Predictors of clinical efficacy of 'Ablate and Pace' therapy in patients with permanent atrial fibrillation.

OBJECTIVE: To evaluate the 2-year clinical improvement after 'Ablate and Pace' therapy and to identify the variables able to influence the efficacy of this therapy in patients with permanent atrial fibrillation (AF). Design Prospective multicentre observational study. Setting Cardiology departments of 19 general hospitals in Italy, Spain and Greece. PATIENTS: 171 patients with drug-refractory severely symptomatic permanent AF considered for AV junction ablation. Interventions Patients underwent AV junction ablation, received a right ventricular (RV) pacing or echo-guided cardiac resynchronisation (CRT) pacing and were followed-up to 24 months. Main outcome measures Non-responders to Ablate and Pace therapy were defined those patients who, during the follow-up period had clinical failure (defined as death or hospitalisation due to heart failure, or worsening heart failure) or showed no improvement in their clinical condition. RESULTS: Responders were 63% of RV-paced patients and 83% of CRT-paced patients. Another 27% showed no clinical improvement (7%) or worsened (20%) (non-responders group). On multivariable Cox regression analysis, CRT mode and echo-optimised CRT were the only independent protective factors against non-response (HR=0.24, 95% CI 0.10-0.58, p=0.001 and HR=0.22, 95% CI 0.07-0.77, p=0.018 respectively). On comparing freedom from non-response, a trend in favour of echo-optimised CRT versus simultaneous biventricular pacing (p=0.077) was seen. CONCLUSIONS: In patients affected by severely symptomatic permanent AF, Ablate and Pace therapy yielded a clinical benefit in 63% of RV-paced patients and 83% of CRT-paced patients. CRT pacing and echo-optimised CRT were the only independent predictor of clinical benefit.

Acute abdomen in the elderly. A peripheral general hospital experience.

We reviewed our experience on 291 consecutive patients aged over 65 years who were operated on for acute abdomen during the period 2003-2007 at "Santo Spirito" Hospital of Casale Monferrato, a peripheral hospital in the Piedmont region. The mean age of the patients was 78 years and the male/female ratio was 149/142. A total of 126 patients (43%) had one or more associated disease. The most common causes for an emergency operation were mechanical bowel obstruction (45%), hollow viscus perforation (18%) and strangulated hernia (18%). 234 patients (80%) recovered and were free from major complications. The remaining 57 (20%) developed at least one major complication (including death). The 30-days postoperative deaths were 33 (11%). Nonlethal major complications were 24 (8%). The commonest complications were cardio-respiratory. Septic complications were 15. Total reoperations for surgical complications were 5. Mesenteric ischaemia and secondary peritonitis were the most important causes of fatal outcome (respectively 42 and 17% of mortality). We also reported high mortality among patients with peritoneal carcinomatosis (24%). Emergency surgery was relatively safe for the remaining groups of patients, with a complexive mortality ratio of 5.3%. We conclude that "acute abdomen" is still an appreciably frequent cause of death in the older age group. A high level of vigilance and early attention is therefore advocated. Anyway, excluding some severe conditions, the overall success of surgical interventions for abdominal emergency is satisfactory in the majority of older people. About the debated role of peripheral hospitals in the health care system, we conclude that the surgical treatment of the acute abdomen in the elderly is safe and feasible in the peripheral hospitals, and that these hospitals play a determining role in the management of old patients, especially in emergency.

Sporadic flat ileal adenocarcinoma: an intriguing challenge in the comprehension of a rare neoplasia and its genesis. Case report and review of literature.

Small bowel adenocarcinoma is a rare tumor, with a still not well studied tumorigenesis process, usually presenting in an advanced stage. The clinical diagnosis is often difficult; surgery is the treatment of choice when feasible, while the chemotherapeutic approach is still not well standardized. We describe the case of a 71-yr-old male patient, presenting with an acute right abdomen. At laparotomy the terminal ileum appeared chronically inflamed and thickened. An ileocecal resection with latero-lateral ileocolic anastomosis was performed. The gross appearance resembled an inflammatory bowel disease, but microscopic examination revealed the extensive presence of an infiltrating ileal adenocarcinoma. Literature about small bowel adenocarcinoma has been reviewed for better understanding its pathogenesis.

