CAPÍTULO I: VISIÓN DEL PROYECTO
2.1. Dispositivos móviles
cal cardioversion is limited by small samples, lack of standard inclusion criteria (many studies include both patients with AF and those with atrial flutter), variable inter- vals from drug administration to assessment of outcome, and arbitrary dose selection. Although pharmacological and direct-current cardioversion have not been compared directly, pharmacological approaches appear simpler but are less efficacious. The major risk is related to the toxicity of antiarrhythmic drugs. In developing these guidelines, placebo-controlled trials of pharmacological cardioversion in which drugs were administered over short periods of time specifically to restore sinus rhythm have been empha- sized. Trials in which the control group was given another antiarrhythmic drug have, however, been considered as well. Pharmacological cardioversion seems most effective when initiated within 7 d after the onset of an episode of AF.489–492 A majority of these patients have a first- documented episode of AF or an unknown pattern of AF at the time of treatment. (See Section 3, Classification.) A large proportion of patients with recent-onset AF experi- ence spontaneous cardioversion within 24 to 48 h.493–495 Spontaneous conversion is less frequent in patients with AF of longer than 7-d duration, and the efficacy of pharmaco- logical cardioversion is markedly reduced in these patients as well. Pharmacological cardioversion may accelerate res- toration of sinus rhythm in patients with recent-onset AF, but the advantage over placebo is modest after 24 to 48 h,
and drug therapy is much less effective in patients with per- sistent AF. Some drugs have a delayed onset of action, and conversion may not occur for several days after initiation of treatment.496 Drug treatment abbreviated the interval to cardioversion compared with placebo in some studies without affecting the proportion of patients who remained in sinus rhythm after 24 h.494A potential interaction of anti-
arrhythmic drugs with vitamin K antagonist oral anticoagu- lants, increasing or decreasing the anticoagulant effect, is an issue whenever these drugs are added or withdrawn from the treatment regimen. The problem is amplified when anticoagulation is initiated in preparation for elective cardioversion. Addition of an antiarrhythmic drug to enhance the likelihood that sinus rhythm will be restored and maintained may perturb the intensity of anticoagulation beyond the intended therapeutic range, raising the risk of bleeding or thromboembolic complications.
A summary of recommendations concerning the use of pharmacological agents and recommended doses is pre- sented in Tables 16–18. Algorithms for pharmacological management of AF are given inFigures 13–16. Throughout this document, reference is made to the Vaughan Williams classification of antiarrhythmic drugs,497 modified to
include drugs that became available after the original classi- fication was developed (Table 19). Considerations specific to individual agents are summarized below. Within each cat- egory, drugs are listed alphabetically. The antiarrhythmic drugs listed have been approved by federal regulatory agencies in the United States and/or Europe for clinical use, but their use for the treatment of AF has not been approved in all cases. Furthermore, not all agents are approved for use in all countries. The recommendations given in this document are based on published data and do not necessarily adhere to the regulations and labeling requirements of government agencies.
8.1.5.4. Agents with proven efficacy for cardioversion of atrial fibrillation
8.1.5.4.1. Amiodarone. Data on amiodarone are confusing because the drug may be given intravenously or orally and the effects vary with the route of administration. Five meta-analyses of trials compared amiodarone to placebo or other drugs for conversion of recent-onset AF.546–549 One concluded that intravenous amiodarone was no more effective than placebo,550while another found amiodarone
effective but associated with adverse reactions.546Another meta-analysis found amiodarone more effective than placebo after 6 to 8 h and at 24 h but not at 1 to 2 h.547 Amiodarone was inferior to type IC drugs for up to 8 h, but there was no difference at 24 h, indicating delayed conver- sion with amiodarone. In another meta-analysis of 21 trials involving heterogeneous populations, the relative likelihood of achieving sinus rhythm over a 4-wk period with oral/intra- venous amiodarone was 4.33 in patients with AF of longer than 48-h duration and 1.40 in those with AF of less than 48-h duration.548In a meta-analysis of 18 trials, the efficacy
of amiodarone ranged from 34% to 69% with bolus (3 to 7 mg/kg body weight) regimens and 55% to 95% when the bolus was followed by a continuous infusion (900 to 3000 mg daily).550Predictors of successful conversion were shorter duration of AF, smaller LA size, and higher amiodar- one dose. Amiodarone was not superior to other anti- arrhythmic drugs for conversion of recent-onset AF but
was relatively safe in patients with structural heart disease, including those with LV dysfunction for whom administration of class IC drugs is contraindicated. In addition, limited information suggests that amiodarone is equally effective for conversion of AF or atrial flutter. Because safety data are limited, randomized trials are needed to determine the benefit of amiodarone for conversion of recent-onset AF in specific patient populations.
