Emergency department use of intravenous procainamide for patients with acute atrial fibrillation or flutter. Efficacy and safety of ibutilide fumarate for the conversion of atrial arrhythmias after cardiac surgery. Atrial fibrillation and flutter. Immediate control and conversion with intravenously administered verapamil. The cost-effectiveness of ibutilide versus electrical cardioversion in the conversion of atrial fibrillation and flutter to normal rhythm. Maintenance of sinus rhythm with oral d,l-sotalol therapy in patients with symptomatic atrial fibrillation and/or atrial flutter. d,l-Sotalol Atrial Fibrillation/Flutter Study Group. Superiority of ibutilide (a new class III agent) overdl-sotalol in converting atrial flutter and atrial fibrillation 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Prediction of uneventful cardioversion and maintenance of sinus rhythm from direct-current electrical cardioversion of chronic atrial fibrillation and flutter. Termination of recent-onset atrial fibrillation/flutter in the emergency department: a sequential approach with intravenous ibutilide and external electrical cardioversion. New atrial fibrillation after acute myocardial infarction independently predicts death: the GUSTO-III experience. Efficacy and safety of repeated intravenous doses of ibutilide for rapid conversion of atrial flutter or fibrillation. Ibutilide Repeat Dose Study Investigators. Intravenous dofetilide, a class III antiarrhythmic agent, for the termination of sustained atrial fibrillation or flutter. Intravenous Dofetilide Investigators. Antiarrhythmic effects of azimilide in atrial fibrillation: efficacy and dose-response. Azimilide Supraventricular Arrhythmia Program 3 (SVA-3) Investigators. Evaluation of an individualized strategy of cavotricuspid isthmus ablation as an adjunct to atrial fibrillation ablation. Work related physical activity and risk of a hospital discharge diagnosis of atrial fibrillation or flutter: the Danish Diet, Cancer, and Health Study Early cardioversion of atrial fibrillation and atrial flutter guided by transoesophageal echocardiography: a single centre 8.5-year experience. Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study. Left atrial reservoir function as a potent marker for first atrial fibrillation or flutter in persons > or = 65 years of age. The value of class IC antiarrhythmic drugs for acute conversion of paroxysmal atrial fibrillation or flutter to sinus rhythm. Efficacy and safety of flecainide acetate in the maintenance of sinus rhythm after electrical cardioversion of chronic atrial fibrillation or atrial flutter. Conversion efficacy and safety of intravenous ibutilide compared with intravenous procainamide in patients with atrial flutter or fibrillation. Thromboembolic risk in atrial flutter. The FLASIEC (FLutter Atriale Società Italiana di Ecografia Cardiovascolare) multicentre study. Efficacy of intravenous ibutilide for rapid termination of atrial fibrillation and atrial flutter: a dose-response study.
OBJECTIVES Acute atrial fibrillation and flutter are very common arrhythmias seen in emergency department ( ED ) patients , but there is no consensus for their optimal management . The objective of this study was to examine the efficacy and safety of intravenous ( IV ) procainamide for acute atrial fibrillation or flutter . METHODS This health records review included a consecutive cohort of ED patients with acute-onset atrial fibrillation or atrial flutter who received IV procainamide at one university hospital ED during a five-year period . The st and ard clinical protocol involved IV infusion of 1 g of procainamide over 60 minutes , followed by electrical cardioversion if necessary . A trained observer extracted data from the original clinical records . Outcome measurements included conversion to sinus rhythm , adverse events , and relapse up to seven days . RESULTS The 341 study patients had a mean age of 63.9 years ( SD + /- 15.5 years ) , and 56.6 % were male . The conversion rates were 52.2 % ( 95 % confidence interval = 47 % to 58 % ) for 316 atrial fibrillation cases and 28.0 % ( 95 % confidence interval = 13 % to 46 % ) for 25 atrial flutter cases . Mean dose given was 860.7 mg ( SD + /- 231.2 mg ) , and median time to conversion was 55 minutes . Adverse events occurred in 34 cases ( 10.0 % ) : hypotension , 8.5 % ; bradycardia , 0.6 % ; atrioventricular block , 0.6 % ; and ventricular tachycardia , 0.3 % . There were no cases of torsades de pointes , cerebrovascular accident , or death . Most patients ( 94.4 % ) were discharged home , but 2.9 % of patients returned with a recurrence of atrial fibrillation within seven days . CONCLUSIONS This study of acute atrial fibrillation or flutter patients treated in the ED with IV procainamide suggests that this treatment is safe and effective in this setting . Procainamide should be prospect ively compared with other ED strategies BACKGROUND Atrial arrhythmias occur commonly after cardiac surgery and are a cause of significant morbidity and increased hospital costs , yet there is no well-studied treatment strategy to deal with them expeditiously . The purpose of this study was to determine the efficacy and safety of ibutilide fumarate , an approved drug for the rapid conversion of atrial fibrillation and flutter , in patients after cardiac surgery . METHODS AND RESULTS Patients with atrial fibrillation or flutter occurring 1 to 7 days after surgery and lasting 1 hour to 3 days were r and omized to receive two 10-minute blinded infusions of placebo or 0.25 , 0.5 , or 1.0 mg of ibutilide fumarate . Treatment was considered successful if sinus rhythm was restored for any period of time by hour 1.5 . A total of 302 patients were r and omized , 201 with fibrillation and 101 with flutter . Treatment with ibutilide result ed in significantly higher conversion rates than placebo , and efficacy was dose related ( placebo 15 % ; ibutilide 0.25 mg 40 % , 0.5 mg 47 % , and 1.0 mg 57 % ) . Conversion rates at all doses were higher for atrial flutter than for atrial fibrillation . Mean time to conversion decreased as the dose was increased . Polymorphic ventricular tachycardia was the most serious adverse effect and occurred in 1.8 % of the ibutilide-treated patients compared with 1.2 % of patients who received placebo . CONCLUSIONS Ibutilide is a useful and safe treatment alternative for the atrial arrhythmias that occur after cardiac surgery The safety and efficacy of the intravenous ( IV ) calcium channel blocker , verapamil , in controlling the ventricular response or converting to sinus rhythm patients with atrial flutter or atrial fibrillation were assessed . Seventeen patients ( nine with atrial flutter and eight with atrial fibrillation ) with these arrhythmias that were difficult to control pharmacologically were chosen for the study . All patients at the time of study were receiving digoxin .  Either verapamil or placebo was chosen r and omly and a bolus of 0.075 mg/kg ( up to 5 mg ) was administered . Twelve patients had a marked reduction in their ventricular response after IV administration of verapamil ( seven with atrial flutter and five with atrial fibrillation ) . None of these 12 patients converted ( nonconverters ) . The average reduction in heart rate was from 120 + /- 6 beats per minute to a minimum of 83 + /- 13 beats per minute within 20 minutes after drug administration . Verapamil was found to convert five patients with atrial arrhythmias to sinus rhythm ( two with atrial flutter and three with atrial fibrillation ) ( converters ) . In addition , three patients with atrial arrhythmias of less than one month who did not convert with parenteral drug therapy converted within 24 hours while receiving the oral drug . Converters had their supraventricular arrhythmias of significantly shorter duration ( median , three hours v 30 days ) and tended to have smaller left atrial size ( 3.8 + /- 0.7 cm v 4.3 + /- 1.3 cm ) compared with the nonconverters . We conclude that verapamil is safe and effective when administered IV to patients with atrial flutter and fibrillation for control of ventricular response . In short duration atrial arrhythmias , conversion to sinus rhythm is likely once the ventricular response is controlled Atrial fibrillation and atrial flutter are cardiac rhythm disorders that are often symptomatic and may interfere with the heart 's function , limiting its effectiveness . These arrhythmias are responsible for a large number of hospitalizations at a significant cost to the healthcare system . Electrical cardioversion ( EC ) is the most common nonpharmacologic intervention used to convert atrial fibrillation and atrial flutter to normal rhythm . Electrical cardioversion is highly successful in converting patients to normal rhythm ; however , it is more traumatic and re source intensive than pharmacologic treatment . Recently , a new rapid-acting drug , ibutilide , was approved for the conversion of atrial fibrillation and atrial flutter . Ibutilide is administered through intravenous infusion and does not require anesthetization of the patient , as is required for EC . A decision-tree model was developed to estimate the cost-effectiveness of ibutilide therapy compared with EC therapy . Clinical outcomes were based on a phase III trial of ibutilide , and re source use was based on the literature and physician clinical judgment . A stepped conversion regimen of first-line ibutilide followed by EC for patients who fail to convert is less expensive and has a higher conversion rate than first-line EC . Sensitivity analysis shows that our results are robust to changes in cost and effectiveness estimates Currently d , l-sotalol is widely used to prevent recurrence of atrial fibrillation and /or atrial flutter , although a r and omized dose-response study has not previously been conducted to guide therapy for this indication . This study summarizes findings of a double-blind , placebo-controlled , multicenter , r and omized trial evaluating the efficacy , safety , and dose-response relation of 3 fixed doses of d , l-sotalol ( 80 , 120 , and 160 mg twice daily ) for the maintenance of sinus rhythm in 253 patients with atrial fibrillation and /or atrial flutter . All patients were in sinus rhythm at r and omization . Treatment ( 69 patients on placebo , 59 on 80 mg , 63 on 120 mg , and 62 on 160 mg given twice daily ) was continued for 12 months or until documented recurrence of symptomatic atrial fibrillation and /or flutter . Transtelephonic electrocardiographic monitoring  was used to detect symptomatic recurrences . Demographic characteristics were not different in the 4 groups . Structural heart disease was present in 57 % of patients . Patients with a history of heart failure were excluded . The time from r and omization to symptomatic arrhythmia recurrence was significantly longer in the 2 higher d , l-sotalol dose groups than in the placebo group . The median times to recurrence were 27 , 106 , 229 , and 175 days for the placebo , 80 , 120 , and 160 mg groups , respectively . There were no deaths or cases of torsade de pointes , sustained ventricular tachycardia , or ventricular fibrillation reported . Thus , d , l-sotalol appeared to be both safe and effective in maintaining sinus rhythm in patients with symptomatic atrial fibrillation and /or flutter . Further , the 120-mg twice daily dose appeared to provide the most favorable benefit and /or risk Objective To compare the efficacy and safety of a single dose of ibutilide , a new class III antiarrhythmic drug , with that of dl-sotalol in terminating chronic atrial fibrillation or flutter in haemodynamically stable patients . Design Double blind , r and omised study . Setting 43 European hospitals . Patients 308 patients ( mean age 60 years , 70 % men , 48 % with heart disease ) with sustained atrial fibrillation ( n = 251 ) or atrial flutter ( n = 57 ) ( duration three hours to 45 days ) were r and omised to three groups to receive a 10 minute infusion of 1 mg ibutilide ( n = 99 ) , 2 mg ibutilide ( n = 106 ) , or 1.5 mg/kg dl-sotalol ( n = 103 ) . Infusion was discontinued at termination of the arrhythmia . Main outcome measure Successful conversion of atrial fibrillation or flutter , defined as termination of arrhythmia within one hour of treatment . Results Both drugs were more effective against atrial flutter than against atrial fibrillation .  