Prophylaxis of Atrial Fibrillation: What are the Benefits and Risks of the Different Antiarrhythmic Drugs?

  • M. Chimienti
  • S. Barbieri
Conference paper


The role of antiarrhythmic drugs in the prevention of chronic recurrences or paroxysmal episodes of atrial fibrillation (AF) has recently come into question after some observations showing the risks that treated patients may face in terms of morbidity or mortality (1–5). On the other hand, AF may be strongly symptomatic, particularly in the paroxysmal form, and is not without risks in terms of complications secondary to thromboembolism (6–8) and left ventricular dysfunction (9–11). For these reasons the decision to treat a patient is not easy and the risks/benefits balance of such a therapeutic intervention should first always be considered.


Atrial Fibrillation Sinus Rhythm Antiarrhythmic Drug Atrial Flutter Paroxysmal Atrial Fibrillation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    IMPACT Research Group (1984) International mexiletine and placebo antiarrhythmic coronary trial: I. Report on arrhythmia and other findings. J Am Coll Cardiol 4: 1148–1163CrossRefGoogle Scholar
  2. 2.
    Coplen SE, Antman EM, Berlin JA et al (1990) Efficacy and safety of quinidine therapy for maintenance of sinus rhythm after cardioversion: a meta-analysis of randomized control trials. Circulation 82: 1106–1116PubMedCrossRefGoogle Scholar
  3. 3.
    Echt DS, Liebson PR, Mitchell LB et al (1991) Mortality and morbidity in patients receiving encainide, flecainide, or placebo: the Cardiac Arrhythmia Suppression Trial. N Engl J Med 324: 781–788PubMedCrossRefGoogle Scholar
  4. 4.
    The Cardiac Arrhythmia Suppression Trial II Investigators (1991) Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Engl J Med 327: 227–233Google Scholar
  5. 5.
    Flaker GC, Blackshear JL, McBride R (1992) Antiarrhythmic drug therapy and cardiac mortality in atrial fibrillation. J Am Coll Cardiol 20: 527–532PubMedCrossRefGoogle Scholar
  6. 6.
    Stroke Prevention in Atrial Fibrillation Investigators (1991) Stroke prevention in atrial fibrillation study: final results. Circulation 84: 527–539Google Scholar
  7. 7.
    Wolf PA, Abbott R, Kannel W (1991) Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke 22: 938–988CrossRefGoogle Scholar
  8. 8.
    Cheng TO (1994) Atrial fibrillation, stroke, and antithrombotic treatment. Am Heart J 127: 961–968PubMedCrossRefGoogle Scholar
  9. 9.
    Grogan M, Smith HC, Gersh BJ, Wood DL (1992) Left ventricular dysfunction due to atrial fibrillation in patients initially believed to have idiopathic dilated cardiomyopathy. Am J Cardiol 69: 1570–1573PubMedCrossRefGoogle Scholar
  10. 10.
    Shite J, Yokoyama M (1993) Heterogeneity and time course of improvement in cardiac function after conversion of chronic atrial fibrillation: assessment of serial echocardiographic indices. Br Heart J 70: 154–159PubMedCrossRefGoogle Scholar
  11. 11.
    Van Gelder IC, Crijns HJGM, Blanksman PK et al (1993) Time course of hemodynamic changes and improvement of exercise tolerance after cardioversion of chronic atrial fibrillation unassociated with cardiac valve disease. Am J Cardiol 72: 560–566PubMedCrossRefGoogle Scholar
  12. 12.
    Velebit V, Podrid P, Lown B et al (1982) Aggravation and provocation of ventricular arrhythmias by antiarrhythmic drugs. Circulation 65: 886–894PubMedCrossRefGoogle Scholar
  13. 13.
    Ruskin JN, McGovern B, Garan H et al (1983) Antiarrhythmic drugs: a possible cause of out-of-hospital cardiac arrest. N Engl J Med 309: 1302–1306PubMedCrossRefGoogle Scholar
  14. 14.
    Morganroth J (1987) Risk factors for the development of proarrhythmic events. Am J Cardiol 59: 32E - 37EPubMedCrossRefGoogle Scholar
  15. 15.
