Conversion Of Recent-onset Atrial Fibrillation Research Articles

Cardioversion of recent-onset atrial fibrillation using intravenous antiarrhythmics: A European perspective.

Pharmacological cardioversion using intravenous antiarrhythmic agents is commonly indicated in symptomatic patients with recent-onset atrial fibrillation (AF). Except in hemodynamically unstable patients who require emergency direct current electrical cardioversion, for the majority of hemodynamically stable patients, pharmacological cardioversion represents a valid option and requires the clinician to be familiar with the properties and use of antiarrhythmic agents. The main characteristics of selected intravenous antiarrhythmic agents for conversion of recent-onset AF, the reported success rates, and possible adverse events are discussed. Among intravenous antiarrhythmics, flecainide, propafenone, amiodarone, sotalol, dofetilide, ibutilide, and vernakalant are commonly used. Antazoline, an old antihistaminic agent with antiarrhythmic properties was also reported to give encouraging results in Poland. Intravenous flecainide and propafenone are the only Class I agents still recommended by recent guidelines. Intravenous new Class III agents as dofetilide and ibutilide have high and rapid efficacy in converting AF to sinus rhythm but require strict surveillance with electrocardiogram (ECG) monitoring during and after intravenous administration because of the potential risk of QT prolongation and Torsades de Pointes, which can be prevented and properly managed. Vernakalant, a partial atrial selective was shown to have a high success rate and to be safe in real-life use.

Abstract 15742: An Open-label, Multicenter Study of Flecainide Acetate Oral Inhalation Solution Shows Acute Conversion of Recent-onset, Symptomatic Atrial Fibrillation to Sinus Rhythm in a Dose- and Concentration-dependent Manner

Introduction: Oral and intravenous (IV) flecainide are recommended as first line therapy for pharmacological cardioversion of recent-onset atrial fibrillation (AF) in patients without known relevant structural heart disease. In the present open-label, dose-escalation study, the feasibility of using flecainide acetate inhalation solution (FlecIH) for acute conversion of recent-onset AF to sinus rhythm (SR) was evaluated. Hypothesis: We hypothesized that FlecIH quickly gives rise to plasma concentrations sufficient to rapidly restore SR in patients with recent-onset AF. Methods: Patients (n=95) with symptomatic AF (for ≤ 48 hours) were enrolled and self-administered FlecIH using a breath-actuated nebulizer (30 mg [n=10], 60 mg [n=20], 90 mg [n=21], 120 mg [n=17], and 120 mg in a formulation containing saccharin [n=27]). Blood samples were collected for flecainide plasma concentrations, electrocardiograms were obtained, cardiac rhythm with a 4-hour Holter and vital signs were monitored, and adverse events (AEs) were recorded. Patients who did not convert to SR were offered alternative treatment per the investigator’s discretion. Results: Conversion rates increased with dose and maximum plasma concentrations (C max ) of flecainide. At the highest dose, 45% of patients converted to normal SR. Patients with C max > 300 ng/mL had a conversion rate of 53% whereas those with C max < 200 ng/mL had a conversion rate of 33%. The median time to conversion was 3.5 min after FlecIH administration. AEs were typically mild and transient. Commonly reported AEs associated with inhalation of flecainide included: cough, throat pain, and throat irritation; at the highest dose with the formulation containing saccharin, these AEs were reported for 37%, 11%, and 4% of patients, respectively. Cardiac AEs consistent with those observed with oral and IV flecainide and considered serious were uncommon and included 2 post-conversion pauses and 1 bradycardia, and 1 atrial flutter with 1:1 atrioventricular conduction; none required treatment and all resolved without sequelae. Conclusions: FlecIH was well tolerated. Inhalation of FlecIH at the 120 mg dose yielded therapeutic plasma levels and conversion rates within the range reported for oral and IV administration.

Anaphylaxis-induced atrial fibrillation and anesthesia: Pathophysiologic and therapeutic considerations.