Ibutilide was superior to dl-sotalol for treating atrial flutter ( 70 % and 56%v 19 % ) , while the high dose of ibutilide was more effective for treating atrial fibrillation than dl-sotalol ( 44 % v 11 % ) and the lower dose of ibutilide ( 44%v 20 % , p < 0.01 ) . The mean ( SD ) time to arrhythmia termination was 13 ( 7 ) minutes with 2 mg ibutilide , 19 ( 15 ) minutes with 1 mg ibutilide , and 25 ( 17 ) minutes with dl-sotalol . In all patients , the duration of arrhythmia before treatment was a predictor of arrhythmia termination , although this was less obvious in the group that received 2 mg ibutilide . This dose converted almost 48 % of atrial fibrillation that was present for more than 30 days . Concomitant use of digitalis or nifedipine and prolongation of the QTc interval were not predictive of arrhythmia termination . Bradycardia ( 6.5 % ) and hypotension ( 3.7 % ) were more common side effects withdl-sotalol . Of 211 patients given ibutilide  , two ( 0.9 % ) who received the higher dose developed polymorphic ventricular tachycardia , one of whom required direct current cardioversion . Conclusion Ibutilide ( given in 1 or 2 mg doses over 10 minutes ) is highly effective for rapidly terminating persistent atrial fibrillation or atrial flutter . This new class III drug , under monitored conditions , is a potential alternative to currently available cardioversion options ACCF : American College of Cardiology Foundation ACCP : American College of Chest Physicians ACS : acute coronary syndrome ACT : Atrial arrhythmia Conversion Trial ADONIS : American – Australian – African trial with DronedarONe In atrial fibrillation or flutter for the maintenance of Sinus rhythm AF : atrial fibrillation AHA : American Heart Association AND ROMEDA : ANtiarrhythmic trial with DROnedarone in Moderate-to-severe congestive heart failure Evaluating morbidity DecreAse APHRS : Asia Pacific Heart Rhythm Society aPTT : activated partial thromboplastin time ARB : angiotensin-receptor blocker ARISTOTLE : Apixaban for Reduction In STroke and Other ThromboemboLic Events in atrial fibrillation ATHENA : A placebo-controlled , double-blind , parallel arm Trial to assess the efficacy of dronedarone 400 mg b.i.d . for the prevention of cardiovascular Hospitalization or death from any cause in patiENts with Atrial fibrillation/atrial flutter ATRIA : AnTicoagulation and Risk factors In Atrial fibrillation AVERROES : Apixaban VErsus acetylsalicylic acid ( ASA ) to Reduce the Rate Of Embolic Stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment AVRO : A prospect i ve , r and omized , double-blind , Active-controlled , superiority study of Vernakalant vs. amiodarone in Recent Onset atrial fibrillation b.i.d : bis in die ( twice daily ) b.p.m . : beats per minute CABANA : Catheter ABlation vs . ANtiarrhythmic drug therapy for Atrial fibrillation CABG : coronary artery bypass graft CAP : Continued Access to Protect AF CHA2DS2-VASc : Congestive heart failure or left ventricular dysfunction Hypertension , Age ≥75 ( doubled ) , Diabetes , Stroke (doubled)-Vascular disease , Age 65–74 , Sex category ( female ) CHADS2 : Congestive heart failure , Hypertension , Age ≥75 , Diabetes , Stroke ( doubled ) CI : confidence interval CRAFT : Controlled R and omized Atrial Fibrillation Trial CrCl : creatinine clearance DAFNE : Dronedarone Atrial FibrillatioN study after Electrical cardioversion DIONYSOS : R and omized Double blind trIal to evaluate efficacy and safety of drOnedarone ( 400 mg b.i.d . ) vs . amiodaroNe ( 600 mg q.d . for 28 daYS , then 200 mg qd thereafter ) for at least 6 mOnths for the maintenance of Sinus rhythm in patients with atrial fibrillation EAST : Early treatment of Atrial fibrillation for Stroke prevention Trial EHRA : European Heart Rhythm Association ECG : electrocardiogram EMA : European Medicines Agency ERATO : Efficacy and safety of dRonedArone for The cOntrol of ventricular rate during atrial fibrillation EURIDIS : EURopean trial In atrial fibrillation or flutter patients receiving Dronedarone for the maIntenance of Sinus rhythm FAST : atrial Fibrillation catheter Ablation vs . Surgical ablation Treatment FDA : Food and Drug Administration Flec-SL : Flecainide Short-Long trial HAS-BLED : Hypertension , Abnormal renal/liver function , Stroke , Bleeding history or predisposition , Labile INR , Elderly , Drugs/alcohol concomitantly HF-PEF : heart failure with preserved ejection fraction HF-REF : heart failure with reduced ejection fraction HR : hazard ratio HRS : Heart Rhythm Society ICH : intracranial haemorrhage INR : international normalized ratio i.v . : intravenous J-RHYTHM : Japanese RHYTHM management trial for atrial fibrillation LAA : left atrial appendage LoE : level of evidence LVEF : left ventricular ejection fraction MANTRA-PAF : Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation NICE : National Institute for Health and Clinical Excellence NOAC : novel oral anticoagulant NSAID : non-steroidal anti-inflammatory drug NYHA : New York Heart Association OAC : oral anticoagulant or oral anticoagulation o.d . : omni die ( every day ) PALLAS : Permanent Atrial fibriLLAtion outcome Study using dronedarone on top of st and ard therapy PCI : percutaneous coronary intervention PREVAIL : Prospect i ve R and omized EVAluation of the LAA closure