In the SAFE-T trial involving 665 patients with persistent AF, conversion occurred in 27% of patients after 28 d of treatment with amiodarone, compared with 24% with sotalol and 0.8% with placebo.292 Although the speed of response may differ during sustained oral therapy, amiodar- one, propafenone, and sotalol seemed equally effective in converting persistent AF to sinus rhythm. Apart from intra- venous drug therapy for conversion early after onset of AF (within 24 h), antiarrhythmic drug agents may also be given over a longer period of time in an effort to achieve cardioversion after a longer period of AF. Under these
circumstances, administration of oral amiodarone is associ- ated with a conversion rate between 15% and 40% over 28 d.292,529,533,551 In a comparative study, amiodarone and propafenone were associated with similar rates (40%) of con- verting persistent AF averaging 5 mo in duration.551Remark- ably, all cases in which conversion followed administration of amiodarone occurred after 7 d, with responses continuing to 28 d, whereas conversion occurred more rapidly with pro- pafenone (between 1 and 14 d).
Adverse effects of amiodarone include bradycardia, hypo- tension, visual disturbances, thyroid abnormalities, nausea, and constipation after oral administration and phlebitis after peripheral intravenous administration. Serious toxicity has been reported, including death due to bradycardia ending in cardiac arrest.496,504,516,527–534,537,551
8.1.5.4.2. Dofetilide. Oral dofetilide is more effective than placebo for cardioversion of AF that has persisted longer than 1 wk, but available studies have not further stratified
Table 17 Recommendations for pharmacological cardioversion of atrial fibrillation present for more than 7 d
Druga Route of administration Recommendation
class
Level of evidence
References
Agents with proven efficacy
Dofetilide Oral I A 498–503
Amiodarone Oral or intravenous IIa A 496, 504, 516, 527–534
Ibutilide Intravenous IIa A 510–515
Less effective or incompletely studied agents
Disopyramide Intravenous IIb B 544
Flecainide Oral IIb B 489–491, 493, 504–509
Procainamide Intravenous IIb C 510, 512, 536, 557
Propafenone Oral or intravenous IIb B 494, 495, 505, 509, 516–526
Quinidine Oral IIb B 489, 494, 524, 529, 537–539, 698
Should not be administered
Digoxin Oral or intravenous III B 375, 494, 505, 526, 530, 542
Sotalol Oral or intravenous III B 513, 538–540, 543
aThe doses of medications used in these studies may not be the same as those recommended by the manufacturers. Drugs are listed alphabetically within each category by class and level of evidence.
Table 16 Recommendations for pharmacological cardioversion of atrial fibrillation of up to 7-d duration
Druga Route of administration Class of recommendation Level of evidence References
Agents with proven efficacy
Dofetilide Oral I A 498–503
Flecainide Oral or intravenous I A 489–491, 493, 504–509
Ibutilide Intravenous I A 510–515
Propafenone Oral or intravenous I A 491, 494, 495, 505, 509, 516–526, 557
Amiodarone Oral or intravenous IIa A 496, 504, 516, 527–534
Less effective or incompletely studied agents
Disopyramide Intravenous IIb B 544
Procainamide Intravenous IIb B 510, 512, 536
Quinidine Oral IIb B 489, 494, 524, 529, 537–539, 698
Should not be administered
Digoxin Oral or intravenous III A 375, 494, 505, 526, 530, 542
Sotalol Oral or intravenous III A 513, 538–540, 543
aThe doses of medications used in these studies may not be the same as those recommended by the manufacturers. Drugs are listed alphabetically within each category of recommendation and level of evidence.
Table 18 Recommended doses of drugs proven effective for pharmacological cardioversion of atrial fibrillation
Druga Route of
administration
Dosageb Potential adverse effects References
Amiodarone Oral Inpatient: 1.2 to 1.8 g per day in divided dose until 10 g total, then 200 to 400 mg per day maintenance or 30 mg/kg as single dose
Hypotension, bradycardia, QT
prolongation, torsades de pointes (rare), GI upset, constipation, phlebitis (IV)
496, 504, 516, 527–534, 537, 545
Outpatient: 600 to 800 mg per day divided dose until 10 g total, then 200 to 400 mg per day maintenance
Intravenous/oral 5 to 7 mg/kg over 30 to 60 min, then 1.2 to 1.8 g per day continuous IV or in divided oral doses until 10 g total, then 200 to 400 mg per day maintenance
Dofetilide Oral Creatinine Clearance (mL/min) Dose (mcg BID)
More than 60 500 QT prolongation, torsades de pointes;
adjust dose for renal function, body size, and age
498–503
40 to 60 250
20 to 40 125
Less than 20 Contraindicated
Flecainide Oral 200 to 300 mgc Hypotension, atrial flutter with high
ventricular rate
489–491, 493, 504, 505, 507–509
Intravenous 1.5 to 3.0 mg/kg over 10 to 20 minc
Ibutilide Intravenous 1 mg over 10 min; repeat 1 mg when necessary QT prolongation, torsades de pointes 510–515
Propafenone Oral 600 mg Hypotension, atrial flutter with high
ventricular rate
491, 494, 495, 505, 506, 509, 516–526, 557 Intravenous 1.5 to 2.0 mg/kg over 10 to 20 minc
Quinidined Oral 0.75 to 1.5 g in divided doses over 6 to 12 h, usually with a rate-slowing drug
QT prolongation, torsades de pointes, GI upset, hypotension
489, 494, 524, 529, 537–539 AF indicates atrial fibrillation; BID, twice a day; GI, gastrointestinal; IV, intravenous.
