Discrepancies found in antiarrhythmic drug prescriptions for atrial fibrillation

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Chern-En Chiang, General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan, and colleagues, investigated the appropriate uses of antiarrhythmic drugs in atrial fibrillation patients and reported that there were inconsistencies in drug prescription compared to guidelines issued in 2006.

The authors wrote that the real-life practice of optimal drug use for patients with atrial fibrillation is unknown. In order to assess this, they set out to evaluate the use of antiarrhythmic drugs in patients with paroxysmal and persistent atrial fibrillation using data from the RealiseAF survey compared with the American College of Cardiology, American Heart Association and the European Society of Cardiology atrial fibrillation guidelines from 2006.

The primary objectives of the study, published in Europace, were to determine the frequency of atrial fibrillation “control” (either in sinus rhythm or in atrial fibrillation with a resting ventricular rate of ≤80bpm at the time of visit resting ECG).

In the study, 4,947 patients with paroxysmal (n=2,606) or persistent (n=2,341) atrial fibrillation were included. Of those treated with antiarrhythmic drugs, 81.1% had paroxysmal atrial fibrillation and 81.4% had persistent atrial fibrillation and 81.2% had either/or paroxysmal/persistent at the end of enrolment. Class II and class III antiarrhythmic drugs were most frequently used. Class Ic drugs were more frequently prescribed in paroxysmal in comparison to persistent atrial fibrillation (15.6 vs.7.8; p=0.001), and more persistent compared to paroxysmal atrial fibrillation patients received more often (37.8 vs. 33.3%; p=0.001).

The authors stated that the American College of Cardiology, American Heart Association and European Society of Cardiology atrial fibrillation guidelines recommend “the most appropriate antiarrhythmic drugs for maintaining sinus rhythm in patients with paroxysmal and persistent atrial fibrillation.” Class Ic drugs were recommended in the guidelines as for patients with no heart disease or hypertensive patients without left ventricular hypertrophy. Sotalol was indicated for similar conditions in patients with coronary artery disease and amiodarone for first-line therapy in heart failure patients or hypertensive patients with substantial left ventricular hypertrophy.

Chiang and colleagues reported that class Ic drugs were prescribed in 589 patients (11.9%), however, in 20% of these patients the “indication was not consistent with published guidelines”.

“The use of antiarrhythmic drugs for persistent and paroxysmal atrial fibrillation in this large contemporary international study showed some deviations from international guidelines,” Chiang et al concluded. “The highest discordance came from the use of amiodarone in first line. Clearly, there is a large discrepancy between published guidelines and current practices.”

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