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Ideas and Opinions |

Is There a Role for Maintaining Sinus Rhythm in Patients with Atrial Fibrillation?

Peter Zimetbaum, MD; and Mark E. Josephson, MD
[+] Article and Author Information

From Beth Israel Deaconess Medical Center, Boston, Massachusetts.


Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Peter Zimetbaum, MD, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Boston, MA 02215.

Current Author Addresses: Drs. Zimetbaum and Josephson: Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Boston, MA 02215.


Ann Intern Med. 2004;141(9):720-726. doi:10.7326/0003-4819-141-9-200411020-00015
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Recent studies have indicated that outcomes in patients with atrial fibrillation who are managed with rate control and anticoagulation are similar to those in patients who have maintenance of sinus rhythm. These studies did not include important groups of patients with atrial fibrillation in whom antiarrhythmic therapy may be appropriate. This perspective argues for the maintenance of sinus rhythm and for the use of antiarrhythmic therapy that includes medications, invasive procedures, and a combination of both in appropriate patients.

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The Dry Pipeline of Antiarrythmic Therapies
Posted on November 1, 2004
Amnon Schlegel
Univesity of California, San Francisco
Conflict of Interest: None Declared

To the Editor:

Zimetbaum and Josephson are confident that "new approaches to drug development and screening for risk for adverse events may ultimately reduce the toxicity of these agents (1)."

Unfortunately, this optimism has fallen on deaf ears in the pharmaceutical industry: the only "new" drugs to treat atrial fibrillation are dofetilide, ibutilide, and azimilide (2,3). These class III antiarrythmics, far from being bold breakthroughs in the management of atrial fibrillation, are "niche" players (2) whose long-term efficacy and toxicity are matters of speculation (3).

The remaining antiarrythmics the authors advocate for those who fail rate control, have contraindications to systemic anticoagulation, or who were otherwise excluded from the AFFIRM study based on age or comorbidites(4); have very high toxicities including lethal arrhythmias. Furthermore, their dosing is a matter of heated debate, and their monitoring is difficult and expensive. Large trials using the "hybrid" therapies they advocate should be organized to determine if the combination of expensive and marginally therapeutic drugs and ablative procedures are better than rate control (4,5).

References: 1. Zimetbaum P, Josephson ME. Is there a role for maintaining sinus rhythm in patients with atrial fibrillation? Ann Intern Med. 2004;141:720-6

2. Sing BN, Sarma, JSM. What niche will newer class III antiarrythmic drugs occupy? Curr Cardiol Rep. 2001;3:314-23. [PMID: 11406090]

3. Naccarelli GV, Wolbrette DL, Bhatta L, Khan M, Hynes J, Samii S, Luck J. A review of clinical trials assessing the efficacy and safety of newer antiarrhythmic drugs in atrial fibrillation. J Interv Card Electrophysiol. 2003;9:215-22. [PMID: 14574034]

4. Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, et al.. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347:1825-33. [PMID: 12466506]

5. Marshall DA, Levy AR, Vidaillet H, et al. Cost- Effectiveness of Rhythm versus Rate Control in Atrial Fibrillation. Ann Intern Med. 2004; 141:653-661.

Conflict of Interest:

None declared

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