aDrugs are listed alphabetically.
bDosages given in the table may differ from those recommended by the manufacturers.
cInsufficient data are available on which to base specific recommendations for the use of one loading regimen over another for patients with ischemic heart disease or impaired left ventricular function, and these drugs should be used cautiously or not at all in such patients.
dThe use of quinidine loading to achieve pharmacological conversion of atrial fibrillation is controversial, and safer methods are available with the alternative agents listed in the table. Quinidine should be used with caution.
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patients on the basis of the duration of the arrhythmia. Dofetilide appears more effective for cardioversion of atrial flutter than of AF. A response may take days or weeks when the drug is given orally. The intravenous form is investigational.498–502
8.1.5.4.3. Flecainide. Flecainide administered orally or intravenously was effective for cardioversion of recent- onset AF in placebo-controlled trials. In 7 studies, the success of a single oral loading dose (300 mg) for cardiover- sion of recent-onset AF ranged from 57% to 68% at 2 to 4 h and 75% to 91% at 8 h after drug administration.552 Single oral loading and intravenous loading regimens of flecainide were equally efficacious, but a response usually occurs within 3 h after oral administration and 1 h after intravenous administration. Arrhythmias, including atrial flutter with rapid ventricular rates and bradycardia after conversion, are relatively frequent adverse effects. Transient hypoten- sion and mild neurological side effects may also occur. Overall, adverse reactions are slightly more frequent with flecainide than with propafenone, and these drugs should be avoided in patients with underlying organic heart disease involving abnormal ventricular function.489– 491,493,504,505,507–509
8.1.5.4.4. Ibutilide. In placebo-controlled trials, intrave- nous ibutilide has proved effective for cardioversion within a few weeks after onset of AF. Available data are insufficient to establish its efficacy for conversion of persistent AF of longer duration. Ibutilide may be used in patients who fail to convert following treatment with propafenone553 or in those in whom the arrhythmia recurs during treatment with propafenone or flecainide.554 The risk of torsades de pointes was about 1% in these studies, lower than the approximate 4% incidence observed during ibutilide mono- therapy.555 Presumably, this is related to the protective
effect of sodium channel blockade with type IC drugs.554Ibu- tilide is more effective for conversion of atrial flutter than of AF. An effect may be expected within 1 h after adminis- tration. In clinical practice, there is a 4% risk of torsades de pointes ventricular tachycardia and appropriate resusci- tation equipment must therefore be immediately available. Women are more susceptible than men to this complication
(5.6% vs. 3% in a meta-analysis).555 Ibutilide should be avoided in patients with very low ejection fractions or HF because of the higher risk of ventricular proarrhythmia.556 Serum concentrations of potassium and magnesium should be measured before administration of ibutilide, and patients should be monitored for at least 4 h afterward. Hypotension is an infrequent adverse response.510–515
8.1.5.4.5. Propafenone. Placebo-controlled trials have veri- fied that propafenone, given orally or intravenously, is effec- tive for pharmacological cardioversion of recent-onset AF. The effect occurs between 2 and 6 h after oral adminis- tration and earlier after intravenous injection, so that when compared with the intravenous regimen, oral propafe- none resulted in fewer conversions in the first 2 h. In 12 placebo-controlled trials, the success rate of oral propafe- none (600 mg) for cardioversion of recent-onset AF ranged from 56% to 83%.557Oral propafenone was as efficacious as flecainide but superior to oral amiodarone and quinidine plus digoxin.494,558 Limited data suggest reduced efficacy in patients with persistent AF, in conversion of atrial flutter, and in patients with structural heart disease. Adverse effects are uncommon but include rapid atrial flutter, ventricular tachycardia, intraventricular conduction disturbances, hypotension, and bradycardia at conversion. Available data on the use of various regimens of propafe- none loading in patients with organic heart disease are scant. This agent should be used cautiously or not at all for conversion of AF in such cases and should be avoided in patients with HF or severe obstructive lung disease.491,495,505,506,509,516–526,557
8.1.5.5. Less effective or incompletely studied agents for