strategies, electrical cardioversion (ECV) is the most commonly used method for restoration of sinus rhythm (SR) in patients with persistent atrial fibrillation (AF)
From among the patients included in the three surveys, we selected 665 patients (n = 211 from REVERSE, n = 180 from REVERCAT and n = 274 from CARDIOVERSE study, respectively) with persistent AF scheduled for ECV who were pre-treated with antiarrhythmic drugs (AADs) and fulfilled the inclusion criteria
Patients treated with amiodarone presented a higher proportion of structural heart disease and hypertension, were older, had a higher CHADS score and a lower left ventricular ejection fraction than patients treated with group Ic AADs (Supplementary Table S1)

Summary

Introduction

In patient candidates for rhythm control strategies, electrical cardioversion (ECV) is the most commonly used method for restoration of sinus rhythm (SR) in patients with persistent atrial fibrillation (AF) This procedure is very effective in the acute setting, but recurrences are common [1,2,3]. Amiodarone appears to be the most effective drug for preventing recurrence [5,6,7], at the cost of a higher incidence of long-term side effects, requiring individualized selection of AAD. In this context, AAD administered pre-ECV in patients with persistent AF has the potential to restore.

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