    Kerin NZ, Somberg J (1994) Proarrhythmia: definition, risk factors, causes, treatment, and controversies. Am Heart J 128: 575–585PubMedCrossRefGoogle Scholar
  16. 16.
    Podrid PJ (1992) Oral antiarrhythmic drugs used for atrial fibrillation: clinical pharmacology. In: Falk RH, Podrid PJ (eds) Atrial fibrillation: mechanisms and management. Raven, New York, pp 197–231Google Scholar
  17. 17.
    Feld GK (1990) Atrial fibrillation: is there a safe and highly effective pharmacological treatment? Circulation 82: 2248–2250PubMedCrossRefGoogle Scholar
  18. 18.
    Pritchett ELC (1992) Management of atrial fibrillation. N Engl J Med 326: 1264–1271PubMedCrossRefGoogle Scholar
  19. 19.
    Mandel WJ (1994) Should every patient with atrial fibrillation have the rhythm converted to sinus rhythm? Clin Cardiol 17:II 16-II 20Google Scholar
  20. 20.
    Roden DM (1994) Risks and benefits of antiarrhythmic therapy. N Engl J Med 331: 785–791PubMedCrossRefGoogle Scholar
  21. 21.
    Crijns HJGM, Van Gelder IC, Lie KI (1994) Benefits and risks of antiarrhythmic drug therapy after DC electrical cardioversion of atrial fibrillation or flutter. Eur Heart J 15 [Suppl] A1: 1721Google Scholar
  22. 22.
    Weld FM, Coromilas J, Rottman JN, Bigger JT (1982) Mechanism of quinidine induced depression of maximum upstroke velocity in ovine cardiac Purkinje fibers. Cire Res 50: 369–376Google Scholar
  23. 23.
    Hartel G, Vouhija A, Konttinen A et al (1970) Value of quinidine in maintenance of sinus rhythm after electric conversion of atrial fibrillation. Br Heart J 32: 57–60PubMedCrossRefGoogle Scholar
  24. 24.
    Sodermark T, Jonsson B, Olsson A et al (1975) Effect of quinidine on maintaining sinus rhythm after conversion of atrial fibrillation or flutter: a multicentre study from Stockholm. Br Heart J 37: 486–492PubMedCrossRefGoogle Scholar
  25. 25.
    Normand JP, Legendre M, Kahn JC et al (1976) Comparative efficacy of short-acting and long-acting quinidine for maintenance of sinus rhythm after electrical conversion of atrial fibrillation. Br Heart J 38: 381–386PubMedCrossRefGoogle Scholar
  26. 26.
    Boissel JP, Wolf E, Gillet J et al (1981) Controlled trial of a long-acting quinidine for maintenance of sinus rhythm after conversion of sustained atrial fibrillation. Eur Heart J 2: 49–55PubMedGoogle Scholar
  27. 27.
    Selzer A, Wray HW (1964) Quinidine syncope: paroxysmal ventricular fibrillation occurring during treatment of chronic atrial arrhythmias. Circulation 30: 17–26PubMedGoogle Scholar
  28. 28.
    Jenzer HR, Hagemeijer F (1976) Quinidine syncope: torsade de pointes with low quinidine plasma concentrations. Eur J Cardiol 4: 447–451PubMedGoogle Scholar
  29. 29.
    Bauman JL, Bauerfeind RA, Hoff JV et al (1984) Torsade de pointes due to quinidine: observations in 31 patients. Am Heart J 107: 425–430PubMedCrossRefGoogle Scholar
  30. 30.
    Morganroth J, Horowitz LN (1985) Incidence of proarrhythmic effects from quinidine in the outpatient treatment of benign or potentially lethal ventricular arrhythmias. Am J Cardiol 56: 585–587PubMedCrossRefGoogle Scholar
  31. 31.
    Roden DM, Woosley RL, Primm RK (1986) Incidence and clinical features of the quinidine-associated long QT syndrome: implications for patient care. Am Heart J 111: 1088–1093PubMedCrossRefGoogle Scholar
  32. 32.
