Serial antiarrhythmic therapy: role of amiodarone in prevention of atrial fibrillation recurrence--a lesson from the HOT CAFE Polish Study

Abstract

Antiarrhythmic drug prophylaxis is known to improve long-term success of electrical cardioversion (CV) in persistent atrial fibrillation (AF). This prospective study evaluates the efficacy of sequential antiarrhythmic drug therapy in sinus rhythm (SR) maintenance after successful elective CV in patients with persistent nonvalvular AF.

Materials and methods: One hundred and twenty-eight patients (61+/-8 years old) with persistent AF underwent CV. Mean AF duration preceding CV was 268+/-99 days. Following SR restoration, patients were treated sequentially with either of the following antiarrhythmic drugs: propafenone, sotalol or disopyramide. Where arrhythmia recurred, patients received another CV and a new drug from the range defined above. Where such treatment failed, patients were loaded with 14.0- to 16.0-gram doses of amiodarone and a third CV was performed. If the first CV failed to restore SR, patients received a loading dose of amiodarone followed by another CV. When successful, amiodarone was administered on continuous basis.

Results: The first CV proved successful in 55.5% of patients. During 1-year of follow-up, 31 patients (43.7%) presented with SR were treated with one antiarrhythmic agent (median does not exist). Application of the second drug proved to be effective in 6 patients (15.0%; median 13 days). Amiodarone was administered as the third antiarrhythmic agent to patients who had AF recurrence on the first two antiarrhythmic agents (propafenone, sotalol or disopyramide). It proved to be effective in 18 patients (52.9%; median does not exist) remaining free from AF for a period of 1 year as of commencement of the sequential antiarrhythmic therapy. Fifty-seven patients, in whom the first CV was ineffective, received amiodarone. During the loading period, SR was restored in 7 patients (12.3%). The remaining 50 patients underwent repeated CV, with SR restored in 37 (74.0%) of them. Long-term amiodarone treatment maintained SR in 30 (68.2%) patients during the follow-up period. Amiodarone helped to maintain SR in a total of 56.5% of patients.

Conclusions: Amiodarone seems to be the drug most effectively restoring and maintaining SR in patients with persistent AF resistant to CV and standard antiarrhythmic drug prophylaxis.