Recent-onset Atrial Fibrillation Research Articles

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.

Health-related quality of life in patients with atrial fibrillation treated with rhythm control versus rate control: insights from a prospective international registry (Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation: RECORD-AF).

Improving health-related quality of life (HRQoL) is an important treatment goal in the management of patients with atrial fibrillation (AF). Uncertainty exists as to whether patients' HRQoL differ when treated with medical rhythm control or rate control. We compared HRQoL between patients treated with rhythm control or rate control in a large observational registry of patients with recent-onset AF. In the Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation (RECORD-AF), 2439 patients with recent onset (<1 year) AF completed an AF-specific HRQoL questionnaire, the University of Toronto Atrial Fibrillation Severity Scale. HRQoL was assessed by the AF symptom severity score (0-35, with higher scores reflecting more severe AF-related symptoms) at baseline and 1 year. The minimal clinically important difference was defined as a change of ≥3 points. The primary analysis was based on a propensity score-adjusted longitudinal regression analysis which compared the change in AF symptom severity scores between the 2 groups. Over an average follow-up of 1 year, the AF symptom severity scores improved in both groups (rhythm control: -2.82 point [95% confidence interval, -3.22 to -2.41]; rate control: -2.11 point [95% confidence interval, -2.54 to -1.67]; P<0.01 for both groups). The magnitude of improvement was higher in the rhythm control group than the rate control group (unadjusted difference: -0.75 point; 95% confidence interval, -1.31 to -0.19; P=0.01; propensity score-adjusted difference: -0.71 point; 95% confidence interval, -1.31 to -0.11; P=0.02). In this observational cohort of recent-onset AF patients, treatment with medical rhythm- or rate control over 1 year was associated with an improvement in HRQoL. The magnitude of HRQoL improvement was minimally higher in patients treated with rhythm control than rate control. However, the overall degree of improvement was not large, and its clinical significance was uncertain.

Impact Of A Pharmacological Cardioversion With Vernakalant On The Management Cost Of Recent Atrial Fibrillation In Belgium.

For further information, please contact: LGerlier@be.imshealth.com ©2014 IMS Health Incorporated and its affiliates. All rights reserved. Trademarks are registered in the United States and in various other countries Introduction and objectives o Atrial fibrillation (AF) is the most common type of cardiac arrhythmia. It is associated with a 5-fold risk of stroke, a 3-fold incidence of congestive heart failure, a 3-fold risk of ventricular fibrillation and higher mortality1,2. o Pharmacological cardioversion or direct current cardioversion (DCC) are done to restore a normal sinus rhythm. o There is evidence that a shorter time to cardioversion significantly reduces the risk of thromboembolic complications3. o Vernakalant is an antiarrhythmic drug indicated to rapidly convert recent onset AF to sinus rhythm in adults, or in case of post-cardiac surgery AF ≤ 3 days4.

Demographic and clinical characteristics of patients with atrial fibrillation and cardioversion as planned therapeutic options in the International Registry on Cardioversion of Atrial Fibrillation RHYTHM-AF Polish substudy

Cardioversion of atrial fibrillation (AF) and maintenance of sinus rhythm are the basic strategies of treating AF patients. Precise data regarding the current practice of AF cardioversion in Europe in clinical practice is lacking. The primary objective of this prospective observational study was to characterise patients and treatment patterns in whom cardioversion was the planned therapeutic option. Patients with recent onset of AF were included, regardless of when the timing of the cardioversion was planned. Ten countries participated in the study, with Poland contributing 501 patients. The global enrollment period lasted from May 2010 to June 2011. Follow-up data was collected 60 days after enrollment via a medical chart abstraction or a telephone interview. The average age of the Polish patient population was 64.2 years, and 38.5% of patients were female. Mean duration of arrhythmia was 3.3 years. Paroxysmal AF was diagnosed in 38.3% and persistent AF in 43.6% of patients. The most prevalent AF risk factors were hypertension (75.0%), diabetes mellitus (20.5%), and family history of AF (12.1%). Mean body mass index of study patients was 29.5 kg/m². The most pertinent factors triggering AF were emotion (12.4%), exercise (6.5%), electrolyte disturbances (5.5%), and acute myocardial infarction (3.7%). Only 14.2% of patients were asymptomatic. Previous episodes of AF were present in 83.1% of patients and 58.5% of them had previous cardioversion: 49.8% pharmacological and 50.2% electrical. The most often used anti-arrhythmic drugs were amiodarone (53.4%) and propafenone (32.2%). The rate of antithrombotic treatment was low: 59.6%. Finally electrical cardioversion had been undergone by 165 (53%) patients and pharmacological by 146 (47%) patients. The population of patients with AF and planned cardioversion represented typical patients with non-valvular AF and standard symptoms, the vast majority of whom were symptomatic. The study group in terms of comprehensive characteristics is representative of the general population of AF patients.