Atrial fibrillation is the most common cardiac arrhythmia in western society affecting more than 35 million individuals worldwide annually. It is a common postoperative complication and may also occur spontaneously during general and local anesthesia administration. Aging, diabetes mellitus, hypertension, and cardiovascular diseases including cardiomyopathies, congenital cardiac anomalies, heart failure, myocardial ischemia, pericarditis, previous cardiac surgery, vascular disease, and valvular heart disease are some correlated factors. Beyond age, increased incidence of atrial fibrillation has been correlated to autoimmune system activation as it is the underlying mechanism of persistent atrial fibrillation development. Current research supports an association between the complement system activation and lymphocyte-pro-inflammatory cytokines release with the cardiac conduction system and atrial fibrosis. The loss of CD28 antigen from CD4+ CD28+ T lymphocytes seems to play a major role in atrial fibrillation development and prognosis. Except atrial fibrillation, a variety of additional electrocardiographic changes, resembling those with digitalis intoxication may accompany anaphylaxis and particularly Kounis syndrome. Histamine is one well-known mediator in allergic and inflammatory conditions as physiologically regulates several cardiovascular and endothelial functions with arrhythmogenic potential. The increased oxidative stress, measured by the redox potentials of glutathione, has been correlated with atrial fibrillation incidence and prevalence. The use of antazoline, a first-generation antihistamine agent used for rapid conversion of recent-onset atrial fibrillation in patients with preserved left ventricular function and for rapid atrial fibrillation termination during accessory pathway ablation denotes that anaphylaxis-induced histamine production could be the cause of atrial fibrillation at least in some instances. The anaphylaxis diagnosis in anesthesia can be challenging owing to the absence of cutaneous manifestetions such as flushing, urticaria, or angioedema. Anticoagulation for stroke prevention, rate and rhythm control medications, invasive methods such as radiofrequency ablation or cryoablation of pulmonary veins as well surgical ablation constitute the treatment basis of atrial fibrillation. Understanding the underlying mechanisms of atrial fibrillation by cardiologists, anesthesiologists and surgeons, as well as potential treatments, to optimize care is of paramount importance.

Potassium infusion increases the likelihood of conversion of recent-onset atrial fibrillation—A single-blinded, randomized clinical trial

The optimal antiarrhythmic management of recent-onset atrial fibrillation (ROAF) or atrial flutter is controversial and there is a considerable variability in clinical treatment strategies. It is not known if potassium infusion has the potential to convert ROAF or atrial flutter to sinus rhythm (SR). Therefore, we aimed to investigate if patients with ROAF or atrial flutter and plasma-potassium levels ≤4.0 mmol/L have increased probability to convert to SR if the plasma-potassium level is increased towards the upper reference range (4.1-5.0 mmol/L). In a placebo-controlled, single-blinded trial, patients with ROAF or atrial flutter and plasma-potassium ≤4.0 mmol/L presenting between April 2013 and November 2017 were randomized to receive potassium chloride (KCl) infusion (n = 60) or placebo (n = 53). Patients in the KCl group received infusions at one of three different rates: 9.4 mmol/h (n = 11), 12 mmol/h (n = 19), or 15 mmol/h (n = 30). There was no statistical difference in the number of conversions to SR between the KCl group and placebo [logrank test, P = .29; hazard ratio (HR) 1.20 (CI 0.72-1.98)]. However, KCl-infused patients who achieved an above-median hourly increase in plasma-potassium (>0.047 mmol/h) exhibited a significantly higher conversion rate compared with placebo [logrank P = .002; HR 2.40 (CI 1.36-4.21)] and KCl patients with below-median change in plasma-potassium [logrank P < .001; HR 4.41 (CI 2.07-9.40)]. Due to pain at the infusion site, the infusion was prematurely terminated in 10 patients (17%). Although increasing plasma-potassium levels did not significantly augment conversion of ROAF or atrial flutter to SR in patients with potassium levels in the lower-normal range, our results indicate that this treatment may be effective when a rapid increase in potassium concentration is tolerated and achieved.

Intravenous antazoline, a first-generation antihistaminic drug with antiarrhythmic properties, is a suitable agent for pharmacological cardioversion of atrial fibrillation induced during pulmonary vein isolation due to the lack of influence on atrio-venous conduction and high clinical effectiveness (AntaEP Study).