device In patients with atrial fibrillation v s. Long-term warfarin therapy PROTECT AF : WATCHMAN LAA system for embolic PROTECTion in patients with Atrial Fibrillation PT : prothrombin time RAAFT : Radio frequency Ablation Atrial Fibrillation Trial RE-LY : R and omized Evaluation of Long-term anticoagulant therapY with dabigatran etexilate ROCKET-AF : Rivaroxaban Once daily oral direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in atrial fibrillation RRR : relative risk reduction TE : thromboembolism TIA : transient ischaemic attack t.i.d . : ter in die ( three times daily ) TOE : transoesophageal echocardiogram TTR : time in therapeutic range VKA : vitamin K antagonist Guidelines summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition , taking into account the impact on The present study was undertaken to reassess prospect ively the immediate and long-term results of direct-current electrical cardioversion in chronic atrial fibrillation or atrial flutter , and to determine factors predicting clinical outcome of the arrhythmia after direct-current cardioversion .  Two-hundred forty-six patients underwent direct-current electrical cardioversion  and were followed during a mean of 260 days . Multivariate analysis was used to identify factors predicting short- and long-term arrhythmia outcome . Cardioversion was achieved in 70 % of patients with atrial fibrillation and in 96 % of patients with atrial flutter . Stepwise logistic regression analysis revealed that arrhythmia duration ( p less than 0.001 ) , type of arrhythmia ( fibrillation vs flutter , p less than 0.02 ) and age ( p less than 0.05 ) independently influenced conversion rate . On an actuarial basis , 42 and 36 % of patients remained in sinus rhythm during 1 and 2 years , respectively . Multivariate regression analysis revealed that the type of arrhythmia ( p = 0.0008 ) , low precardioversion functional class ( p = 0.002 ) and the presence of nonrheumatic mitral valve disease ( p = 0.03 ) independently increased the length of the arrhythmia-free episode . Rheumatic heart disease shortened this period ( p = 0.03 ) . In conclusion , patients having a high probability of conversion together with a prolonged post-shock arrhythmia-free episode can be identified . This may improve the cost-benefit ratio of cardioversion Safety and effectiveness are the goals in treating patients with arrhythmias . In an open prospect i ve study , we observed the efficacy and safety of up to 2 mg intravenous ibutilide , a new class III antiarrhythmic agent in haemodynamically stable patients presenting in the emergency department ( ED ) with symptoms of recent-onset ( < 48 h ) atrial fibrillation/flutter . Arrhythmia termination within 90 min , haemodynamic parameters and proarrhythmic effects were assessed . Non-responders to the ibutilide infusion underwent external electrical cardioversion .  We included 51 patients . In 31 patients therapeutic intervention with intravenous ibutilide was successful within 90 min ( 61 % ) . In another seven patients conversion to sinus rhythm occurred after 90 min without any other intervention ( 14 % ) . Blood pressure remained stable and no relevant proarrhythmic effects were observed . The 13 patients who did not respond to ibutilide treatment underwent successful external electrical cardioversion . The overall conversion rate was 100 % . Forty-seven patients ( 92 % ) were discharged within a median of 9 h and managed as out patients . In conclusion , in haemodynamically stable patients with recent-onset atrial fibrillation/flutter intravenous ibutilide and external electrical cardioversion for conversion to sinus rhythm turned out to be effective and safe . The short duration of admission makes this strategy attractive for use in the ED BACKGROUND Atrial fibrillation ( AF ) or flutter occurring after myocardial infa rct ion may occur alone or in association with other complications . Whether the arrhythmia portends a poor prognosis independent of other complications with contemporary therapy is unknown . METHODS AND RESULTS As part of the Global Use of Strategies To Open occluded coronary arteries ( GUSTO-III ) trial , we evaluated whether postinfa rct ion complications were associated with the subsequent development of  AF  and whether AF independently predicted death over periods of 30 days and 1 year . Information including exact timing was collected on deaths and major in-hospital postinfa rct ion complications up to 30 days . Of the 13,858 patients with sinus rhythm at enrollment , 906 later had AF or flutter and 12 , 952 did not . We compared outcomes between these 2 groups , adjusting for differences in baseline characteristics and prefibrillation complications . Worsening heart failure , hypotension , third-degree heart block , and ventricular fibrillation were independent predictors of new-onset AF . The unadjusted odds ratio ( OR ) for death among patients with versus those without AF was 2.74 ( 95 % confidence interval [ 95 % CI ] , 2.56 - 3.34 ) . After adjusting for baseline differences , the OR was reduced to 1.63 ( 95 % CI , 1.31 - 2.02 ) . Adjustment for other in-hospital complications before the onset of AF further reduced the OR to 1.49 ( 95 % CI , 1.17 - 1.89 ) . CONCLUSIONS Atrial fibrillation or flutter occurs secondary to other postinfa rct ion complications but independently portends a worse prognosis . Prevention and management may improve outcome BACKGROUND Currently available antiarrhythmic drugs have limited efficacy for acute termination of atrial fibrillation and flutter , especially if the arrhythmia is not of recent onset . The purpose of this multicenter study was to determine the efficacy and safety of repeated doses of intravenous ibutilide , a class III antiarrhythmic drug , in terminating atrial fibrillation or flutter . METHODS AND RESULTS Two hundred sixty-six patients with sustained atrial fibrillation ( n = 133 ) or flutter ( n = 133 ) , with an arrhythmia duration of 3 hours to 45 days , were r and omized to receive up to two 10-minute infusions , separated by 10 minutes , of ibutilide ( 1.0 and 0.5 mg or 1.0 and 1.0 mg ) or placebo . The conversion rate was 47 % after ibutilide and 2 % after placebo ( P < .0001 ) . The two ibutilide dosing regimens did not differ in conversion efficacy ( 44 % versus 49 % ) . Efficacy was higher in atrial flutter than fibrillation ( 63 % versus 31 % , P < .0001 ) . In atrial fibrillation but not flutter , conversion rates were higher in patients with a shorter arrhythmia duration or a normal left atrial size . Arrhythmia termination occurred a mean of 27 minutes after start of the infusion . Of 180 ibutilide-treated patients , 15 ( 8.3 % ) developed polymorphic ventricular tachycardia during or soon after the infusion . The arrhythmia required cardioversion in 3 patients ( 1.7 % ) and was nonsustained in 12 patients ( 6.7 % ) . CONCLUSIONS Intravenous ibutilide given in repeated doses is effective in rapidly terminating atrial fibrillation and flutter and under monitored conditions is an alternative to current cardioversion options OBJECTIVES This study sought to determine the safety and efficacy of a single bolus of intravenous dofetilide , a pure class III antiarrhythmic agent , for the termination of sustained atrial fibrillation or flutter . BACKGROUND Dofetilide is a highly selective blocker of the rapid component of the delayed rectifier current causing action potential prolongation . These effects , and preliminary clinical data , suggest that it may be effective in the treatment of atrial fibrillation and flutter . METHODS Ninety-one patients with sustained atrial fibrillation ( 75 patients ) or flutter ( 16 patients ) were entered into a double-blind , r and omized multicenter study of one of two doses of dofetilide ( 4 or 8 micrograms/kg body weight ) or placebo . RESULTS Dofetilide  effectively terminated the arrhythmia in 31 % of patients receiving 8 micrograms/kg , a statistically significant difference from those receiving 4 micrograms/kg ( conversion rate 12.5 % , p < 0.05 ) or placebo ( no conversion , p < 0.01 ) . Patients with atrial flutter had a greater response to dofetilide ( 54 % conversion rate ) than those with atrial fibrillation ( 14.5 % conversion rate , p < 0.001 ) . CONCLUSIONS Intravenous dofetilide can convert sustained atrial fibrillation or flutter to sinus rhythm . However , its efficacy is greater in flutter -- a response that contrasts with the poorer response seen with class I agents . This finding potentially represents an important advance in the pharmacologic termination of atrial flutter OBJECTIVES The purpose of this study was to assess the effectiveness of azimilide , a class III antiarrhythmic drug , in reducing the frequency of symptomatic arrhythmia recurrences in patients with atrial fibrillation , atrial flutter or both . BACKGROUND Atrial fibrillation is an increasingly common disorder of the heart rhythm , and most patients with this problem are identified because they have symptoms associated with their arrhythmia . New antiarrhythmic therapies are needed to treat patients with this problem . METHODS A total of 384 patients with a history of atrial fibrillation , atrial flutter or both were r and omly assigned to receive once daily doses of placebo or azimilide ; recurrent symptomatic arrhythmias were documented using transtelephonic electrocardiogram ( ECG ) recording . Azimilide 50 mg , 100 mg or 125 mg was tested ; the primary efficacy analysis compared the time to first symptomatic recurrence in the combined azimilide 100 mg and 125 mg dose groups with that in the placebo group using the log-rank test . RESULTS In the primary efficacy analysis , the time to first symptomatic arrhythmia recurrence was significantly prolonged in the combined azimilide 100 mg and 125 mg daily dose group compared with the placebo group ( chi-square 7.96 , p = 0.005 ) ; the hazard ratio ( placebo : azimilide ) for this comparison was 1.58 ( 95 % confidence interval [ CI ] = 1.15 , 2.16 ) . In comparisons between individual doses and placebo , the hazard ratio for the 50 mg daily dose was 1.17 ( 95 % CI = 0.83 , 1.66 ; p = 0.37 ) ; for the 100 mg group , dose was 1.38 ( 95 % CI = 0.96 , 1.98 ; p = 0.08 ) , and for the 125 mg group , dose was 1.83 ( 95 % CI = 1.24 , 2.70 ; p = 0.002 ) . CONCLUSIONS Azimilide significantly lengthened the symptomatic arrhythmia-free interval in patients with a history of atrial fibrillation , atrial flutter or both OBJECTIVES To evaluate supplementary cavotricuspid isthmus ( CTI ) ablation as an adjunct to  atrial fibrillation ( AF ) ablation in selected patients . BACKGROUND It is unclear whether routine CTI ablation is beneficial in all patients undergoing AF ablation . METHODS AND RESULTS In patients undergoing AF ablation , additional CTI block was created only for those with typical atrial flutter ( Afl ) before or during the ablation . Out of 188 consecutive patients ( 108 male , 56 + /- 9 years ) , 75 underwent CTI ablation ( Group CTI+ ) and left atrial ( LA ) ablation ( circular mapping-guided extensive pulmonary vein isolation in all and linear LA ablation when required ) , while 113 underwent LA ablation alone ( Group CTI- ) . Group CTI+ patients had smaller LA and less frequently persistent/permanent AF and linear LA ablation . Over a follow-up of 30 + /- 10 months , complications ( 4 % vs 5 % , P = NS ) , typical Afl occurrence ( 1.3 % and 2.6 % , P = NS ) and AF recurrence ( 25 % and 28 % , P = NS ) were similar . Atypical Afl was more common in Group CTI- ( 4 vs 14 % , P = 0.026 ) . Eighty-two percent and 79 % of patients in Groups CTI+ and CTI- , respectively , remained arrhythmia free in stable sinus rhythm without antiarrhythmic drug treatment ( P = NS ) . CONCLUSIONS Avoiding supplementary CTI ablation in AF ablation patients without evidence of typical flutter does not result in a higher incidence of typical Afl . Despite more persistent/permanent AF and larger LA in patients without evidence of typical flutter , a strategy of selective supplementary ablation result ed in similar and low AF recurrence rates in the group without CTI ablation compared with the group with CTI ablation Background and Aims : Excessive sporting activities have been associated with risk of  atrial fibrillation .  