Limitations to antiarrhythmic drug use in patients with atrial fibrillation

Systematic Review and Meta-analysis of the Efficacy of Cardioversion by Vernakalant and Comparators in Patients with Atrial Fibrillation

“…However, class Ic agents, including flecainide and propafenone, may be especially prone to trigger ventricular arrhythmias in patients with left ventricular dysfunction, a left ventricular scar, or coexisting ventricular arrhythmias [54]. In particular, flecainide is contraindicated in patients with structural heart disease (including ischemic heart disease, significant valvular heart disease, congenital heart disease, heart failure, cardiomyopathy, left ventricular hypertrophy, and left ventricular systolic dysfunction) [22], and is associated with increased risk for torsades de pointes and bradycardia [6]. Use of propafenone is either contraindicated or subject to warnings in patients with bradycardia, history of myocardial infarction, or congestive heart failure [22] and is associated with increased risk for bradycardia and ventricular tachycardia.…”

“…Although existing evidence does not show one approach to be clearly superior to the other [10][11][12][13][14][15], in AF patients with distressing symptoms and/or seriously compromised cardiac function, it is of particular interest that cardioversion be achieved rapidly [5][6][7][8]16], as delayed cardioversion may worsen AF-associated symptoms and promote structural remodeling of the atria [17]. While various cardioversion therapies exist, their limitations, including limited use in certain comorbid patients, drug-drug interactions, and slow cardioversion rates, highlight the need for new treatments that are safer, more effective, and more timely in action [6,[18][19][20][21][22][23][24][25][26][27][28].…”

Atrial Fibrillation and Heart Failure

“…Third, although the prevalence of sinus rhythm in the group assigned to rhythm control was as high as 80%, the actual percentage of patients free of AF after randomization may have been lower, reflecting a more traditional success rate of amiodarone in the range of 60% to 65%. 66 In addition, heart failure is caused by heterogeneous pathophysiological processes; hence, the hemodynamic effects of AF may be different in various forms of heart failure. It is plausible that the reduction in diastolic filling time (caused by elevation in heart rate) and the atrial contribution to LV filling is greater in patients with restrictive physiology such as patients with diastolic dysfunction.…”

Docosahexaenoic Acid, but Not Eicosapentaenoic Acid, Supplementation Reduces Vulnerability to Atrial Fibrillation

“…2 Current treatments (cardioversion, antiarrhythmic drugs, ablation) are limited in their efficacy. 3 …”