The efficacy and safety of oral (up to 400 mg in 3 h) and intravenous regimens (up to 150 mg in 10 min) of flecainide acetate were compared in the acute conversion of atrial fibrillation to sinus rhythm. Acute conversion was defined as conversion occurring within 5 h (oral) or within 30 min (intravenous regimen). Following classification in recent onset (duration less than 24 h) atrial fibrillation (n = 27) and chronic (greater than 24 h) atrial fibrillation (n = 13), patients were randomly assigned to one of the two regimens. In the group of patients with recent onset atrial fibrillation, 10 out of 14 (oral treatment) and 10 out of 13 (intravenous treatment) responded acutely. Approximately half of responding patients converted after the first oral dose or within the infusion time. In contrast, no patient with chronic atrial fibrillation showed conversion on flecainide. No serious adverse effects were encountered with the regimens used, not even in patients concomitantly using digitalis or verapamil. Thus, patients with recent onset atrial fibrillation can safely be converted to sinus rhythm using oral or intravenous regimens of flecainide.
The incidence of cardiac arrhythmia increases with advancing age, as does the prevalence of structural heart disease. Serious arrhythmias, such as sustained ventricular tachycardias, are uncommon in elderly patients, but nonsustained ventricular tachycardias and atrial fibrillation are relatively frequent. The first step in the treatment of supraventricular and ventricular arrhythmias is the identification of an underlying (cardiac) disease, which should be treated appropriately. Patients with supraventricular arrhythmias who do not have a severe underlying cardiac disease may be treated with antiarrhythmic drugs to prevent recurrences of the arrhythmia. In selected patients, radiofrequency catheter ablation may nowadays be the first-line therapeutic strategy. In elderly patients with underlying cardiac disease who are experiencing non-life-threatening arrhythmias, antiarrhythmic drugs are generally discouraged because of the risk of proarrhythmic effects or other adverse events. In patients experiencing life-threatening ventricular arrhythmias, beta-blockers may be the first-line therapy. If these drugs are not effective, or cause adverse effects, class III or class IC antiarrhythmic drugs may be used as alternatives. Radiofrequency ablation is only moderately effective for haemodynamically stable ventricular tachycardias occurring post-myocardial infarction, but may be an option in drug-refractory patients.
Arm veins have been used in myocardial revascularisation procedures as a last resort bypass conduit because of their associated low patency. Nevertheless, leg veins and mammary arteries, which are the most commonly used, are sometimes not sufficient, leaving little choice as to the bypass conduit. To assess the properties of arm veins in bypass surgery, we compared a group of 28 patients that underwent an arm vein graft coronary bypass procedure with a matched group of patients in which leg veins were used. In 28 patients, 40 arm vein grafts with 77 distal anastomoses were used (mean 1.9 +/- 0.9; range 1-5). A cerebrovascular accident was the cause of the sole death (2%) during the study period. The mean follow-up was 4.6 years (Standard deviation, SD: 1.5 years). More antianginal medication was used in the arm vein group (P = 0.017). Additionally, the percentage of the expected maximal frequency during exercise testing was lower in the arm vein group as compared to the leg vein group. Digital subtraction angiography showed that the patency of the arm vein bypass grafts was 47% (70% confidence limits, CL: 32%-62%) while the patency of the leg vein grafts was 77% (CL: 64%-87%), which was statistically significant (P = 0.051). Comparison of these figures with the few published reports on arm veins used as coronary bypass grafts reveals similar results. We conclude that the arm vein as a coronary bypass graft is only to be used when mammary arteries and leg veins are not available.
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