Efficacy of a dual chamber defibrillator with atrial antitachycardia functions in treating spontaneous atrial tachyarrhythmias in patients with life-threatening ventricular tachyarrhythmias.

BACKGROUND: Atrial fibrillation has a high incidence in patients wearing an implantable cardioverter defibrillator for ventricular tachyarrhythmias and may lead to palpitations, heart failure, angina, stroke and inappropriate defibrillator discharge. The aim of the study was to evaluate the efficacy of a dual chamber defibrillator with atrial antitachycardia functions in treating spontaneous atrial tachyarrhythmias. METHODS: One hundred and twelve patients, 88 male, mean age 64+/-11 years, were enrolled. Seventy-six had ischaemic heart disease, 21 idiopathic dilated cardiomyopathy, nine other heart diseases, six no structural heart disease. The mean left ventricular ejection fraction was 40+/-11%. Sixty-two had prior atrial tachyarrhythmias. RESULTS: Follow-up lasted 11+/-9 months (range 1-42). Among 933 ventricular tachyarrhythmia episodes, 100% of ventricular fibrillation and 92% of ventricular tachycardia were successfully cardioverted. Among 414 detected sustained atrial tachyarrhythmias, 195 were classified as atrial tachycardia (47.1%), 192 as atrial fibrillation (46.4%) and 27 (6.5%) as sinus rhythm. The detection-positive predictive value was 93.5%. Therapy success rates: antitachy pacing on atrial tachycardia = 71.3% (crude estimate); 66.1% (adjusted estimate); 50 Hertz on atrial fibrillation=36.2% (crude estimate); 13.5% (adjusted estimate); atrial shock on atrial fibrillation = 62.5% (mean energy 7.8+/-14.1J). Shock efficacy was 32% when delivered energy was < or = 2 atrial defibrillation threshold at implant and 92% when >2. Duration of successfully treated atrial episodes was significantly lower than that of unsuccessfully treated (6+/-26 min vs 42+/-60). CONCLUSIONS: Atrial antitachy pacing and shock therapies demonstrated very high efficacy in treating atrial tachyarrhythmias in defibrillator patients.

An evaluation of the strategy of maintenance of sinus rhythm by antiarrhythmic drug therapy after ablation and pacing therapy in patients with paroxysmal atrial fibrillation.

AIMS: Permanent atrial fibrillation develops in many patients after ablation and pacing therapy. We compared a strategy that initially allowed patients to remain in atrial fibrillation with a strategy that initially attempted to restore and maintain sinus rhythm. METHODS AND RESULTS: In this multicentre randomized controlled trial, 68 patients affected by severely symptomatic paroxysmal atrial fibrillation were assigned, after successful atrioventricular junction ablation and pacing treatment, to antiarrhythmic drug therapy with amiodarone, propafenone, flecainide or sotalol and were compared with 69 patients assigned, after successful AV junction ablation and pacing treatment, to no antiarrhythmic drug therapy. The patients were followed-up for 12 to 24 months (mean 16+/-4). The drug arm patients had a 57% reduction in the risk of developing permanent atrial fibrillation (21% vs 37%, P=0.02). Evaluation after 12 months revealed similar quality of life scores and echocardiographic parameters in the two groups, but the drug arm patients had more episodes of heart failure and hospitalizations (P=0.05). The outcome was similar between the 40 patients who developed permanent atrial fibrillation and the 97 who did not. CONCLUSION: Conventional antiarrhythmic therapy reduces the risk of development of permanent atrial fibrillation after ablation and pacing therapy. The present data do not support the concept that the development of permanent atrial fibrillation is related to an adverse outcome when a perfect control of heart rate is obtained by ablation and pacing.

Randomized crossover comparison of right atrial appendage pacing versus interatrial septum pacing for prevention of paroxysmal atrial fibrillation in patients with sinus bradycardia.

