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15 March 1994 | Volume 120 Issue 6 | Pages 449-457
Objective: To compare the relative risks and benefits of several clinical strategies for managing patients with chronic atrial fibrillation.
Design: Five recent randomized controlled trials of warfarin in atrial fibrillation, 6 randomized controlled trials of quinidine, and 13 longitudinal studies of low-dose amiodarone were used. A MEDLINE search was also done (1966 to present).
Measurements: A Markov decision analysis model was used to assess outcomes in large, hypothetical cohorts of patients with atrial fibrillation followed from 65 to 70 years of age within four clinical strategies: 1) no treatment; 2) warfarin; 3) electrical cardioversion followed by quinidine to maintain normal sinus rhythm; and 4) electrical cardioversion followed by low-dose amiodarone.
Results: In this hypothetical cohort, fewer patients had disabling events with amiodarone (1.4%) than with quinidine (1.8%), warfarin (2.6%), or no treatment (7.4%). Amiodarone appeared to be associated with the lowest 5-year mortality (13.6%) when compared with warfarin (14.4%), quinidine (15.2%), and no treatment (18.2%). In terms of quality-adjusted life-years, amiodarone had the highest expected value (4.75 years), followed by warfarin (4.72 years), quinidine (4.68 years), and no treatment (4.55 years). Amiodarone remained the preferred strategy using the most plausible scenarios of risks associated with atrial fibrillation. Choices among warfarin, quinidine, and no treatment depended on estimates of bleeding rates with warfarin, stroke rates after discontinuing warfarin, quinidine-related mortality, and the quality of life with warfarin.
Conclusion: Cardioversion followed by low-dose amiodarone to maintain normal sinus rhythm appears to be a relatively safe and effective treatment for patients with chronic atrial fibrillation.
Author and Article Information
From the Department of Veterans Affairs Medical Center, White River Junction, Vermont; Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
ARTICLE
Managing Chronic Atrial Fibrillation: A Markov Decision Analysis Comparing Warfarin, Quinidine, and Low-Dose Amiodarone
Request for Reprints: Dennis L. Disch, MD, Cardiovascular Division, Washington University School of Medicine, 660 South Euclid Avenue, Box 8086, St. Louis, MO 63110.
Acknowledgments: The authors thank Drs. H. Gilbert Welch, Robert A. Nease, and Harold C. Sox, Jr., for their helpful critiques of the decision model and the manuscript.
Grant Support: Dr. Disch was supported by the Veterans Affairs fellowship in ambulatory care. Dr. Birkmeyer was supported by a training grant from the National Library of Medicine (NIH 5 T15 LM07044).
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