Objective-To assess and compare the safety and eYcacy of amiodarone and sotalol in the treatment of patients with recurrent symptomatic atrial fibrillation. Design-Prospective, randomised, single blind, placebo controlled study. Setting-Tertiary cardiac referral centre. Patients-186 consecutive patients (97 men, 89 women; mean (SD) age, 63 (10) years) with recurrent, symptomatic atrial fibrillation. Interventions-65 patients were randomised to amiodarone, 61 to sotalol, and 60 to placebo. Patients receiving amiodarone were maintained at a dose of 200 mg/day after a 30 day loading phase. The sotalol dose was 160-480 mg daily, as tolerated. Main outcome measures-Recurrence of atrial fibrillation or side eVects. Results-In the amiodarone group, 31 of the 65 patients developed atrial fibrillation after an average of six months, while 15 (11 in sinus rhythm and four in atrial fibrillation) experienced significant side eVects after an average of 16 months. In the sotalol group, relapse to atrial fibrillation occurred in 47 of the 61 patients after an average of eight months; three experienced side eVects during the titration phase. In the placebo group, 53 of the 60 patients developed atrial fibrillation after an average of four months (p < 0.001 for amiodarone and sotalol v placebo; p < 0.001 for amiodarone v sotalol). Conclusions-Both amiodarone and sotalol can be used for the maintenance of normal sinus rhythm in patients with symptomatic atrial fibrillation. Amiodarone is more eVective but causes more side eVects. (Heart 2000;84:251-257) Keywords: amiodarone; sotalol; atrial fibrillation Various antiarrhythmic drugs, especially those belonging to class I (quinidine, procainamide, flecainide, propafenone), have been used to prevent recurrence of atrial fibrillation in patients with paroxysmal atrial fibrillation or with chronic atrial fibrillation after successful cardioversion. However, their use is fraught with problems, including incomplete eYcacy, proarrhythmic properties, and possibly increased mortality. [1][2][3][4][5][6][7][8][9][10] Recently, the development of new antiarrhythmic agents has focused on the class III mode of action-that is, the prolongation of myocardial repolarisation and refractoriness.2-5 11-13 Only two antiarrhythmic agents that are available on the market and are suitable for long term administration possess this property-sotalol and amiodarone. [14][15][16][17][18] Previous studies suggest that both these drugs are eVective in the management of refractory atrial fibrillation. However, the data must be interpreted with caution because of small sample sizes, short follow up, and the fact that most of the studies were not controlled or randomised.This prospective, randomised, single blind trial was designed: first, to determine whether amiodarone and sotalol are superior to placebo for the long term maintenance of sinus rhythm in patients with recurrent, symptomatic atrial fibrillation; second, to examine the safety of the drugs when used in this setting; and third, to compare ...

Amiodarone, Sotalol, or Propafenone in Atrial Fibrillation: Which Is Pre ferred to Maintain Normal Sinus Rhythm? This randomized study compared the efficacy and safety of amiodarone, propafenone and sotalol in the prevention of atrial fibrillation. Methods: The population consisted of 214 consecutive patients (mean age 64 ± 8 years, 106 men) with recurrent symptomatic atrial fibrillation. After restoration of sinus rhythm, patients were randomized to amiodarone (200 mg/day), propafenone (450 mg/day) or sotalol (320 ± 20 mg/day). Follow-up evaluations were conducted at 1,2, 4 and 6 months, and at 3-month intervals thereafter. The proportion of patients developing recurrent atrial fibrillation and/or experiencing unacceptable adverse effects was measured in the three groups by the Ka plan-Meier method. Results: Recurrent atrial fibrillation occurred in 25 of the 75 patients treated with amiodarone compared to 51 of the 75 patients treated with sotalol and 24 of the 64 patients treated with propafenone. Fourteen patients treated with amiodarone, five with sotalol, and one with propafenone ex perienced adverse effects while in sinus rhythm, necessitating discontinuation of treatment (P < 0.001 for amiodarone and propafenone vs sotalol). The difference between amiodarone and propafenone was sta tistically nonsignificant when all events were included in the analysis. However, if the analysis was lim ited to recurrent atrial fibrillation events, amiodarone was more effective than propafenone (P < 0.05). Conclusions: Amiodarone and propafenone were superior to sotalol in maintaining long-term normal si nus rhythm in patients with atrial fibrillation. Amiodarone tended to be superior to propafenone, though its long-term efficacy was limited by adverse side effects. (PACE 2000; 23[Pt. II] -.1883-1887) amiodarone, sotalol, propafenone, atrial fibrillation, sinus rhythm maintenance DefinitionsParoxysmal AF was defined as recurrent selfterminating episodes lasting < 48 hours, alternat- PACE, Vol. 23 N o v e m b e r 2000, Part II 1883

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This study evaluated the possibility of diagnosing chronic myocardial infarction in the presence of the pacing electrocardiogram. Forty-five patients with known myocardial infarction (anterior 23, inferior 22) and 26 healthy controls were studied. After coronary angiography, pacing was applied from the right ventricular apex, and the sensitivity, specificity, and average diagnostic accuracy of five criteria on the paced electrocardiogram were assessed: (1) Notching 0.04 second in duration in the ascending limb of the S wave of leads V3, V4, or V5 (Cabrera's sign); (2) Notching of the upstroke of the R wave in leads I, aVL, or V6 (Chapman's sign); (3) Q waves > 0.03 second in duration in leads I, aVL, or V6; (4) Notching of the first 0.04 second of the QRS complex in leads II, III, and aVF; (5) Q wave > 0.03 second in duration in leads II, III, and aVF. The most sensitive criteria, for anterior and inferior myocardial infarctions were Cabrera's and Chapman's (91.1 and 86.6%, respectively). All criteria had low specificity (range 42.3-69.2%). The combination of Cabrera's and Chapman's sign decreased the sensitivity to 77.7%, but increased specificity to 82.2%. The sensitivity and specificity of all the criteria were independent of the myocardial infarction site. In paced patients, the application of electrocardiographic criteria, and especially the combination of Cabrera and Chapman, provides useful clinical information in recognizing prior myocardial infarction but not in assigning the specific infarct site.

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