LETTER
Management of Atrial Fibrillation
Michael A. Brodsky;
Byron J. Allen; and
James G. Chun
15 September 1994 | Volume 121 Issue 6 | Pages 466-467
TO THE EDITOR:
Important miscalculations were made in a recently published Markov decision analysis of atrial fibrillation [1]. In their review comparing warfarin with no treatment, the authors considered randomized, placebo-controlled trials that evaluated intention to treat and all-cause mortality. This was only slightly altered regarding quinidine. When evaluating amiodarone, the authors considered open-label, nonrandomized studies and only looked at drug-associated mortality. Second, Disch and colleagues [1] may have underestimated the amiodarone-associated annual mortality rate at 0.09%. One study acknowledged that amiodarone proarrhythmia was underestimated and reported a 25% incidence of pulmonary fibrosis over 5 years, with a higher incidence in those older than 60 years of age [2]. A review of pulmonary fibrosis listed the mortality rate as 23% [3]. If the mortality rate related to pulmonary fibrosis were only 10%, the amiodarone-associated mortality rate would be at least 2% (20 times higher than 0.09%). Third, the Markov decision analysis relied on studies with short-term follow-up periods inadequate to analyze quality of life. Side effects of amiodarone often depend on the dose duration. We reported a few side effects over a 1.8-year follow-up period [4]. Over the next 5 years, however, most of our patients could not tolerate amiodarone and required dose reductions to subtherapeutic levels, resulting in a resumption of atrial fibrillation. Only Herre and colleagues [2] have published a report with a mean 5-year follow-up that evaluated long-term side effects. Herre [5] later cautioned about the side-effect profile of amiodarone for atrial fibrillation. Disch and colleagues also failed to compare the financial cost of amiodarone with that of other therapies. Amiodarone and its necessary follow-up laboratory testing are more expensive than the alternative therapies. We agree that amiodarone should be considered for the treatment of atrial fibrillation, but only in high-risk or refractory patients.
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Author and Article Information
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University of California, Irvine, Orange, CA 92668-3298
1. Disch DL, Greenberg ML, Holzberger PT, Malenka DJ, Birkmeyer JD. Managing chronic atrial fibrillation: a Markov decision analysis comparing warfarin, quinidine, and low-dose amiodarone. Ann Intern Med. 1994; 120:449-57.
2. Herre JM, Sauve MJ, Malone P, Griffin JC, Helmy I, Langberg JJ, et al. Long-term results of amiodarone therapy in patients with recurrent sustained ventricular tachycardia or ventricular fibrillation. J Am Coll Cardiol. 1989; 13:442-9.
3. Rakita L, Sobol SM, Mostow N, Vrobel T. Amiodarone pulmonary toxicity. Am Heart J. 1983; 106:906.
4. Brodsky MA, Allen BJ, Walker CJ 3d, Casey TP, Luckett CR, Henry WL. Amiodarone for maintenance of sinus rhythm after conversion of atrial fibrillation in the setting of a dilated left atrium. Am J Cardiol. 1987; 60:572-5.
5. Herre JM. A proposed trial of atrial fibrillation (Letter). Ann Intern Med. 1992; 117:972.
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