Cardioversion of recent‐onset atrial fibrillation using intravenous antiarrhythmics: A European perspective

Abstract

Pharmacological cardioversion using intravenous antiarrhythmic agents is commonly indicated in symptomatic patients with recent‐onset atrial fibrillation (AF). Except in hemodynamically unstable patients who require emergency direct current electrical cardioversion, for the majority of hemodynamically stable patients, pharmacological cardioversion represents a valid option and requires the clinician to be familiar with the properties and use of antiarrhythmic agents. The main characteristics of selected intravenous antiarrhythmic agents for conversion of recent‐onset AF, the reported success rates, and possible adverse events are discussed. Among intravenous antiarrhythmics, flecainide, propafenone, amiodarone, sotalol, dofetilide, ibutilide, and vernakalant are commonly used. Antazoline, an old antihistaminic agent with antiarrhythmic properties was also reported to give encouraging results in Poland. Intravenous flecainide and propafenone are the only Class I agents still recommended by recent guidelines. Intravenous new Class III agents as dofetilide and ibutilide have high and rapid efficacy in converting AF to sinus rhythm but require strict surveillance with electrocardiogram (ECG) monitoring during and after intravenous administration because of the potential risk of QT prolongation and Torsades de Pointes, which can be prevented and properly managed. Vernakalant, a partial atrial selective was shown to have a high success rate and to be safe in real‐life use.

Natural Substances vs. Approved Drugs in the Treatment of Main Cardiovascular Disorders—Is There a Breakthrough?

“…Administration of beta-blockers and calcium channel blockers is recommended as a first-line treatment for rate control of atrial fibrillation (Figure 3) [24]. Oral or intravenous application of different antiarrhythmic drugs, amiodarone, digoxin, flecainide, and ibutilide, increase the likelihood of reversion to sinus rhythm and can cause ventricular arrhythmias [25,26,81,82]. In addition, there are limitations such as that flecainide and propafenone should not be used in people with ischemic heart disease [25,26].…”

“…In addition, there are limitations such as that flecainide and propafenone should not be used in people with ischemic heart disease [25,26]. Treatment with verapamil, diltiazem, and digoxin may control heart rate, but they are unlikely to restore sinus rhythm [82]. On the other side, the long-time application of amiodarone can cause hepatotoxicity, interstitial lung disease, and thyroid dysfunction [83].…”

Meta‑analysis of the efficacy and safety of nifekalant in the conversion of atrial fibrillation

“…However, all drugs have certain drawbacks. For example, propafenone is only efficient for AF within the first 48-72 h, while amiodarone takes longer to convert the abnormal heartbeat to sinus rhythm (SR) than propafenone and is prone to adverse effects, even malignant arrhythmias ( 9 ).…”