Predictors of successful cardioversion with vernakalant in patients with recent-onset atrial fibrillation.

Vernakalant is a novel atrial-selective antiarrhythmic drug able to convert recent-onset atrial fibrillation (AF) with reportedly low proarrhythmic risk. Successful cardioversion predictors are largely unknown. We sought to evaluate clinical and electrocardiographic predictors of cardioversion of recent-onset AF with vernakalant. Consecutive patients with AF ≤48 hours admitted for cardioversion with vernakalant (n = 113, median age 62 years, 69 male) were included. Sinus rhythm (SR) within 90 minutes after infusion start was considered to be successful cardioversion. Predictive values of demographics, concomitant therapy, comorbidities, and electrocardiographic parameters were assessed. Atrial fibrillatory rate (AFR), exponential decay, and mean fibrillatory wave amplitude were measured from surface ECG using QRST cancellation and time-frequency analysis. Cardioversion was achieved in 66% of patients. Conversion rate was higher in women than in men (80% vs 58%, P = 0.02) while none of other clinical characteristics, including index AF episode duration, could predict SR restoration. Female gender was predictive of vernakalant's effect in logistic regression analysis (OR = 2.82 95%CI 1.18-6.76, P = 0.020). There was no difference in AFR (350 ± 60 vs 348 ± 62 fibrillations per minute [fpm], P = 0.893), mean fibrillatory wave amplitude (86 ± 33 vs 88 ± 67 μV, P = 0.852), or exponential decay (1.30 ± 0.42 vs 1.35 ± 0.42, P = 0.376) between responders and nonresponders. Female gender is associated with a higher rate of SR restoration using intravenous (i.v.) vernakalant for recent-onset AF. ECG-derived indices of AF organization, which previous studies associated with effect of rhythm control interventions, did not predict vernakalant's effect.

The efficacy of pad placement for electrical cardioversion of atrial fibrillation/flutter: a systematic review.

Electrical cardioversion is commonly used to treat patients with atrial fibrillation and atrial flutter to restore normal sinus rhythm. There has been considerable debate as to whether the electrode placement affects the efficacy of electrical cardioversion. The objective of this study was to examine the effectiveness of anteroposterior (A-P) versus anterolateral (A-L) electrode placement to restore normal sinus rhythm. A search of eight electronic databases, including Medline, EMBASE, CINAHL, and Cochrane was completed. Grey literature (hand-searching, Google, and SCOPUS) searching was also conducted. Studies were included if they were controlled clinical trials comparing the effectiveness of A-P versus A-L pad placement to restore normal sinus rhythm in adult patients with atrial fibrillation and flutter. Two independent reviewers judged study relevance, inclusion, and quality (e.g., risk of bias). Individual and pooled statistics were calculated as relative risks (RRs) with 95% confidence intervals (CIs) using a random-effects model, and heterogeneity (I(2) ) was reported. From 788 citations, 13 studies were included; seven involved monophasic, five involved biphasic, and one analyzed both waveform devices. The included studies tended to report cumulative success rates to restoring normal sinus rhythm after one to five sequential shocks of increasing energy; the number of shocks and energy used differed among studies. The risk of bias of the studies was "unclear." After the first shock, pad placement was not associated with an increased likelihood of restoring normal sinus rhythm (RR = 0.88; 95% CI = 0.73 to 1.06); however, heterogeneity was high (I(2) = 63%). Subgroup comparisons revealed that the A-L position was more effective (RR = 0.77; 95% CI = 0.59 to 1.00) at restoring normal sinus rhythm when using biphasic shocks (comparison p = 0.04). Overall, the pooled results failed to identify a difference between A-P and A-L pad placement in restoring normal sinus rhythm at any time (RR = 1.00; 95% CI = 0.95 to 1.05); however, heterogeneity was high (I(2) = 61%). No significant subgroup differences were found. Side effects were reported in only three studies. The published literature is restricted to persistent atrial fibrillation and atrial flutter, pad placement varied, and energy levels used were lower than currently recommended; however, the accumulated evidence suggests that electrical pad placement is not a critically important factor in successful cardioversion in atrial fibrillation and flutter (AF/AFL). A trial is urgently needed in recent-onset atrial fibrillation and atrial flutter patients using biphasic devices and high energy levels to resolve the debate.