To study if work related physical activity also confers risk of atrial fibrillation or flutter , the association between work related physical strain and the risk of a hospital discharge diagnosis ( inpatient as well as outpatient ) of atrial fibrillation or flutter was examined . Methods : A population based prospect i ve cohort study was conducted from December 1993 to December 2001 among 19 593 men and 18 807 women with a mean age at baseline of 56 years ( range 50–65 years ) in the Danish Diet , Cancer , and Health Study . The physical strain during working hours was categorised as sedentary , light , or heavy , and analysed using proportional hazard models . Subjects were followed up in the Danish National Registry of Patients and in the Danish Civil Registration System . Results : During follow up ( mean 5.7 years ) a hospital discharge diagnosis of atrial fibrillation or flutter occurred in 305 men and 113 women . When using the risk of atrial fibrillation or flutter associated with sedentary work at a sitting position as a reference , no excess risk ( unadjusted as well as adjusted ) was found of atrial fibrillation or flutter associated with sedentary work in a st and ing position , light workload , or heavy workload in men or women . Conclusion : No evidence was found of an association between physical activities during working hours and risk of a hospital discharge diagnosis of atrial fibrillation or flutter for men and women in the age group of 50–65 years AIMS To analyse the safety and impact on maintenance of sinus rhythm of transoesophageal echocardiographically guided early cardioversion associated with short-term anticoagulation in a large series of patients with atrial fibrillation and atrial flutter . METHODS AND RESULTS Patients who were c and i date s for cardioversion were eligible for inclusion if they had atrial fibrillation or atrial flutter lasting longer than 2 days or of unknown duration . Patients received short-term anticoagulation with warfarin or heparin and underwent transthoracic echocardiography followed by transoesophageal echocardiography . Early cardioversion was performed if no thrombus was seen on the transoesophageal study . Warfarin was maintained for 1 month after cardioversion . In patients with atrial thrombi , cardioversion was deferred and prolonged anticoagulation was prescribed . The study population included 183 patients . One hundred and sixty nine patients without atrial thrombi underwent early cardioversion . Fourteen patients with atrial thrombi ( 7.6 % ) underwent a second transoesophageal echocardiogram after a median of 4 weeks of oral warfarin , and cardioversion was performed if clot regression was documented . No patient in our study population had a clinical thromboembolic event at 1 month follow-up ( 95 % C.I. 0 - 0.016 ) . The immediate success rate of cardioversion was better among patients with atrial fibrillation < 4 weeks duration compared with patients with atrial fibrillation of longer or of unknown duration : 96.6 % vs 85 % , respectively ( P = 0.014 ) . At 1 month follow-up , the percentage of arrhythmia relapses in patients with initially successful cardioversion was similar in the two groups ( 29 % vs 26 % , P = ns ) ; thus the initial better outcome in patients with recent-onset arrhythmia was not lost . CONCLUSION Transoesophageal echocardiography-guided early cardioversion in concert with short-term anticoagulation is safe . This approach permits abbreviation of the overall duration of atrial fibrillation and has a better impact on the maintenance of sinus rhythm for patients in whom the duration of atrial fibrillation is < 4 weeks OBJECTIVES This study was design ed to compare two treatment strategies in patients with atrial fibrillation(AF ) :  rhythm-control ( restoration and maintenance of sinus rhythm ) and rate-control ( pharmacologic or invasive rate-control and anticoagulation ) . BACKGROUND Atrial fibrillation is the most common arrhythmia . It is unclear whether a strategy of rhythm- or rate-control is better in terms of mortality , morbidity , and quality of life . METHODS The Strategies of Treatment of Atrial Fibrillation ( STAF ) multicenter pilot trial r and omized 200 patients ( 100 per group ) with persistent AF to rhythm- or rate-control .  The combined primary end point was a combination of death , cardiopulmonary resuscitation , cerebrovascular event , and systemic embolism . RESULTS After 19.6 + /- 8.9 months ( range 0 to 36 months ) there was no difference in the primary end point between rhythm-control ( 9/100 ; 5.54%/year ) and rate-control ( 10/100 ; 6.09%/year ; p = 0.99 ) . The percentage of patients in sinus rhythm in the rhythm-control group after up to four cardioversions during the follow-up period ( rate-control group ) was 23 % ( 0 % ) at 36 months . Eighteen primary end points occurred in atrial fibrillation ; only one occurred in sinus rhythm ( p = 0.049 ) . CONCLUSIONS The STAF pilot study showed no differences between the two treatment strategies in all end points except hospitalizations . These data suggest that there was no benefit in attempting rhythm-control in these patients with a high risk of arrhythmia recurrence . It remains unclear whether the results in the rhythm-control group would have been better if sinus rhythm had been maintained in a higher proportion of patients , as all but one end point occurred during AF The aim