TO THE EDITOR:
In their otherwise excellent review of intravenous amiodarone for arrhythmia management [1], Desai and colleagues misquoted the first reference they cited for the comparison of amiodarone with propafenone in conversion of recent-onset atrial fibrillation (reference 34 in their article, cited on page 297). This trial actually compared prophylactic amiodarone with placebo for the prevention of supraventricular and ventricular tachyarrhythmias in 77 patients recovering from coronary artery bypass surgery [2]. The investigators did not randomly assign patients to either propafenone or flecainide as stated by Desai and colleagues. Amiodarone and propafenone for conversion of atrial fibrillation or flutter to sinus rhythm in the post-operative setting were recently compared in a randomized trial [3]. Although eventual success rates did not differ significantly for both drugs (77% for amiodarone and 67% for propafenone), propafenone resulted in earlier reversion to sinus rhythm. Similar findings have been reported in other clinical settings, but some still consider amiodarone the drug of choice in patients with paroxysmal atrial fibrillation and left ventricular dysfunction or acute myocardial infarction because of its less potent negative inotropic effect [4].
Desai and colleagues provide no data to support their assumption on the relative cost-effectiveness of amiodarone and other drugs used for recent-onset atrial fibrillation. Given this and the significant rate of early adverse cardiac events in patients with atrial fibrillation receiving other antiarrhythmic drugs [5], amiodarone should be considered a first-line agent for cardioversion of selected patients with recent-onset atrial fibrillation or flutter.
1. Desai AD, Chun S, Sung RJ. The role of intravenous amiodarone in the management of cardiac arrhythmias. Ann Intern Med. 1997; 127:294-303.
2. Hohnloser SH, Meinertz T, Dammbacher T, Steiert K, Jahnchen E, Zehender M, et al. Electrocardiographic and antiarrhythmic effects of intravenous amiodarone: results of a prospective, placebo-controlled study. Am Heart J. 1991; 121:89-94.
3. Larbuisson R, Venneman I, Stiels B. The efficacy and safety of intravenous propafenone versus intravenous amiodarone in the conversion of atrial fibrillation or flutter after cardiac surgery. J Cardiothorac Vasc Anesth. 1996; 10:229-34.
4. Fresco C, Proclemer A. Clinical challenge II. Management of recent onset atrial fibrillation. PAFIT-2 investigators. Eur Heart J. 1996; 17(Suppl C):41-7.
5. Maisel WH, Kuntz KM, Reimold SC, Lee TH, Antman EM, Friedman PL, et al. Risk of initiating antiarrhythmic drug therapy for atrial fibrillation in patients admitted to a university hospital. Ann Intern Med. 1997; 127:281-4.
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