    Chimienti M, Panciroli C, Salerno JA et al (1984) Dihydroquinidine versus disopyramide: efficacy in patients with chronic stable ventricular ectopy. Clin Cardiol 7: 538–546PubMedCrossRefGoogle Scholar
  33. 33.
    Chimienti M, Regazzi BM, La Rovere MT et al (1988) Comparison of the effectiveness of dihydroquinidine and quinidine on ventricular ectopy after acute and chronic administration. Cardiovasc Drugs Ther 2: 679–686PubMedCrossRefGoogle Scholar
  34. 34.
    Kus T, Sasyniuk BI (1975) Electrophysiologic actions of disopyramide phosphate on canine ventricular muscle and Purkinje fibers. Cir Res 37: 844–854Google Scholar
  35. 35.
    Hartel G, Louhija A, Konttinen A (1974) Disopyramide in the prevention of recurrence atrial fibrillation after electroversion. Clin Pharmacol Ther 15: 551–555PubMedGoogle Scholar
  36. 36.
    Karlson BW, Torstensson I, Abjorn C et al (1988) Disopyramide in the maintenance of sinus rhythm after electroconversion of atrial fibrillation. A placebo-controlled one-year follow-up study. Eur Heart J 9: 284–290Google Scholar
  37. 37.
    Wald RW, Waxman MB, Colman JM (1981) Torsade de pointes ventricular tachycardia: a complication of disopyramide shared with quinidine. J Electrocardiol 14: 301–307PubMedCrossRefGoogle Scholar
  38. 38.
    Podrid PJ, Schoeneberger A, Lown B (1980) Congestive heart failure caused by oral disopyramide. N Engl J Med 302: 614–620PubMedCrossRefGoogle Scholar
  39. 39.
    Hodess AB, Follansbee WP, Spear JF, Moore EM (1979) Electrophysiologic effects of a new antiarrhythmic drug, flecainide, on the intact canine heart. J Cardiovasc Pharmacol 1: 427–439PubMedCrossRefGoogle Scholar
  40. 40.
    Van Gelder IC, Crijns HJGM, Van Gilst WH et al (1989) Efficacy and safety of flecainide acetate in the maintenance of sinus rhythm after electrical conversion of chronic atrial fibrillation or atrial flutter. Am J Cardiol 64: 1317–1321PubMedCrossRefGoogle Scholar
  41. 41.
    Anderson JL, Gilbert EM, Alpert BL et al (1989) Prevention of symptomatic recurrences of paroxysmal atrial fibrillation in patients initially tolerating antiarrhythmic therapy: a multicenter, double-blind, crossover study of flecainide and placebo with transtelephonic monitoring. Circulation 80: 1557–1569PubMedCrossRefGoogle Scholar
  42. 42.
    Pietersen AH, Hellemann H, for the Danish-Norwegian Flecainide Multicenter Study Group (1991) Usefulness of flecainide for prevention of paroxysmal atrial fibrillation and flutter. Am J Cardiol 67: 713–717PubMedCrossRefGoogle Scholar
  43. 43.
    Leclercq JF, Chouty F, Denjoy I et al (1992) Flecainide in quinidine-resistant atrial fibrillation. Am J Cardiol 70: 62A - 65APubMedCrossRefGoogle Scholar
  44. 44.
    Hohnloser SH, Zabel M (1992) Short-and long-term efficacy and safety of flecainide acetate for supraventricular arrhythmias. Am J Cardiol 70: 3A - 10APubMedCrossRefGoogle Scholar
  45. 45.
    Chimienti M, Cullen MT, Casadei G (1995) Safety of long-term flecainide and propafenone in the management of patients with symptomatic paroxysmal atrial fibrillation: report from the Flecainide and Propafenone Italian Study (FAPIS) investigators. Am J Cardiol (in press)Google Scholar
  46. 46.
    Chimienti M, Cullen MT, Casadei G (1995) Safety of flecainide versus propafenone for the long-term management of symptomatic paroxysmal supraventricular tachyarrhythmias. Eur Heart J (in press)Google Scholar
  47. 47.