BACKGROUND: New atrial pacing techniques and overdrive pacing algorithms have been introduced to prevent atrial fibrillation. This study was designed to test the hypotheses that (1) interatrial septum pacing (IASP) at the triangle of Koch would be more effective than right atrial appendage pacing (RAAP) in preventing paroxysmal atrial fibrillation (PAF) in patients with sinus bradycardia and (2) an algorithm (CAP) designed to achieve constant atrial capture would increase the efficacy of rate-responsive atrial pacing. METHODS: We studied 46 patients with PAF and sinus bradycardia implanted with a DDD(R) (Medtronic Thera) pacemaker. Twenty-four patients (6.0 +/- 10.1 PAF episodes/month within 3 months before study) were randomized to RAAP and 22 patients (5.4 +/- 7.1, not significant) to IASP. Within each arm 2 randomized crossover periods of CAP-OFF and CAP-ON function were programed. RESULTS: The PAF episodes per month significantly decreased in the RAAP (CAP-OFF: 2.1 +/- 4.2, P <.05; CAP-ON: 1.9 +/- 3.8, P <.05) and in the IASP group (CAP-OFF: 0.2 +/- 0.5, P <.05; CAP-ON: 0.2 +/- 0.5, P <.05). Values were significantly lower in the IASP group than in the RAAP group in both CAP-OFF (0.2 +/- 0.5 vs 2.1 +/- 4.2, P <.05) and CAP-ON (0.2 +/- 0.5 vs 1.9 +/- 3.8, P <.05) conditions. PAF burden was significantly lower in the IASP than in the RAAP group in CAP-OFF (47 +/- 84 min/d vs 140 +/- 217, P <.05) and in CAP-ON (41 +/- 72 vs 193 +/- 266, P <.05) conditions. No differences were observed within each arm in PAF burden between the 2 crossover CAP programing periods. CONCLUSIONS: Rate-adaptive IASP at the triangle of Koch is more effective than RAAP in preventing PAF in patients with sinus bradycardia. In our sample of patients no additional clinical benefit is furnished by the CAP algorithm.

Mechanism of syncope in patients with isolated syncope and in patients with tilt-positive syncope.

BACKGROUND: Because of its episodic behavior, the correlation of spontaneous syncope with an abnormal finding can be considered a reference standard. METHODS AND RESULTS: We inserted an implantable loop recorder in 111 patients with syncope, absence of significant structural heart disease, and a normal ECG; tilt-testing was negative in 82 (isolated syncope) and positive in 29 (tilt-positive). The patients had had >/=3 episodes of syncope in the previous 2 years and were followed up for 3 to 15 months. Results were similar in the isolated syncope group and the tilt-positive group: syncope recurred in 28 (34%) and 10 patients (34%), respectively, and electrocardiographic correlation was found in 24 (23%) and 8 (28%) patients, respectively. The most frequent finding, which was recorded in 46% and 62% of patients, respectively, was one or more prolonged asystolic pauses, mainly due to sinus arrest, preceded for a few minutes by progressive bradycardia or progressive tachycardia-bradycardia. Bradycardia without pauses was observed in 8% and 12% of cases, respectively. The remaining patients had normal sinus rhythm or sinus tachycardia, except for one, who had ectopic atrial tachycardia. In the tilt-positive group, an asystolic syncope was also recorded when the type of response to tilt-testing was vasodepressor or mixed. Presyncopal episodes were never characterized by asystolic pauses; normal sinus rhythm was the most frequent finding. CONCLUSIONS: Homogeneous findings were observed during syncope. In most patients, the likely cause was neurally-mediated, and the most frequent mechanism was a bradycardic reflex. In the other cases, a normal sinus rhythm was frequently recorded. Presyncope was not an accurate surrogate for syncope in establishing a diagnosis.

Arthroscopic repair of acute traumatic anterior shoulder dislocation in young athletes.

