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Amiodarone
- Thread starter Ariee
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Carvedilol or metoprolol (probably the Toprol XL, once/day long acting one if I used metoprolol). I agree that amio has some nasty long term side effects...based on my experience the use of amio among cardiologists is variable. It didn't seem to be much used by the ones where I did residency but plenty of them still use it quite a bit at the place where I'm doing my fellowship. I like it fine for use in the hospital...for example for tachycardias in the ER especially...b/c can be safe for both VT and SVT and not as bad in wolf-parkinson-white as some of the AV node blockers.
Since the patient in your scenario already has a pacemaker, you can beta block the heck out of them to slow down the a. fib and not have to worry about making the patient too bradycardic.
You also don't say what the LVEF of the patient is. Remember if the LVEF is subnormal you don't want to use the antiarrhythmics like sotalol or propafenone b/c they can increase mortality in such patients. Also, if the LVEF is low, I'd prefer carvedilol over Toprol XL (though both would be good, the carvedilol has the edge in the patient with lower LVEF...COPERNICUS trial I think it was).
Since the patient in your scenario already has a pacemaker, you can beta block the heck out of them to slow down the a. fib and not have to worry about making the patient too bradycardic.
You also don't say what the LVEF of the patient is. Remember if the LVEF is subnormal you don't want to use the antiarrhythmics like sotalol or propafenone b/c they can increase mortality in such patients. Also, if the LVEF is low, I'd prefer carvedilol over Toprol XL (though both would be good, the carvedilol has the edge in the patient with lower LVEF...COPERNICUS trial I think it was).
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As always, if this is a personal case please heed the disclaimer about medical advice on these forums 🙂
The history is key here. Does the patient have CAD or HF? If so then flecainide and propafenone are out. Does the patient have contraindications (absolute or relative) to amiodarone such as severe lung or liver disease? Is the patient symptomatic enough to require an antiarrhythmic, or can the pt be managed with rate control medications in the presence of a pacemaker? How old is the patient, and what is their left atrial volume index?
Depending on the answers to these questions, if the patient is symptomatic, two viable options are catheter ablation (pulmonary vein isolation) and/or antiarrhythmics. Amiodarone is significantly more effective than all the other antiarrhythmics, so keep that in mind. If she has failed adequate doses of propafenone and sotalol in the past I would not go back to these. If the last time she tried antiarrhythmics was 15 years ago, then dofetilide (Tikosyn) is a new option to try if you want to avoid amiodarone. Dronedarone is also an option although I am not a fan; it seems to be fairly ineffective in my anecdotal experience.
The history is key here. Does the patient have CAD or HF? If so then flecainide and propafenone are out. Does the patient have contraindications (absolute or relative) to amiodarone such as severe lung or liver disease? Is the patient symptomatic enough to require an antiarrhythmic, or can the pt be managed with rate control medications in the presence of a pacemaker? How old is the patient, and what is their left atrial volume index?
Depending on the answers to these questions, if the patient is symptomatic, two viable options are catheter ablation (pulmonary vein isolation) and/or antiarrhythmics. Amiodarone is significantly more effective than all the other antiarrhythmics, so keep that in mind. If she has failed adequate doses of propafenone and sotalol in the past I would not go back to these. If the last time she tried antiarrhythmics was 15 years ago, then dofetilide (Tikosyn) is a new option to try if you want to avoid amiodarone. Dronedarone is also an option although I am not a fan; it seems to be fairly ineffective in my anecdotal experience.