of this prospect i ve study was to evaluate the incremental value of left atrial ( LA ) function for the prediction of risk for first atrial fibrillation ( AF ) or atrial flutter . Maximum and minimum LA volumes were quantitated by echocardiography in 574 adults ( mean age 74 + /- 6 years , 52 % men ) without a history or evidence of atrial arrhythmia . During a mean follow-up period of 1.9 + /- 1.2 years , 30 subjects ( 5.2 % ) developed electrocardiographically confirmed AF or atrial flutter . Subjects with new AF or atrial flutter had lower LA reservoir function , as measured by total LA emptying fraction ( 38 % vs 49 % , p < 0.0001 ) and higher maximum LA volumes ( 47 vs 40 ml/m(2 ) , p = 0.005 ) . An increase in age-adjusted risk for AF or atrial flutter was evident when the cohort was stratified according to medians of LA emptying fraction ( < or = 49 % : hazard ratio 6.5 , p = 0.001 ) and LA volume ( > or = 38 ml/m(2 ) : hazard ratio 2.0 , p = 0.07 ) , with the risk being highest for subjects with concomitant LA emptying fractions < or = 49 % and LA volume > or = 38 ml/m(2 ) ( hazard ratio 9.3 , p = 0.003 ) . LA emptying fraction ( p = 0.002 ) was associated with risk for first AF or atrial flutter after adjusting for baseline clinical risk factors for AF or atrial flutter , left ventricular ejection fraction , diastolic function grade , and LA volume . In conclusion , reduced LA reservoir function markedly increases the propensity for first AF or atrial flutter , independent of LA volume , left ventricular function , and clinical risk factors In a single-blind r and omized study , the efficacy and safety of intravenous propafenone ( 2 mg/kg body weight per 10 min ) versus flecainide ( 2 mg/kg per 10 min ) were assessed in 50 patients with atrial fibrillation or flutter . Treatment was considered successful if sinus rhythm occurred within 1 h. Conversion to sinus was achieved in 11 ( 55 % ) of 20 patients with atrial fibrillation treated with propafenone and in 18 ( 90 % ) of 20 with atrial fibrillation treated with flecainide ( p less than 0.02 ) . If atrial fibrillation was present less than or equal to 24 h , conversion to sinus rhythm was achieved in 8 ( 57 % ) of 14 patients in the propafenone group and 13 ( 93 % ) of 14 in the flecainide group ( p less than 0.05 ) . Atrial flutter was converted in two ( 40 % ) of five patients treated with propafenone and in one ( 20 % ) of five with flecainide ( p = NS ) . Mean time to conversion was 16 + /- 10 min in the propafenone group versus 18 + /- 13 min in the flecainide group ( p = NS ) . QRS lengthening ( 83 + /- 15 to 99 + /- 20 ms ) was observed only in the patients treated with flecainide ( p less than 0.001 ) . Patients successfully treated with propafenone showed significantly higher plasma levels than those whose arrhythmia did not convert to sinus rhythm . Transient adverse effects were more frequent in the flecainide group ( 40 % ) than in the propafenone group ( 8 % ) ( p less than 0.01 ) . In conclusion , at a dose of 2 mg/kg in 10 min , flecainide is more effective than propafenone for conversion of paroxysmal atrial fibrillation to sinus rhythm . However , considering the propafenone plasma levels and very few adverse effects , the dose or infusion rate , or both , used in the propafenone group may not have been sufficient to achieve an optimal effect . Neither drug seems very effective in patients with atrial flutter The efficacy and safety of flecainide were studied in the maintenance of sinus rhythm after electrical cardioversion for chronic atrial fibrillation or atrial flutter . Eighty-one patients were r and omized to flecainide treatment or no treatment .  Baseline characteristics of both groups were comparable . Compared to previous studies , patients could be classified as difficult-to-treat patients . Multiple regression analysis showed New York Heart Association class I for exercise tolerance ( p = 0.0004 ) and flecainide treatment ( p = 0.01 ) to be the main factors increasing the arrhythmia-free episode . However , Mantel-Cox lifetable analysis did not reveal significant differences between arrhythmia-free survival curves of both treatment groups . In the flecainide-treated group , 9 % of patients experienced side effects , mostly related to negative dromotropic effects . The incidence of ventricular proarrhythmia in this group of patients was low . Thus , flecainide may be effective in postponing arrhythmia recurrence , even in difficult-to-treat patients . Caution should be excercised in treating patients with underlying conduction disturbances , sick sinus syndrome or characteristics favoring development of ventricular proarrhythmia OBJECTIVES This multicenter study compared the efficacy and safety of ibutilide versus procainamide for conversion of recent-onset atrial flutter or fibrillation . BACKGROUND Ibutilide fumarate is an intravenous ( IV ) class III antiarrhythmic agent that has been shown to be significantly more effective than placebo in the pharmacologic conversion of atrial flutter and fibrillation to sinus rhythm . Procainamide is commonly used for conversion of recent-onset atrial fibrillation to normal sinus rhythm . METHODS One hundred twenty-seven patients ( age range 22 to 92 years ) with atrial flutter or fibrillation of 3 h to 90 days ' ( mean 21 days ) duration were r and omized to receive either two 10-min IV infusions of 1 mg of ibutilide fumarate , separated by a 10-min infusion of 5 % dextrose in sterile water , or three successive 10-min IV infusions of 400 mg of procainamide hydrochloride . RESULTS Of the 127 patients , 120 were evaluated for efficacy : 35 ( 58.3 % ) of 60 in the ibutilide group compared with 11 ( 18.3 % ) of 60 in the procainamide group had successful termination within 1.5 h of treatment ( p < 0.0001 ) . Seven patients were found to have violated the protocol and were not included in the final evaluation . In the patients with atrial flutter , ibutilide had a significantly higher success rate than procainamide ( 76 % [ 13 of 17 ] vs. 14 % [ 3 of 22 ] , p=0.001 ) . Similarly , in the atrial fibrillation group , ibutilide had a significantly higher success rate than procainamide ( 51 % [ 22 of 43 ] vs. 21 % [ 8 of 38 ] , p=0.005 ) . One patient who received ibutilide , which was found to be a protocol violation , had sustained polymorphic ventricular tachycardia requiring direct current cardioversion . Seven patients who received procainamide became hypotensive . CONCLUSIONS This study establishes the superior efficacy of ibutilide over procainamide when administered to patients to convert either atrial fibrillation or atrial flutter to sinus rhythm .  