Guide safe use of antiarrhythmics for atrial fibrillation

Flecainide or propafenone can be good options in atrial fibrillation. But they’re only for select patients, such as those withOUT heart failure...

As a clinical pharmacist, you will see antiarrhythmics used more often for “rhythm control” in some patients with atrial fibrillation. Older data found that reducing frequency and duration of atrial fibrillation with antiarrhythmics doesn’t reduce mortality versus rate control with beta-blockers, CCBs, and may increase hospitalizations.

Now data suggest that rhythm control may benefit patients with onset of atrial fibrillation in the last year who are at high CV risk. This early rhythm control strategy prevents 1 CV death, stroke, or CV hospitalization for every 91 of these patients treated for about 5 years, versus rate control alone. But about 2% of patients have serious adverse effects. Keep in mind, rhythm control should be COMBINED with usual management, including anticoagulation, and rate control as needed. Collaborate with cardiology colleagues to ensure safe antiarrhythmic use, considering CV history, risks, etc.

For instance, flecainide or propafenone can be good options in atrial fibrillation. But they’re only for select patients, such as those withOUT heart failure, since these medications reduce contractility, and withOUT ischemic heart disease, due to increased mortality risk. As either of these medications control atrial fibrillation, they may lead to other dangerous rhythms. Ensure patients also get a beta-blocker or CCB to slow A-V node conduction and limit proarrhythmic effects. And educate that either medication may cause minor visual effects, such as seeing spots, and propafenone can cause a metallic taste.

On the other hand, amiodarone may be used when other antiarrhythmics can’t be, such as for some patients with heart failure. It’s the most effective antiarrhythmic but carries the most baggage. Emphasize the importance of sticking to routine follow-up and monitoring, including liver, thyroid, lung function, and eye exams. Review interaction alerts closely and be ready to adjust medications. For example, amiodarone increases direct oral anticoagulant levels. Generally, avoid rivaroxaban (Xarelto) with amiodarone if CrCl is under 80 mL/min. But it’s usually okay to use apixaban (Eliquis).

References

Kirchhof P, Camm AJ, Goette A, Brandes A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020 Oct 1;383(14):1305-1316.
Camm AJ, Naccarelli GV, Mittal S, et al. The Increasing Role of Rhythm Control in Patients With Atrial Fibrillation: JACC State-of-the-Art Review. J Am Coll Cardiol. 2022 May 17;79(19):1932-1948.
Lacoste JL, Szymanski TW, Avalon JC, Kabulski G, Kohli U, Marrouche N, Singla A, Balla S, Jahangir A. Atrial Fibrillation Management: A Comprehensive Review with a Focus on Pharmacotherapy, Rate, and Rhythm Control Strategies. Am J Cardiovasc Drugs. 2022 Sep;22(5):475-496.
Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498.