Antazoline is a first-generation antihistaminic drug used primarily in eye drop formulations. When administered intravenously, antazoline displays antiarrhythmic properties resulting in a rapid conversion of recent-onset atrial fibrillation (AF) to sinus rhythm (SR). The aim of the study was to assess the influence of antazoline on atrio-venous conduction and other electrophysiological parameters in patients undergoing AF ablation. An experimental prospective study. Patients scheduled for the first-time AF ablation, in SR and not on amiodarone were enrolled. Atrio-venous conduction assessment and invasive electrophysiological study (EPS) were performed before and after intravenous administration of 250mg of antazoline. In case of AF induction during EPS, antazoline was administered until conversion to SR or a cumulative dose of 300mg. We enrolled 14 patients: 13 (93%) men, mean age 63.4 (59.9-66.8) years, mean CHA2 DS2 -VASc score 1.6 (1.0-2.2). Antazoline was administered in a mean dose 257.1 (246.7-267.6) mg. Pulmonary vein potentials and atrial capture during pulmonary vein stimulation were present before and after the administration of antazoline. Wenckebach point and atrial conduction times did not change significantly, but atrio-ventricular node effective refractory period improved-324.7 (275.9-373.5) ms vs 284.3 (256.2-312.4) ms, P=0.02. Antazoline was effective in all 5 (100%) cases of AF induction during EPS. There were no serious adverse events. Due to the lack of influence on atrio-venous conduction and high clinical effectiveness, antazoline may be suitable for pharmacological cardioversion of AF occurring during AF ablation.

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

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.

Efficacy and safety of intravenous vernakalant for the rapid conversion of recent-onset atrial fibrillation: A meta-analysis.

Atrial fibrillation is a common cardiac arrhythmia with increasing prevalence in the aging population. It is a major cause of emergency department visits worldwide. Vernakalant, a relatively new antiarrhythmic drug with selectively preferential effects on the atrial tissue is currently used in many European countries for the termination of recent-onset atrial fibrillation. Presently, the drug is still not approved by the United States Food and Drug Administration due to safety concerns. We evaluate the efficacy and safety of vernakalant for the conversion of recent-onset atrial fibrillation or atrial flutter into normal sinus rhythm (NSR). PubMed/MEDLINE (1993-2017), the Cochrane Central Register of Controlled Trials (2000-2017), and reference lists of relevant articles were searched for randomized controlled trials (RCTs) comparing vernakalant to a control drug and extracted subsequently. Nine RCTs were identified and included in the meta-analysis. Pooled analysis of events extracted for a total of 1421 patients with recent-onset atrial fibrillation showed a statistically significant increase in cardioversion within 90minutes from drug infusion (Relative Risk [RR], 6.61; 95% Confidence Interval [CI], 2.78 - 15.71; p<.00001). In terms of adverse events, vernakalant was considered safe in comparison to control drugs (RR, 0.80; 95% CI, 0.61-1.05; p=.11). Vernakalant is effective for rapid conversion of recent-onset atrial fibrillation into NSR. However, although it showed a safe profile in terms of side effects in this analysis, we are still hesitant about this conclusion and few safety issues should be addressed within specific patients' subgroups.

Chemical cardioversion of recent-onset atrial fibrillation in the emergency department using vernakalant hydrochloride achieves safe and rapid restoration of sinus rhythm and facilitates same day discharge.

Vernakalant hydrochloride is a rapid-acting antiarrhythmic drug licensed in the EU since 2010 for the conversion of recent-onset atrial fibrillation with proven efficacy and safety when compared with placebo and amiodarone in randomized clinical trials. The aim of our study was to determine the feasibility of same day discharge (following 2h monitoring) from the emergency department after successful cardioversion using vernakalant hydrochloride. Patients with recent-onset atrial fibrillation treated in the emergency department of a large Dublin academic teaching hospital. Patients received a maximum of two weight based 10min infusions of vernakalant. Hypotensive events (>30% initial blood pressure), arrhythmias, conversion rates, and time to conversion were recorded. Sinus rhythm was restored in 35 out of 42 patients (83%) in an average of 8.8min (median 8min), average CHA2DS2-VASc of 0.92, HAS-BLED of 0.21 and average symptoms duration of 12h. There were no hypotensive or arrhythmogenic events. 41 out of 42 patients were discharged after 2h of monitoring. Vernakalant hydrochloride has provided a quick, safe, and practical means of achieving rapid restoration of sinus rhythm in our ED population with stable recent-onset AF who would otherwise not have undergone routine electrically cardioversion and same day discharge.