    Kohlhardt M (1984) Block of sodium currents by antiarrhythmic agents: analysis of the electrophysiologic effects of propafenone in heart muscle. Am J Cardiol 54: 13D - 19DPubMedCrossRefGoogle Scholar
  48. 48.
    Baker BJ, Dinh H, Kroskey D et al (1984) Effect of propafenone on left ventricular ejection fraction. Am J Cardiol 54: 20D - 22DPubMedCrossRefGoogle Scholar
  49. 49.
    Antman EM, Beamer AD, Cantillon CO et al (1988) Longterm oral propafenone therapy for suppression of refractory symptomatic atrial fibrillation and atrial flutter. J Am Coll Cardiol 12: 1005–1011PubMedCrossRefGoogle Scholar
  50. 50.
    Connolly Si, Hoffert DL (1989) Usefulness of propafenone for recurrent paroxysmal atrial fibrillation. Am J Cardiol 63: 817–819PubMedCrossRefGoogle Scholar
  51. 51.
    Reimold SC, Cantillon CO, Friedman PL, Antman EM (1993) Propafenone versus sotalol for suppression of recurrent symptomatic atrial fibrillation. Am J Cardiol 71: 558–563PubMedCrossRefGoogle Scholar
  52. 52.
    Mason JW (1987) Drug therapy: amiodarone. N Engl J Med 316: 455–466PubMedCrossRefGoogle Scholar
  53. 53.
    Sclarovsky S, Lewin RF, Krakoff O et al (1983) Amiodaroneinduced polymorphous ventricular tachycardia. Am Heart J 105: 6–12PubMedCrossRefGoogle Scholar
  54. 54.
    Graboys TB, Podrid PJ, Lown B (1983) Efficacy of amiodarone for refractory supraventricular arrhythmias. Am Heart J 106: 870–876PubMedCrossRefGoogle Scholar
  55. 55.
    Gold RL, Haffajee CL, Charos G et al (1986) Amiodarone for refractory atrial fibrillation. Am J Cardiol 57: 124–127PubMedCrossRefGoogle Scholar
  56. 56.
    Brodsky MA, Allen BJ, Waler CJ et al (1987) Amiodarone for maintenance of sinus rhythm after conversion of atrial fibrillation in the setting of a dilated left atrium. Am J Cardiol 60: 572–575PubMedCrossRefGoogle Scholar
  57. 57.
    Gosselink ATM, Crijns HJGM, Van Gelder IC et al (1992) Low-dose amiodarone for maintenance of sinus rhythm after cardioversion of atrial fibrillation or flutter. JAMA 267: 3289–3293PubMedCrossRefGoogle Scholar
  58. 58.
    Bhandari AK, Anderson JL, Gilbert EM et al (1992) Correlation of symptoms with occurrence of paroxysmal supraventricular tachycardia or atrial fibrillation: a transtelephonic monitoring study. Am Heart J 124: 381–386PubMedCrossRefGoogle Scholar
  59. 59.
    Singh BN, Deedwania P, Nademanee K et al (1987) Sotalol: a review of its pharmacodynamic and pharmacokinetic properties and therapeutic use. Drugs 34: 311–349PubMedCrossRefGoogle Scholar
  60. 60.
    Juul-Moller S, Edvardsson N, Rehnqvist-Ahlberg (1990) Sotalol versus quinidine for the maintenance of sinus rhythm after direct current conversion of atrial fibrillation. Circulation 82: 1932–1939PubMedCrossRefGoogle Scholar
  61. 61.
    McKibbin JK, Pocock WA, Barlow JB et al (1984) Sotalol, hypokalemia, syncope and torsade de pointes. Br Heart J 51: 157–162.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia, Milano 1996

Authors and Affiliations

  • M. Chimienti
    • 1
  • S. Barbieri
    • 2
  1. 1.Sezione di Cardiologia, Istituto di Medicina InternaUniversità di PaviaPaviaItaly
  2. 2.Centro Cardiovascolare “E. Malan”Ospedale Universitario di S. DonatoS. Donato MilaneseItaly

Personalised recommendations