PURPOSE: To compare the results of arthroscopic repair in acute anterior shoulder traumatic dislocation with those of nonoperative treatment. TYPE OF STUDY: A prospective nonrandomized study was performed. METHODS: Between August 1989 and April 1997, 46 patients were seen after a first episode of traumatic anterior shoulder dislocation. The average age was 21 years (range, 17 to 27 years). Most dislocations were in rugby players (36 patients). There were 18 patients treated by nonoperative methods and 28 patients treated by acute arthroscopic repair; 22 patients using transglenoid suture and 6 patients with bone anchor suture fixation. RESULTS: Of the patients treated nonoperatively, 94.5% suffered a redislocation between 4 and 18 months (average, 6 months). In the operative group, 96% of the patients (27) obtained excellent results according to the Rowe scale. Only 1 patient suffered a redislocation 1 year after surgery. Three different types of lesions were found during surgery: group I, capsular tear with no labrum lesion (4%); group II, capsular tear with partial labrum detachment (32%); and group III, capsular tear and full anterior labrum detachment (64%). The average follow-up was 67.4 months (range, 28 to 120). There were no surgical complications. CONCLUSIONS: The operative group obtained 96% excellent results, but the nonoperative group only obtained 5.5% excellent results, according to the Rowe scale. The nonoperative group showed a high incidence of redislocation (94.5%) compared with the operative group (4%). Based on the findings of this study, we recommend using an arthroscopic evaluation and repair after an initial anterior traumatic shoulder dislocation in young athletes.

Impact of consistent atrial pacing algorithm on premature atrial complexe number and paroxysmal atrial fibrillation recurrences in brady-tachy syndrome: a randomized prospective cross over study.

AIM OF THE STUDY: The Consistent Atrial Pacing (CAP) algorithm has been designed to achieve a high percentage of atrial pacing to suppress paroxysmal atrial fibrillation. The aim of our study was to compare the impact of DDDR+CAP versus DDDR pacing on paroxysmal atrial fibrillation recurrences and triggers in patients with Brady-Tachy Syndrome. METHODS: 61 patients, 23 M and 38 F, mean age 75+/-9 y, affected by Brady-Tachy Syndrome, implanted with a DDDR pacemaker, were randomized to DDDR or DDDR+CAP pacing with cross over of pacing modality after 1 month. RESULTS: 78 % of patients in DDDR pacing and 73 % in DDDR + CAP pacing (p=n.s.) were free from symptomatic paroxysmal atrial fibrillation recurrences. During DDDR+CAP pacing, the atrial pacing percentage increased from 77+/-29 % to 96+/-7 % (p<0.0001). Automatic mode switch episodes/day were 0.73+/-1.09 in DDDR and 0.79+/-1.14 (p=n.s.) in DDDR+CAP. In patients with less than 50 % of atrial pacing during DDDR, automaticmode switch episodes/day decreased during DDDR+CAP from 1.13+/-1.59 to 0.23+/-0.32 (p<0.05) and in patients with less than 90 % from 1.23+/-1.27 to 0.75+/-1.10 (p<0.001). The number of premature atrial complexes per day decreased during DDDR + CAP from 2665+/-4468 to 556+/-704 (p<0.02). CONCLUSION: CAP algorithm allowed continuous overdrive atrial pacing without major side effects. Triggers of paroxysmal atrial fibrillation induction, such as premature atrial complexes, were critically decreased. Paroxysmal atrial fibrillation episodes were reduced in patients with atrial pacing percentage lower than 90 % during DDDR pacing.

Pregnancy with an ICD and a documented ICD discharge.

We report a successful pregnancy in a patient affected by idiopathic ventricular fibrillation 3 years after insertion of an ICD, with a documented defibrillator discharge.

[Steatohepatic cirrhosis in a morbidly obese patient]. / Cirrosis esteatohepatítica en un paciente obeso mórbido.

Sixty to ninety percent of obese subjects show histological abnormalities of the liver. The hepatic lesion can be classified into one of the four following groups: steatosis, steatohepatitis, fibrosis and cirrhosis. The incidence of cirrhosis among patients with fatty liver changes ranges from 1.5% to 8%. The now abandoned surgery procedures performed for the treatment of morbid obesity (jejunoileal bypass) had left a negative experience: the onset of acute hepatic failure in subjects with no previous hepatic disease or the development of cirrhosis within one year of the bypass. Very low formula diets leading to precipitous weight loss in morbidly obese people induce metabolic changes similar to those observed after jejunoileal bypass. We report the case of a morbidly obese patient who had lost 40 kg of weight during the 6 months previous to his hospitalization. He came with signs of hepatic failure. He worsened rapidly and died in a month-time. The hepatic tissue obtained post-mortem showed a non alcoholic steatohepatitic cirrhosis.