Acil serviste yeni başlangıçlı atriyal fibrilasyon ve flutter kardiyoversiyonu

Acil serviste yeni başlangıçlı atriyal fibrilasyon ve flutter kardiyoversiyonu

Cardioversion of recent-onset atrial fibrillation and flutter in the emergency department

Atriyal fibrilasyon, akut tibbi uygulamada karsilasilan en sik aritmidir. Kalp ritm bozukluklari nedeniyle hastaneye yatanlarin ucte birinde neden AF olup son on yilda sikligi giderek artmaktadir. AF belirgin mortalite ve morbiditeye neden olmaktadir. Tum iskemik inmelerin %15%20’si ve tum inmelerin %20’si AF nedenlidir. AF’si olan hastalarda genel olum orani, normal sinus ritmi olanlara gore yaklasik iki kat fazladir. Atriyal flutter (AFL)’in AF’e benzer bircok klinik yonleri bulnumaktadir, acil durumlarda AF ve AFL ayni tedavi stratejilerine sahiptir. Tedavinin baslica hedefleri, ilgili semptom ve/veya hemodinamik bozuklugun azaltilmasi, sistemik tromboembolik riskin azaltilmasi ve hastanede kalis suresinin kisaltilmasini icermektedir. Cok buyuk olcekli AFFIRM ve AF-CHF calismalari, hiz ve ritim kontrolu (kardiyoversiyon) stratejilerini kiyasladi, fakat, semptom baslangicinin 48 saati icerisinde acile servise(AS) basvuran, yeni baslangicli AF/AFL hastalarinda optimal tedavi yontemini aciga kavusturamadi. Uluslararasi standart kilavuzlar bulunmasina ragmen AS’de AF tedavisi, secilen tedavi stratejisi (hiz veya ritim) yonunden hala heterojendir. Son zamanlarda bu sorunu cozmek amaciyla, AS’de AF tedavisine yonelik ulusal kaynakli kilavuzlar ve konsensus belgeleri gelistirilmis ve yayinlanmistir. Bu derlemenin amaci, AS ekibine, kilavuzlara bagli kalinarak kardiyoversiyonu destekleyen ekokardiyografik parametreler, kardiyoversiyon isleminin kendisi ve yeni antiaritmik ve antikoagulan ilaclar hakkinda ayrintili bilgi sunmaktir.

Vernakalant: Perception of state of health in patients with a recent-onset atrial fibrillation

Vernakalant is a new, safe and effective drug used intravenously, which has proved to be more rapid in converting recent onset atrial fibrillation (AF) to sinus rhythm compared to placebo, amiodarone, propafenone, and flecainide in clinical studies. Until now no study has been conducted comparing the perception of state of health in patients who received vernakalant versus propafenone or flecainide for conversion of recent-onset AF. The aim of our study is to compare the change of perception of state of health from screening to hour 2 in patients treated with vernakalant and propafenone or flecainide for conversion of recent-onset AF. Eighty 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 30 patients, 30 patients received intravenous vernakalant and the remaining 20 patients received a single oral dose of flecainide 300 mg. Clinical, laboratory variables and perception of state of health from screening to hour 2 treated with these drugs measured by the EQ-5 D quality-of-life assessments visual analog scale were recorded. Baseline characteristics were similar in the three groups. Treatment with vernakalant resulted in a significantly greater improvement in patient perception of state of health at hour 2 compared with propafenone and flecainide. In the vernakalant group, a mean increase (from baseline) of 12.1 points was seen compared with a mean increase of 5.4 points in the propafenone group or 5.2 points in flecainide group (p < 0.01). The change of perception of state of health from screening to hour 2 treated with vernakalant had a significantly statistical improvement compared with propafenone or flecainide for conversion recent-onset AF.

Vernakalant for the conversion of atrial fibrillation: the new kid on the block?