Amiodarone Versus Propafenone to Treat Atrial Fibrillation after Coronary Artery Bypass Grafting: A Randomized Double Blind Controlled Trial

BackgroundAtrial fibrillation (AF) is one of the most common complications after cardiac surgery. Several therapeutic and preventive strategies have been introduced for postoperative AF, but the treatment and prophylaxis of AF remain controversial. We aimed to compare the efficacy of intravenous amiodarone and oral propafenone in the treatment of AF after coronary artery bypass grafting (CABG).MethodsThis was a randomized controlled trial performed in two hospitals in Shiraz, Iran from 2009 to 2012. We included all patients who underwent elective CABG and developed AF postoperatively. The patients were randomly assigned to receive propafenone or amiodarone. The duration of AF, the success rate of the treatment, the need for cardioversion, the frequency of repeated AF, and the need for repeating the treatment were compared.ResultsThe duration of the first (p=0.361), second (p=0.832), and third (p=0.298) episodes of AF, the need for cardioversion (p=0.998), and the need to repeat the first and second doses of drugs (p=0.557, 0.699) were comparable between the study groups. Repeated AF was observed in 17 patients (30.9%) in the propafenone group and 23 patients (34.3%) in the amiodarone group (p=0.704).ConclusionOral propafenone and intravenous amiodarone are equally effective in the treatment and conversion of recent-onset AF after CABG.

Vernakalant is superior to ibutilide for achieving sinus rhythm in patients with recent-onset atrial fibrillation: a randomized controlled trial at the emergency department.

AimsIbutilide is a rapid-acting antiarrhythmic drug with worldwide use for conversion of recent-onset atrial fibrillation. Vernakalant, approved in the EU in 2010, is likewise used intravenously, with proven efficacy and safety compared with placebo and amiodarone in randomized clinical trials. The aim of our study was to compare the time to conversion and the conversion rate within 90 min in patients with recent-onset atrial fibrillation treated with vernakalant or ibutilide.Methods and resultsA randomized controlled trial registered at clinicaltrials.gov (NCT01447862) was performed in 100 patients with recent-onset atrial fibrillation treated at the emergency department of a tertiary care hospital. Patients received up to two short infusions of vernakalant (n = 49; 3 mg/kg followed by 2 mg/kg if necessary) or ibutilide (n = 51; 1 mg followed by another 1 mg if necessary) according to the manufacturer's instructions. Clinical and laboratory variables, adverse events, conversion rates, and time to conversion were recorded. Time to conversion of AF to sinus rhythm was significantly shorter in the vernakalant group compared with the ibutilide group (median time: 10 vs. 26 min, P = 0.01), and likewise the conversion success within 90 min was significantly higher in the vernakalant group (69 vs. 43%, log-rank P = 0.002). No serious adverse events occurred.ConclusionVernakalant was superior to ibutilide in converting recent-onset atrial fibrillation to sinus rhythm in the emergency department setting.

Abstract 15296: Vernakalant Shows Superiority to Ibutilide in Recent-onset Atrial Fibrillation: A Randomized Controlled Trial at the Emergency Department

Introduction: Ibutilide is a rapid-acting antiarrhythmic drug with worldwide use for conversion of recent-onset atrial fibrillation. Vernakalant is a novel drug, which is likewise used intravenously, with proven effectiveness and safety compared to placebo and amiodarone in randomized clinical trials. Hypothesis: We hypothesized that the time to sinus rhythm and the conversion rate within 90 minutes is different between vernakalant and ibutilide in patients with recent-onset atrial fibrillation. Methods: A randomized, controlled, open-label trial registered at clinicaltrials.gov (NCT01447862) was performed in one hundred patients with recent-onset atrial fibrillation treated at the emergency department of a tertiary care hospital. Patients received up to two short-infusions of vernakalant (n= 49; 3mg/kg, 2mg/kg) or ibutilide (n= 51; 1mg, 1mg) according to the manufacturer’s instructions. Clinical and laboratory variables, adverse events, conversion rates and time to conversion were recorded. Results: Time to conversion of AF to sinus rhythm was significantly shorter in the vernakalant group compared to the ibutilide group (median time: 10min vs. 26min, p=0.02), and likewise the conversion success within 90 minutes was significantly higher (69% vs. 43%, p=0.01) in the vernakalant group. In both groups no serious adverse events occurred. Conclusion: Vernakalant was significantly faster and more effective in converting recent-onset atrial fibrillation to sinus rhythm at the emergency department.