External cardioversion of atrial fibrillation: role of paddle position on technical efficacy and energy requirements.

AIM: To define the effect of defibrillator paddle position on technical success and dc shock energy requirements of external cardioversion of atrial fibrillation. METHODS: 301 patients (mean (SD) age 62 (11) years) with stable atrial fibrillation were randomly assigned to elective external cardioversion using anterolateral paddle position (ventricular apex-right infraclavicular area; group AL (151 patients)) or anteroposterior paddle position (sternal body-angle of the left scapula; group AP (150 patients)). A step up protocol was used, delivering a 3 J/kg body weight dc shock, then a 4 J/kg shock (maximum 360 J), and finally a second 4 J/kg shock using the alternative paddle location. RESULTS: The two groups were comparable for the all clinical variables evaluated. The cumulative percentage of patients successfully converted to sinus rhythm was 58% in group AL and 67% in group AP with low energy dc shock (NS); this rose to 76% in group AL and to 87% in group AP with high energy dc shock (p = 0.013). Thirty seven patients in group AL and 19 in group AP experienced dc shock with the alternative paddle position; atrial fibrillation persisted in 10/37 in group AL and in 10/19 in group AP. Mean dc shock energy requirements were lower for group AP patients than for group AL patients, at 383 (235) v 451 (287) J, p = 0.025. Arrhythmia duration was the only factor that affected the technical success of external cardioversion (successful: 281 patients, 80 (109) days; unsuccessful: 20 patients, 193 (229) days; p < 0.0001). The success rate was lower if atrial fibrillation persisted for > 6 months: 29 of 37 (78%) v 252 of 264 (95%); p = 0.0001. CONCLUSIONS: An anteroposterior defibrillator paddle position is superior to an anterolateral location with regard to technical success in external cardioversion of stable atrial fibrillation, and permits lower dc shock energy requirements. Arrhythmia duration is the only clinical variable that can limit the restoration of sinus rhythm.

Antiarrhythmic benefits of dual chamber stimulation with rate-response in patients with paroxysmal atrial fibrillation and chronotropic incompetence: a prospective, multicentre study.

BACKGROUND: While the haemodynamic benefits of DDDR pacing compared with DDD pacing in patients with brady-tachy syndrome and chronotropic incompetence (CI) are well demonstrated, the antiarrhythmic advantage is controversial and so far not clearly demonstrated. AIM: We have performed a prospective, randomized, multicentre study to evaluate the efficacy of DDDR and DDD pacing modes in preventing paroxysmal atrial fibrillation (PAF) episodes in patients with brady-tachy syndrome and CI. METHODS AND RESULTS: Seventy-eight patients were included in the study. All patients had a dual chamber pacemaker implanted and were randomly programmed to DDD or DDDR with a cross over (DDD --> DDDR or vice versa) at 3 months. The final evaluation was performed at 6 months by means of two self-administered symptom questionnaires to evaluate activity. Symptoms of palpitations were analysed and scored. The patients were less symptomatic with the DDDR mode. The number of mode-switch activations compared with symptomatic episodes of PAF confirmed the high rate of asymptomatic PAF episodes in patients with brady-tachy syndrome. We conclude that in a small but well defined population of patients affected by sick sinus syndrome with CI and severely symptomatic PAF, DDDR pacing compared with DDD pacing may offer an additional antiarrhythmic benefit and should be considered the primary mode of pacing.

Modulation of ventricular rate in permanent atrial fibrillation: randomized, crossover study of the effects of slow-release formulations of gallopamil, diltiazem, or verapamil.