Conversion of recent onset atrial fibrillation (AF) to sinus rhythm with antiarrhythmic drugs reduces the risk of hemodynamic instability, hospitalizations, and atrial remodeling seen with persistent AF. This is the main reason for pharmacological or electrical cardioversion to be considered first line of treatment for recent onset AF. Is there a role for new antiarrhythmic drugs in the conversion of AF as the first approach to a rhythm-control strategy? Vernakalant is a novel and relativity atrial selective drug which inhibits atrial-selective K(+) currents, with only a small inhibitory effect on the rapidly activating delayed rectifier K(+) current (IKr) in the ventricle. In this brief Review, we tell the journey of vernakalant to become an attractive alternative to achieve pharmacological cardioversion of AF.

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

Advanced Interatrial Block is Associated with Recurrence of Atrial Fibrillation Post Pharmacological Cardioversion

Management of atrial fibrillation (AF) is hampered by frequent recurrences after restoration of sinus rhythm. Delayed interatrial conduction has been associated with the development of AF in different clinical settings. The aim of our study was to assess whether advanced interatrial block (aIAB) was associated with AF recurrence after pharmacological cardioversion with two different antiarrhythmic drugs. We included 61 patients with recent onset AF without structural heart disease that underwent successful pharmacological cardioversion. Thirty-one patients received a single oral dose of propafenone, and 30 patients received iv vernakalant. A 12-lead ECG (filter 150Hz, 25mm/s, 10mm/mV) after conversion was evaluated for the presence of interatrial block (IAB); partial (pIAB): P-wave duration>120ms, and advanced (aIAB): P-wave>120ms and biphasic morphology (±) in inferior leads. Clinical follow-up and electrocardiographic recordings were performed for a 12-month period. Age was 58±10.4years and 50.8% were male. aIAB was present in 11 patients (18%) and pIAB in 10 (16.4%). At 1-year follow-up, 22 patients (36%) had AF recurrence. The recurrence rate with aIAB was 90.9% versus 70% in those with pIAB and 12.5% in normal P-wave duration (P=0.001). The presence of aIAB was strongly associated with AF recurrence (odds ratio 18.4 in multivariable modeling). Recurrence was not affected by the drug used for cardioversion (P=0.92). Advanced interatrial block is associated with higher risk of AF recurrence at 1year after pharmacological cardioversion, independent of the drug used.

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.

Contemporary real life cardioversion of atrial fibrillation: Results from the multinational RHYTHM-AF study

AimsElectrical and pharmacological cardioversion (ECV, PCV) are important treatment options for symptomatic patients with recent onset atrial fibrillation (AF). RHYTHM-AF is an international registry of present-day cardioversion providing information that is not currently available on country differences and acute and long-term arrhythmia outcomes of ECV and PCV. Methods and results3940 patients were enrolled, of whom 75% underwent CV. All patients were followed for 2months. There were large variations concerning mode of CV used, ECV being heterogeneous. A choice of PCV drug depended on the clinical patient profile. Sinus rhythm was restored in 89.7% of patients by ECV and in 69.1% after PCV. Among patients not undergoing CV during admission, 34% spontaneously converted to sinus rhythm within 24h. ECV was most successful in patients pretreated with antiarrhythmic drugs (mostly amiodarone). PCV was enhanced by class Ic antiarrhythmic drugs; conversion rate on amiodarone was similar to that seen with rate control drugs. Female patients and those with paroxysmal and first detected AF as well as those without previous ECV responded well to PCV. The median duration of hospital stay was 16.2 and 24.0h for ECV and PCV patients, respectively. There were very few CV-related complications regardless of mode of CV. Chronic maintenance of sinus rhythm was enhanced in patients on chronic antiarrhythmic drugs, beta-blockers or inhibitors of the renin–angiotensin system. ConclusionsMode of CV varied significantly, but both PCV and ECV were safe and effective. Class Ic drugs were most effective conversion drugs, but amiodarone is used most frequently despite providing merely rate control rather than shorten time to conversion.

Atrial flutter with 1 : 1 atrioventricular conduction after administration of vernakalant for atrial fibrillation

A 44-year-old healthy woman presented with a first episode of recent onset atrial fibrillation ( Panel A ). Intravenous vernakalant was administered. Organization to atrial flutter with 2 : 1 atrioventricular conduction occurred ( Panel B ). After completion of the second infusion, the atrial cycle length prolonged …

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.