Predictors of conversion of recent-onset atrial fibrillation treated with vernakalant.

Vernakalant is an available drug for the treatment of recent-onset atrial fibrillation, producing conversion between 55% and 87% of the patients treated. In this sense, little is known about the predictors of conversion with this agent. The aim of our study was to analyze the predictors of conversion in our 2-year experience using vernakalant for the treatment of recent-onset atrial fibrillation. One hundred twenty-one patients with recent-onset atrial fibrillation without hemodynamic impairment received pharmacological treatment with vernakalant. Clinical variables, history of cardiovascular diseases, and echocardiographic data were recorded. Mean age was 58.1 ± 13.9 years and 13.4% of patients had structural heart disease. Conversion to sinus rhythm was achieved in 84.5% of patients, and 46% required the second dose of vernakalant. After analyzing the predictors of conversion, the presence of structural heart disease was significantly larger in the group without conversion (35.3 vs 9.7%; P = 0.02). The mean ejection fraction in the group with conversion was 61.05 ± 5.7% versus 54.9 ± 8.4% in the group without conversion (P = 0.016). After dichotomizing the variable ejection fraction, patients with ejection fraction <55% had a lower conversion rate (P = 0.001). In our study, the absence of any kind of structural heart disease and preserved systolic function were associated with greater conversion rate with vernakalant.

VERNAKALANT FOR RAPID CARDIOVERSION OF RECENT ONSET ATRIAL FIBRILLATION: A META-ANALYSIS

We intended to assess the safety and efficacy of intravenous vernakalant for rapid conversion of recent-onset atrial fibrillation (ROAF). We searched PubMed, Cochrane library and Embase for studies comparing intravenous vernakalant with placebo or other antiarrhythmic drugs (AAD) for treatment of

Ranolazine for the prevention or treatment of atrial fibrillation

The use of currently available antiarrhythmic drugs for atrial fibrillation is limited by their moderate efficacy and the considerable proarrhythmic risk. Ranolazine, an antianginal agent, has been reported to possess antiarrhythmic properties, resulting in a reduction of supraventricular and ventricular arrhythmias. We performed a systematic review of the clinical studies reporting the outcome of patients treated with ranolazine for the prevention or treatment of atrial fibrillation in various clinical settings. We searched PubMed and abstracts of major conferences for clinical studies using ranolazine, either alone or in combination with other antiarrhythmic agents for the prevention or treatment of atrial fibrillation. Ten relevant records were identified. These included both randomized trials and retrospective cohort studies concerning the use of ranolazine in different clinical settings; prevention of atrial fibrillation in patients with acute coronary syndrome, prevention as well as conversion of postoperative atrial fibrillation after coronary artery bypass grafting, conversion of recent-onset atrial fibrillation, sinus rhythm maintenance in drug-resistant recurrent atrial fibrillation and facilitation of electrical cardioversion in cardioversion-resistant patients. A beneficial, mostly modest effect of ranolazine was homogeneously reported in all clinical settings. There were no substantial proarrhythmic effects. No meta-analysis could be performed because for most of the clinical scenarios, there was only one study investigating the effect of ranolazine. Except for one large randomized trial, all the other studies were either relatively small randomized studies or retrospective cohort analyses, which in several cases lacked a control group. This systematic review indicates a modest beneficial effect of ranolazine administered for the prevention or treatment of atrial fibrillation across several clinical settings without substantial proarrhythmic risk.