BACKGROUND: The management of permanent atrial fibrillation (PAF) consists primarily of long-term anticoagulation with either aspirin or warfarin to prevent systemic embolization, and modulation of ventricular rate (VR) to improve cardiac function by prolonging the ventricular diastolic filling time. HYPOTHESIS: The effects of slow-release formulations of gallopamil (100 mg b.i.d.), diltiazem (120 mg b.i.d.), or verapamil (120 mg b.i.d.) on VR were evaluated in 18 patients with PAF without organic heart disease. METHODS: In all patients, each treatment was administered randomly, was compared with oral digoxin, and was assessed by 24-h Holter monitoring during daily life and by a 6-min walking test. RESULTS: There were no significant differences in mean and minimum VR recorded during 24-h Holter monitoring among the four treatments. Peak heart rates recorded during the 6-min walking test with digoxin treatment was 167 +/- 12 beats/min. This was significantly reduced by gallopamil (149 +/- 23 beats/min, p = 0.01), diltiazem (142 +/- 24 beats/min, p < 0.001), and verapamil (137 +/- 30 beats/min, p < 0.001). There were no significant differences in peak VR during the walking test among the three calcium antagonists. Pauses of > 3 s were observed in 3 of 18 (17%) patients who received digoxin (max 3.4 s) and in 5 of 18 (28%) patients who received diltiazem (max 3.4 s); p = NS. Periods of bradycardia < 30 beats/min were observed in 5 of 18 (28%) patients during digoxin treatment, and in 3 of 18 (17%) patients during treatment with gallopamil, diltiazem, and verapamil; p = NS. CONCLUSION: Gallopamil, diltiazem, or verapamil are superior to digoxin in controlling VR during mild exercise in patients with PAF without organic heart disease. The reduction of peak VR is obtainable without further slowing of resting VR. However, gallopamil appears to be the least effective calcium blocker at controlling resting and exercise VR; thus, there are no advantages over the other calcium blockers in its use in the clinical setting.

Oral loading with propafenone: a placebo-controlled study in elderly and nonelderly patients with recent onset atrial fibrillation.

UNLABELLED: The efficacy and safety of propafenone as an oral loading dose (600-mg single oral dose) in converting recent-onset atrial fibrillation (< or = 7 days duration) to sinus rhythm were evaluated in a single-blind, placebo-controlled study according to patients' age. Overall, 240 hospitalized patients, NYHA Class < or = 2 without signs or symptoms of heart failure were enrolled: among patients aged < or = 60 years, 55 were allocated to propafenone treatment and 59 to placebo, respectively, and among patients aged > 60 years, 64 were allocated to propafenone treatment and 62 to placebo, respectively. RESULTS: In each age group, the likelihood of conversion to sinus rhythm was significantly greater after propafenone compared with placebo at 3 and 8 hours. For patients aged < or = 60 years, corresponding odd ratios were 3.78 (95% CI = 1.80-7.92, P = 0.04) at 3 hours and 4.74 (95% CI = 2.12-10.54, P = 0.02) at 8 hours; for patients aged > 60 years odd ratios were 5.03 (95% CI = 2.08-12.12, P = 0.02) at 3 hours and 6.75 (95% CI = 3.28-73.86, P = 0.01) at 8 hours, respectively. Logistic regression analysis showed that conversion to sinus rhythm within 3 hours was predicted by age < or = 60 years (P = 0.0064) and by propafenone treatment (P < 0.0001), and conversion to sinus rhythm within 8 hours was predicted by age < or = 60 years (P = 0.0467) and by propafenone treatment (P < 0.0001). The occurrence of adverse effects was observed in 14%-16% of propafenone treated patients and in 8% of placebo treated patients without significant differences according to age. In conclusion, in patients with recent-onset atrial fibrillation without signs of heart failure, propafenone as a single oral loading dose is effective. It is also effective in selected elderly subjects with a favorable safety profile. Moreover, spontaneous conversion to sinus rhythm appears to occur less frequently in elderly patients.

Conversion of recent-onset atrial fibrillation to sinus rhythm: effects of different drug protocols.

