Despite the introduction of new alternatives, amiodarone remains the most effective antiarrhythmic drug for maintaining sinus rhythm in patients with atrial fibrillation.
Amiodarone may remain preferred for AF rhythm control; reinforces prior syntheses but leaves open need for safer alternatives in trials.
Atrial fibrillation (AF) is the most common heart rhythm disturbance, effecting more than six million individuals in North America, Europe, and Japan. Atrial fibrillation is associated with increased morbidities, including thrombo-embolism, stroke, and decreased cardiac function. However, some patients experience debilitating symptoms and decreased quality of life for which elimination of the arrhythmia is an important goal. Although AF ablation is quickly expanding to treat some of these patients, first-line therapy remains antiarrhythmic drugs (AADs). Furthermore, there are many patients with symptomatic AF who are not candidates for ablation due to associated comorbidity. Thus, there remains a great interest in pursuing novel AAD therapy. In spite of numerous available AADs and introduction of new alternatives, the most effective available antiarrhythmic remains amiodarone. 1‐3 No oral AAD to date has proven efficacy superior to amiodarone for long-term maintenance of sinus rhythm. 4 This is in part due to the fact that amiodarone has several mechanisms of action on cardiac conduction. In addition to traditional class III effects, amiodarone also has beta-blocker, calcium channel blocker, and sodium channel blockade effects. The iodine moiety may also have independent antiarrhythmic effects. In the Canadian Trial of Atrial Fibrillation (CTAF), 1 amiodarone was shown to be superior to both class Ic (propafenone) and other class III (sotalol) AADs. After 1 year, the calculated probability of remaining in sinus rhythm was 69% for patients on amiodarone compared with only 39% in the sotalol/propafenone group. In another study by Singh et al., 2 amiodarone was again shown to be superior to sotalol, with a median time to recurrence of 487 days compared with 74 days in the sotalol group. Furthermore, amiodarone is effective in reducing AF burden without causing proarrhythmia, particularly in patients with congestive heart failure or structural heart disease. 5 Amiodarone has been shown to be effective in preventing AF in heart failure patients. 5 Only dofetilide has been shown to have a comparable efficacy profile in heart failure, but with a 3.3%
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Abhinav Verma (2008) studied this question.
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