Ranolazine enhances the efficacy of amiodarone for conversion of recent-onset atrial fibrillation

Amiodarone is used commonly for pharmacological cardioversion of atrial fibrillation (AF), but it is limited by moderate efficacy and delayed action. Ranolazine and amiodarone are markedly synergistic in suppressing experimental AF in vitro, yet the clinical efficacy of ranolazine combined with amiodarone for AF conversion has only undergone minimal investigation. This prospective, single-blinded, randomized study compared the safety and efficacy of ranolazine added to amiodarone vs. amiodarone alone for conversion of recent-onset AF. We enroled 121 patients (64 ± 10 years, 45% male) with recent-onset (<48 h duration) AF who were eligible for pharmacological cardioversion. Patients received either 24 h amiodarone infusion (loading dose 5 mg/kg followed by maintenance dose of 50 mg/h; n = 60), or amiodarone infusion at the same dosage plus a single oral dose of ranolazine 1500 mg (n = 61). Patients in the amiodarone plus ranolazine group compared with the amiodarone-only group showed significantly higher conversion rates at 24 h (87 vs. 70%, respectively; P = 0.024) and at 12 h (52 vs. 32%; P = 0.021), and shorter time to conversion (10.2 ± 3.3 vs. 13.3 ± 4.1 h; P = 0.001). Subgroup analysis identified higher 24 h conversion in patients with left atrial (LA) diameter >46 mm who received the combination treatment vs. amiodarone alone (81 vs. 54%; P = 0.02), whereas the efficacy of the two interventions did not differ among patients with LA diameter ≤46 mm (P = 0.77). There was modest QT prolongation in both the groups, no serious adverse reactions, and no pro-arrhythmic events. Addition of ranolazine to amiodarone was safe and well tolerated in this study, and it demonstrated efficacy superior to amiodarone alone for conversion of recent-onset AF. These findings may have clinical implications by offering a simple therapeutic manoeuvre to enhance amiodarone's effectiveness for conversion of AF.

Propafenone Versus Vernakalant for Conversion of Recent‐Onset Atrial Fibrillation

An oral loading dose of propafenone 600mg is used in our center as in other places around the world for conversion of recent-onset atrial fibrillation (AF) in patients without structural heart disease. Vernakalant is a novel, safe, and effective drug used intravenously and has proved to be more rapid in converting recent-onset AF to sinus rhythm compared with placebo and amiodarone. There is no study that compares vernakalant with propafenone. The aim of our study is to compare the time taken for conversion of recent-onset AF in patients treated with vernakalant and propafenone. Thirty-six hemodynamically stable patients with recent-onset AF without structural heart disease were prospectively included. A single oral dose of propafenone 600mg was administered to 19 patients and 17 received intravenous vernakalant. Clinical and laboratory variables, conversion rate, and time to conversion were recorded. Baseline characteristics were similar in both groups. Time to conversion to sinus rhythm was of 166min (120-300) in the propafenone group versus 9min (6-18) in the vernakalant group (P=0.0001). Conversion rate was of 78% in the propafenone group at 8h and of 93% in the vernakalant group at 2h; yet, this difference was not statistically significant (P=0.4). Time to conversion had a direct impact in hospital stay, which was 43% shorter in the vernakalant group (P=0.0001). Time to conversion of AF to sinus rhythm was significantly shorter in the vernakalant group compared with the propafenone group and was associated with shorter hospital stay.

Conversion of Recent-Onset Atrial Fibrillation: Which Drug is the Best?

Introduction: Vernakalant is a new, safe and effective drug used intravenously. It has proven to be more rapid in converting recent onset atrial fibrillation (AF) to sinus rhythm compared to placebo, amiodarone, propafenone and flecainide in clinical studies with few patients. At present no study has been conducted comparing these three drugs with a more substantial number of patients. The aim of our study is to compare the time to conversion to sinus rhythm, hospital stay and adverse events between vernakalant versus flecainide and propafenone in patients with a recent-onset AF. Materials and Methods: 150 hemodynamically stable patients with recent onset AF without structural heart disease were prospectively included. A single oral dose of propafenone 600 mg was administered to 50 patients; 50 patients received intravenous vernakalant; and 50 patients received a single oral dose of flecainide 300 mg. Clinical and laboratory variables were recorded. Results: Baseline characteristics were similar in the three groups.Time to conversion to sinus rhythm was 12 minutes in the vernakalant group versus 151 minutes in the propafenone group and 162 minutes in flecainide group (p< 0.01) The hospital stay was 243 minutes in the vernakalant group versus 422 minutes in the propafenone group and 410 minutes in flecainide group (p<0.01) (Figure 2). No adverse events were reported. Conclusion: The time to conversion to sinus rhythm and hospital stay were statistically shorter in vernakalant group compared to flecainide and to propafenone. There were no adverse events in the three groups.