UNLABELLED: In a population of 417 hospitalized patients, the efficacy and safety of different drug regimens administered to convert atrial fibrillation (AF) of recent onset (< or = 7 days duration) to sinus rhythm were evaluated. All patients were in NYHA Class < or = 2, and free of heart failure. They were randomly allocated to treatment with placebo in 121 patients; i.v. amiodarone, 5 mg/kg bolus, followed by 1.8 g/24 hours in 51 patients; i.v. propafenone, 2 mg/kg bolus, followed by 0.0078 mg/kg/min in 57 patients; p.o. propafenone, 600 mg p.o. in a single dose in 119 patients; and p.o. flecainide, 300 mg p.o. in a single dose in 69 patients. All patients were continuously monitored by Holter ECG, and the number of conversions to sinus rhythm was measured at 1, 3, and 8 hours. RESULTS: (1) I.v. propafenone resulted in a higher conversion rate within 1 hour compared with the oral loading regimens of propafenone or flecainide, but the conversion rates at 3 and 8 hours were comparable, approximately 75% at 8 hours; 2) i.v. amiodarone was not different from placebo until 8 hours when it was associated with 57% of conversions; (3) conversion to sinus rhythm at 8 hours was observed in 37% of the placebo treated patients. Serious adverse effects occurred in few patients: two patients treated with flecainide and one treated with i.v. propafenone experienced left ventricular decompensation; one patient treated with placebo and two treated with flecainide had atrial flutter with rapid ventricular response. In conclusion, single-dose, oral loading with propafenone or flecainide are acceptable alternatives to conventional drug regimens in selected hospitalized patients. In addition, the measure of a placebo effect is mandatory in studies of recent-onset AF.

Randomized, crossover, controlled comparison of oral loading versus intravenous infusion of propafenone in recent-onset atrial fibrillation.

A population of 123 patients with recent-onset (< 72 hours) atrial fibrillation (AF) without heart failure was randomly treated with propafenone (PFN) intravenously (i.v.) (2 mg/kg bolus followed by 0.0078 mg/kg/min infusion) or in a single oral dose (o.s.) (600 mg), or with placebo (PLA) (phase 1). If AF persisted 8 hours later, patients on active drugs received the alternative formulation (crossover), and patients receiving PLA remained on PLA (phase 2). A 24-hour Holter monitoring was performed and conversion to sinus rhythm (SR) at 1, 4, and 8 hours of each phase was used as the criterion of efficacy. Conversion to SR occurred within 1 hour in 48% of patients with i.v.-PFN, 15% with o.s.-PFN, and in 17% with PLA (both P < 0.05 vs i.v.-PFN). Oral PFN was superior to PLA at 4 hours (71% vs 33%, P = 0.001) and 8 hours (78% vs 48%, P < 0.01), and 1 at 8 hours also superior to i.v.-PFN (53%, P < 0.03). The mean conversion time within 4 hours was shorter with i.v.-PFN (25 +/- 15') than with o.s.-PFN (167 +/- 166', P < 0.001) or with PLA (156 +/- 107', P < 0.001). The rates of conversion to SR with i.v.-PFN after o.s.-PFN failure were comparable to PLA at any observation time, whereas nonresponders to i.v.-PFN who received o.s.-PFN had significantly higher conversion rates than with placebo at both 4 hours (65% vs 19%) and 8 hours (76% vs 24%; both P < 0.045). Neither serious adverse effects nor episodes of regular tachycardia with 1:1 AV conduction were noted. PFN administered intravenously or in a single oral loading dose was safe and efficacious in converting recent-onset AF to SR. The rates of conversion were different with different routes of administration: i.v.-PFN was superior to o.s.-PFN over a short observation period, while the overall efficacy of o.s.-PFN was superior at 8 hours.

Oral propafenone to convert recent-onset atrial fibrillation in patients with and without underlying heart disease. A randomized, controlled trial.

