From the Guidelines
The primary goal of anti-arrhythmic therapy in patients with arrhythmias is to improve symptoms and quality of life by reducing AF-related symptoms, rather than solely focusing on maintaining sinus rhythm. According to the 2016 ESC guidelines for the management of atrial fibrillation 1, the aim of antiarrhythmic drug therapy is to improve AF-related symptoms, and the decision to initiate long-term antiarrhythmic drug therapy should balance symptom burden, possible adverse drug reactions, and patient preferences.
The principles of antiarrhythmic drug therapy outlined in the guidelines include:
- Treatment is aimed at reducing AF-related symptoms;
- Efficacy of antiarrhythmic drugs to maintain sinus rhythm is modest;
- Clinically successful antiarrhythmic drug therapy may reduce rather than eliminate the recurrence of AF;
- If one antiarrhythmic drug ‘fails’, a clinically acceptable response may be achieved with another agent;
- Drug-induced pro-arrhythmia or extracardiac side-effects are frequent;
- Safety rather than efficacy considerations should primarily guide the choice of antiarrhythmic drug.
It's also important to consider the type of arrhythmia, patient characteristics, and comorbidities when choosing an anti-arrhythmic medication, as noted in the acc/aha/esc 2006 guidelines for the management of patients with atrial fibrillation 1. For example, in patients with heart failure, amiodarone and dofetilide are recommended for maintenance of sinus rhythm, while in patients with coronary artery disease, beta blockers may be considered first.
Overall, the goal of anti-arrhythmic therapy is to improve symptoms and quality of life, while minimizing the risk of adverse effects and considering individual patient factors, as supported by the most recent and highest quality evidence 1.
From the FDA Drug Label
In patients without structural heart disease, propafenone is indicated to prolong the time to recurrence of – paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms. Propafenone HCl is also indicated for the treatment of – documented ventricular arrhythmias, such as sustained ventricular tachycardia, that, in the judgment of the physician, are life-threatening Amiodarone taken concomitantly with other antiarrhythmic therapy should be reserved for patients with life-threatening ventricular arrhythmias who are incompletely responsive to a single agent or incompletely responsive to amiodarone
The goal of anti-arrhythmic therapy with propafenone or amiodarone in a patient with arrhythmia is to:
- Prolong the time to recurrence of paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms
- Treat documented ventricular arrhythmias, such as sustained ventricular tachycardia, that are life-threatening
- Reserve combination therapy for patients with life-threatening ventricular arrhythmias who are incompletely responsive to a single agent 2, 3 Key points:
- Propafenone is indicated for patients without structural heart disease
- Amiodarone can be used in combination with other antiarrhythmic therapy for life-threatening ventricular arrhythmias
- The goal of therapy is to improve symptoms and prevent life-threatening arrhythmias, not to enhance survival 2
From the Research
Goal of Anti-Arrhythmic Drugs
The primary goal of anti-arrhythmic drugs in patients with arrhythmia is to:
- Restore and maintain a normal heart rhythm
- Reduce symptoms and improve exercise tolerance
- Improve quality of life
- Prevent complications associated with arrhythmia, such as stroke and heart failure 4, 5
Types of Anti-Arrhythmic Drugs
There are several types of anti-arrhythmic drugs available, including:
- Class 1C agents, such as flecainide and propafenone
- Class III agents, such as amiodarone, dronedarone, and sotalol
- Beta-blockers, such as metoprolol and carvedilol
- Calcium channel blockers, such as diltiazem and verapamil 4, 5, 6, 7
Efficacy of Anti-Arrhythmic Drugs
Studies have shown that:
- Amiodarone is the most effective anti-arrhythmic drug for maintaining sinus rhythm and reducing the incidence of hospitalization due to cardiovascular events or death in patients with atrial fibrillation 4, 5
- Class 1C agents and sotalol are also effective for rhythm control, while dofetilide has similar efficacy to dronedarone 4
- Beta-blockers and calcium channel blockers are commonly used for rate control, with beta-blockers being more potent for rapid reduction of heart rate 6
- Calcium channel blockers may be more effective than beta-blockers in improving exercise capacity and reducing N-terminal pro-B-type natriuretic peptide levels in patients with permanent atrial fibrillation 7
Treatment Considerations
Treatment with anti-arrhythmic drugs should be individualized to the patient, taking into account their specific condition, medical history, and potential risks and benefits of each drug 5, 8