Low atrial fibrillatory rate is associated with spontaneous conversion of recent-onset atrial fibrillation

Atrial fibrillatory rate (AFR) is considered a non-invasive index of atrial remodelling. Low AFR has been associated with favourable outcome of interventions in patients with persistent atrial fibrillation (AF). However, AFR has never been studied in unselected patients with short duration of AF, prone to regain sinus rhythm (SR) spontaneously. The aim of the study was to assess if AFR can predict spontaneous conversion in patients with recent-onset AF. Files of consecutive patients with AF < 48 h seeking emergency room care during a 12-month period were screened (n = 225). Patients with thyroid illness, acute ischaemic heart disease (IHD) or acute congestive heart failure, significant valvular heart disease, congenital heart disease, history of cardiac surgery or catheter ablation, or on class I/III antiarrhythmics were excluded. Atrial fibrillatory rate was obtained by QRST cancellation and time frequency analysis of electrocardiogram at admission. The study population comprised 148 patients (age 64 ± 13 years, 52 men), of whom 48 converted to SR within 18 h. Those converting spontaneously comprised more women, had a higher prevalence of first-ever AF episode, IHD, and a lower AFR. The multivariate analysis revealed: AFR < 350 fibrillations per minute [odds ratio (OR) 3.7, 95% confidence interval (CI) 1.3-10.5, P = 0.016], IHD (OR 5.7, 95% CI 1.5-22.4, P = 0.012) and first-ever AF episode (OR 4.1, 95% CI 1.3-13.0, P = 0.015) as independent predictors of spontaneous conversion. A low AFR was predictive of spontaneous conversion in patients with recent-onset AF. Along with first-ever AF episode and IHD, AFR can be used in assessing likelihood of spontaneous conversion, if proven in prospective studies.

Flecainide versus vernakalant for conversion of recent-onset atrial fibrillation

An oral single dose of flecainide is used worldwide for conversion of recent onset atrial fibrillation (AF) in hemodynamically stable patients without structural heart disease. Vernakalant is a novel, rapid drug, which is used intravenously, with proven effectiveness and safety compared to placebo and amiodarone in randomized clinical trials. The aim of our study was to compare the time taken for conversion of recent onset AF in patients treated with vernakalant or flecainide. This is a sequential study in which 32 hemodynamically stable patients with recent onset AF without structural heart disease were prospectively and consecutively included in two periods, one for each drug. A single oral dose of flecainide 300 mg was administered to 15 patients and 17 patients received intravenous vernakalant. Clinical and laboratory variables, conversion rate and time to conversion were recorded. Baseline characteristics were similar in both groups. Time to conversion to sinus rhythm was of 163 min (120-300) in the flecainide group versus 10 min (6-18) in the vernakalant group (p=0.0001). Time to conversion of AF to sinus rhythm was significantly shorter in the vernakalant group compared with the flecainide group, and was associated with shorter hospital stay. This reduction in hospital stay length may produce benefits in patients' medical care, costs and welfare.

Flecainide versus Electrical Cardio Version in Patients with a Recent-Onset Atrial Fibrillation

Introduction: Flecainide is a Class IA drug according the European Guidelines for conversion of recent-onset atrial fibrillation in patients without structural heart disease. Electrical Cardio version is the first line in many centers in all over the world in this population. Up to the present no study has been conducted comparing Flecainide with Electrical Cardio version (EC) for conversion of recent-onset atrial fibrillation. The goal of our study was to compare the conversion rate of recent-onset AF, hospital stay length and adverse events in hemodynamically stable patients without structural heart disease treated with flecainide or EC. Methods: 50 hemodynamically stable patients with recent onset AF without structural heart disease were included. 30 patients received oral loading dose of flecainide 300 mg and other 20 patients EC. Clinical and laboratory variables were recorded. Results: Baseline characteristics were similar in both groups. The conversion rate was 70% in the flecainide group and 100 % in the EC group (p<0.01). Hospital stay length was 432 minutes and 263 minutes in EC (p<0.05).There were no adverse events in both groups. Conclusion: The conversion rate of recent-onset AF was lower and hospital stay length was shorter in EC group compared with flecainide group with significantly statistical differences. In both groups were no adverse events.