Hypotension was the major adverse effect seen with procainamide . A low incidence of serious proarrhythmia was seen with the administration of ibutilide occurring at the end of infusion AIMS Patients with atrial flutter are believed to be at lower risk of thromboembolism than patients with atrial fibrillation . However , the incidence of atrial thrombi and the need for anticoagulation in patients with atrial flutter is not well established . METHODS AND RESULTS A prospect i ve observational multicentre study was undertaken to assess the frequency of atrial thrombi and spontaneous echocontrast and the prevalence for aortic complex atherosclerotic lesions in a cohort of unselected patients with atrial flutter . We evaluated 134 patients ( 102 male , aged 70+/-9 years ) ; exclusion criteria were history of atrial fibrillation , rheumatic mitral valve disease and mitral mechanical prosthesis . The median of atrial flutter duration was 33 days . Twelve patients had been taking warfarin for more than 7 days . One hundred and twenty-four patients ( 94 % ) underwent a transoesophageal echocardiogram , which revealed left atrial appendage thrombi in two patients ( 1.6 % ) and right atrial thrombi in one patient ( 1 % ) . At least moderate left atrial echocontrast was found in 16/124 patients ( 13 % ) . Complex atherosclerotic aortic plaques were detected in 10 patients ( 8 % ) . Atrial flutter conversion was attempted in 93/134 patients ( 69 % ) . At the 1-month follow-up , two patients experienced a thromboembolic event following restoration of sinus rhythm . CONCLUSIONS Atrial thrombi and echocontrast , and complex aortic atherosclerotic plaques are relatively uncommon in patients with atrial flutter . Post-cardioversion embolism was observed in two patients in our study population OBJECTIVES Currently available antiarrhythmic drugs have limited efficacy for short-term , rapid termination of atrial fibrillation and atrial flutter . BACKGROUND Ibutilide fumarate is an investigational class III antiarrhythmic agent that prolongs repolarization by increasing the slow inward sodium current and by blocking the delayed rectifier current . It can be administered intravenously and has a rapid onset of electrophysiologic effects . METHODS The efficacy and safety of ibutilide were studied in 200 patients with atrial flutter > 3 h in duration or atrial fibrillation 3 h to 90 days in duration . Patients were r and omized to receive a single intravenous dose of placebo or an infusion of ibutilide fumarate at 0.005 , 0.010 , 0.015 or 0.025 mg/kg body weight over 10 min . Conversion was defined as termination of the atrial arrhythmia during or within 60 min after infusion . Forty-one patients received placebo  and 159 received ibutilide ( 0.005 mg/kg [ n = 41 ] , 0.010 mg/kg [ n = 40 ] , 0.015 mg/kg [ n = 38 ] or 0.025 mg/kg [ n = 40 ] ) . RESULTS The arrhythmia terminated in 34 % of drug-treated patients . The rates of successful arrhythmia termination were 3 % for placebo and 12 % , 33 % , 45 % and 46 % , respectively , for 0.005- , 0.010- , 0.015- and 0.025-mg/kg ibutilide . The placebo and 0.005-mg/kg ibutilide groups had lower success rates than all other dose groups ( p < 0.05 ) . The mean time to termination of the arrhythmia was 19 min ( range 3 to 70 ) from the start of infusion . Successful arrhythmia termination was not affected by enlarged left atrial diameter , decreased ejection fraction , presence of valvular heart disease or the use of concomitant medications ( beta-adrenergic blocking agents , calcium channel blocking agents or digoxin ) . Arrhythmia termination was not predicted by the magnitude of corrected QT interval prolongation but was associated with a shorter duration of atrial arrhythmia . The most frequent adverse events in ibutilide-treated patients were sustained and nonsustained polymorphic ventricular tachycardia ( 3.6 % ) . All patients with sustained polymorphic ventricular tachycardia were successfully treated with direct current cardioversion and had no recurrence . The occurrence of proarrhythmia did not correlate with ibutilide plasma concentration . CONCLUSIONS These data demonstrate that ibutilide is able to rapidly terminate atrial fibrillation and atrial flutter
Discussion The results of this systematic review have the potential to benefit thous and s of patients worldwide as well as healthcare systems and healthcare economy .
Background Atrial fibrillation is the most common arrhythmia of the heart with a prevalence of approximately 2 % in the western world .
Atrial flutter , another arrhythmia , occurs less often with an incidence of approximately 200,000 new patients per year in the USA .
Patients with atrial fibrillation and atrial flutter have an increased risk of death and morbidities .
The management of atrial fibrillation and atrial flutter is often based on interventions aim ing at either a rhythm control strategy or a rate control strategy .
The evidence on the comparable effects of these strategies is unclear .
This protocol for a systematic review aims at identifying the best overall treatment strategy for atrial fibrillation and atrial flutter .