Predictors of obstructive coronary artery disease in otherwise ‘healthy’ individuals with ST-segment depression during paroxysms of atrial fibrillation

Paroxysmal atrial fibrillation Coronary artery disease Intima-media thickness C-reactive protein Ischemic ST-segment depression only during paroxysms of atrial fibrillation (AF), while the ECG appears unremarkable or non-specific during sinus rhythm, is not uncommon. This presentation is usually considered as a positive stress-test equivalent. However, we [1] and other investigators [2] have recently shown that in subjects without a history of cardiac disease, the presence of transient ischemic ECG changes during a paroxysm of AF, is not strongly associated with occult obstructive coronary artery disease (CAD). The present study aimed to investigate whether certain clinical factors or biochemical variables could predict the presence of underlying severe CAD in otherwise healthy individuals, who present with transient ischemic-type ST-depression only during AF, and have no evidence of profound structural heart disease or a concomitant acute cardiopulmonary event. Weassessedconsecutivepatientsolderthan40yearswhopresented to the emergency department with AF of recent onset (paroxysmal AF or persistent AF with duration of less than 30 days) and concomitant ischemic ST-segment depression. Ischemic ST-segment changes were defined according to exercise testing standards [3] .P atients with a history of CAD, other cardiac disοrders or severe co-morbidities were excluded from the study. Those who had biochemical and/or echocardiographic findings indicating an acute cardiopulmonary event or structural heart disorder were also excluded. Conversion to sinus rhythm was attempted in all admitted patients, either pharmaceutically or by synchronised transthoracic cardioversion, unless AF terminated spontaneously. Cardioverted patients with persistent ST-segment depression of more than 48h and patients in whom cardioversion was unsuccessful, were excluded. Patients who fulfilled all entry criteria and consented to the study protocol underwent the following investigations:

Pharmacological cardioversion of atrial fibrillation with vernakalant: evidence in support of the ESC Guidelines

Pharmacological rhythm control (often including electrical or pharmacological cardioversion) is an integral part of therapy for atrial fibrillation (AF) worldwide. Antiarrhythmic drug strategies would be preferred in many patients provided effective and safe antiarrhythmic agents are available. Also, pharmacological cardioversion could be the preferred option if the limitations of currently available drugs, such as restriction to patients without structural heart disease (flecainide and propafenone), risk of torsade de pointes (ibutilide), and slow onset of action (amiodarone), were overcome. The intravenous formulation of vernakalant (Brinavess, Cardiome) has been approved for pharmacological cardioversion of recent-onset AF (≤7 days) and early (≤3 days) post-operative AF in the European Union, Iceland, and Norway. Vernakalant has a high affinity to ion channels specifically involved in repolarization of atrial tissue and has minimal effects in the ventricles and thus, is thought to have a low proarrhythmic potential. Vernakalant is administered as a 10 min infusion of 3 mg/kg, and if AF persists after 15 min, an additional dose of 2 mg/kg can be given. The efficacy and safety of the drug has been extensively investigated in randomized controlled trials against placebo and an active comparator (amiodarone). The placebo-extracted efficacy of vernakalant is ∼47%. A significant advantage is a rapid effect, with the median to conversion ranging between 8 and 14 min, with the majority of patients (75-82%) converting after the first dose. Vernakalant retained its efficacy in subgroups of patients with associated cardiovascular disease such as hypertension and ischaemic heart disease, but its benefit may be lower and risk of adverse effects is higher in patients with heart failure. In the post-market reports, cardioversion rates with vernakalant are 65-70%. This review focuses on the role of vernakalant in pharmacological cardioversion for AF.

A New Antiarrhythmic Drug in the Treatment of Recent‐Onset Atrial Fibrillation: Vernakalant

Vernakalant is a new antiarrhythmic agent recently approved in Europe for the rapid cardioversion of recent-onset atrial fibrillation. It works by blocking early-activating K+ atrial channels and frequency-dependent atrial Na+ channels, prolonging atrial refractory periods and rate-dependent slowing atrial conduction, without promoting ventricular arrhythmia. Preclinical and clinical trials showed good toleration of this drug. The main purpose of our review is to describe all the trials that led to the incorporation of vernakalant into the current European atrial fibrillation guidelines.