BACKGROUND: The effectiveness of oral propafenone in converting recent-onset atrial fibrillation to sinus rhythm has been established by controlled trials. However, it is not clear whether the effectiveness of propafenone is affected by the presence or absence of underlying heart disease. OBJECTIVES: To investigate the safety and effectiveness of oral propafenone and the role of underlying heart disease. DESIGN: Randomized, single-blind, controlled study. SETTING: 3 teaching hospitals. PATIENTS: 240 hospitalized patients with recent-onset atrial fibrillation. INTERVENTION: Propafenone (one 500-mg oral dose) or placebo. MEASUREMENTS: Conversion rates at 3 and 8 hours. RESULTS: Propafenone was more effective than placebo for converting atrial fibrillation to sinus rhythm at 3 hours: Fifty-four of 119 patients (45%) receiving propafenone and 22 of 121 patients (18%) receiving placebo had conversion (P < 0.001). It was also more effective at 8 hours: Ninety-one of 119 patients (76%) receiving propafenone and 45 of 121 patients (37%) receiving placebo had conversion (P < 0.001). Subgroup analysis showed that among patients without heart disease, 78% of those receiving propafenone and 56% of those receiving placebo converted to sinus rhythm within 8 hours (P = 0.02). In those with hypertension, the rate was 70% for those receiving propafenone and 27% for those receiving placebo (P < 0.001); in patients with structural heart disease, the rate was 81% for those receiving propafenone and 17% for those receiving placebo (P < 0.001). CONCLUSIONS: Oral loading of propafenone was more effective than placebo for conversion to sinus rhythm within 8 hours and had a favorable safety profile. The rate of spontaneous conversion to sinus rhythm was higher in patients without structural heart disease; this finding has important implications for the assessment of drug effectiveness in recent-onset atrial fibrillation.

Conversion of recent onset atrial fibrillation to sinus rhythm using a single oral loading dose of propafenone: comparison of two regimens.

A population of 105 patients with recent onset (< 72 h) atrial fibrillation was randomly treated with propafenone as a single oral loading dose of 450 mg (Regimen A) or 600 mg (Regimen B) or with placebo. A 24-h Holter was performed. Criteria of efficacy were conversion to sinus rhythm at 2, 4 and 8 h compared to placebo and also significant reduction of mean ventricular rate in persistent atrial fibrillation. After 2 h, regimen B was more effective than either regimen A (43% vs. 8%; p = 0.001) or placebo (11%; p = 0.004). At 4 h, both the active treatments were more effective than placebo (17% vs. 46% regimen A and 57% vs. regimen B; p < 0.04 and p < 0.001, respectively). Sinus rhythm resumed within 24 h in 71%, 80% and 69% of the patients with regimen A, B and placebo, respectively (p = not significant). The mean ventricular rate reduction after 1 h was 8%, 11% and 4% for regimen A, B and placebo, respectively (p < 0.005 vs. regimen B), and 17%, 25% and 6% respectively (p < 0.001 placebo vs. regimen A and B, p < 0.05 regimen B vs. A) at 2 h. No major adverse effect occurred. Atrial flutter with 1:1 atrioventricular conduction only in one case who received placebo. Propafenone acute oral administration is more effective than placebo in rapidly converting recent-onset atrial fibrillation to sinus rhythm and may be the treatment of choice in this setting limiting hospitalization and contributing to improved quality of life.

Conversion of recent onset atrial fibrillation with single loading oral dose of propafenone: is in-hospital admission absolutely necessary?

A population of 283 patients with recent onset (< 72 hours) AF, without heart failure, who received a single 450- or 600-mg oral dose of propafenone, or digoxin 1 mg, or placebo for conversion to sinus rhythm (SR), was studied to determine whether a routine admission to the hospital for drug administration is justified. Previous bradyarrhythmias or sick sinus syndrome (SSS), and concomitant use of antiarrhythmic drugs were exclusion criteria. None of the 283 patients studied experienced VT or VF and none of them needed implantation of a temporary pacemaker. Periods of atrial tachyarrhythmias with regularization of atrial waves and 1:1 AV conduction were observed in only two cases, both receiving placebo. No predictor of proarrhythmia was found among the clinical variables considered (age, etiology, arrhythmia duration, atrial dimension, and blood potassium). No serious hemodynamic adverse effects were noted in either group. The rates of conversion to SR after 4 hours were: 80 (57%) of 141 patients who received propafenone and 35 (25%) of 142 patients who received digoxin or placebo (P < 0.001). Acute oral treatment with propafenone is simple and effective for the conversion of recent onset AF to SR in patients without clinical signs of heart failure. The routine admission of these patients to the hospital is not necessary. Home-based administration of oral propafenone to a selected group of patients could significantly increase the cost effectiveness of this treatment.