Background:Multiple studies have shown that amiodarone is effective in treating atrial fibrillation (AF), but is associated with a relatively high incidence of side effects; however, due to amiodarone's long elimination half‐life (20–100 days), physicians may hesitate to start other drugs until it has fully cleared.Hypothesis:A rapid switch from amiodarone to dronedarone is feasible.Methods:EURIDIS and ADONIS were double‐blind, multinational, parallel‐group trials comparing the efficacy and safety of dronedarone with placebo over 12 months. This retrospective subanalysis of EURIDIS/ADONIS compared the effects of dronedarone in patients discontinuing amiodarone within 2 days before randomization (“rapid switch”) with results in patients who had received no amiodarone during the 2 months preceding randomization.Results:In total, 1237 patients were enrolled (“rapid switch”, n = 154; “no amiodarone”, n = 1014). In both the “rapid switch” and the “no amiodarone” groups, dronedarone users had significantly lower AF recurrence than patients receiving placebo (HR = 0.64, 95% CI, 0.44–0.95; P = 0.0224 and HR = 0.79, 95% CI, 0.67–0.92; P = 0.0027, respectively). Dronedarone users had a higher incidence of bradyarrhythmic events than placebo‐treated patients. A “rapid switch” from amiodarone to dronedarone was associated with a higher incidence of serious heart failure events and heart failure hospitalizations versus all other groups. Overall event rates were low and there was no significant difference in total adverse event rates or deaths between groups.Conclusion:In this patient population, a switch from amiodarone to dronedarone within a 2‐day time frame might be feasible in certain patient categories, but further investigation is warranted.The ADONIS/EURIDIS studies and this post hoc analysis were funded by sanofi‐aventis.The authors have no other funding, financial relationships, or conflicts of interest to disclose.
The patient is a 24 year-old pregnant female at 31 and 6/7 weeks estimated gestational age, who presented to the emergency department with complaint of intermittent right-sided abdominal pain, nausea, vomiting and fevers over the past twenty-four hours. The patient's vital signs at presentation were significant for a heart rate of 130 beats/minute and a blood pressure of 90/32 mm Hg. Her physical examination was otherwise unremarkable, and she was initially admitted to the maternal-fetal medicine service and started on intravenous fluids. Over the next 12 hours, the patient remained tachycardic with blood pressures in the 80s/40s. She began to develop respiratory distress, and an ICU evaluation was requested.At the time of evaluation, the patient's physical exam revealed a well-developed, gravid woman in moderate distress. Her temperature was 100.7º Fahrenheit, pulse was 136 beats/minute, blood pressure was 94/41 mm Hg, respiratory rate was 38 breaths/ minute, and pulse oximetry was 99% on a 100% non-rebreather mask. She was anicteric with moist mucous membranes and normal skin turgor. On cardiac examination, her heart rate was tachycardic and regular, without any murmurs. Her lungs were clear to auscultation and abdomen was soft and gravid without any tenderness to palpation. She had no peripheral edema. On vaginal exam, her cervix was long and one centimeter dilated.Laboratory results were significant for a white blood cell (WBC) count of 19.8 B/L and CO2 of 17 mmol/L. Arterial blood gas was 7.46/25/125/18/99% on a 100% non-rebreather mask. Broad spectrum antibiotics were started, and a stat CT of the chest, abdomen and pelvis was performed, which showed dense consolidation of the left lower lobe, consistent with pneumonia.The patient was maintained on a non-rebreather with stable oxygen saturations for several hours, but eventually decompensated, requiring emergent intubation. She was initially placed on assist-control ventilation; however, her oxygen saturations remained in the 60s to 70s. She was noted to have decreased left-sided breath sounds, despite pulling back the endotracheal tube. A stat chest radiograph was performed, which showed near complete collapse of the left lung.The patient was subsequently switched to bilevel ventilation with eventual improvement in her oxygenation (see Figures 1 and 2). She initially required high level settings, with an inspiratory/ expiratory pressure of 35/10 mm Hg. The patient's status improved over the next few days with antibiotic treatment, and cultures all remained negative, but serologies were positive for Mycoplasma IgM. Pressure support was discontinued on hospital day four, and ventilatory support was titrated down slowly over the next few days. On hospital day seven, the patient was successfully extubated. Antibiotics were narrowed to oral azithromycin to complete a fourteen day course of antibiotics for mycoplasma pneumonia. Case Presentation 2The patient is a 19 year-old pregnant woman at 29 and 6/7 weeks estimated gestational age, transferred from an outs...
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