Pill in Pocket for Atrial Fib

[atpsynthase]

I recently had a patient who was instructed to use the pill in pocket method for what I assume is his paroxysmal atrial fib. He explains his atrial fib events as infrequent and was given metoprolol succinate (I would think the higher Cmax of tartrate may be more beneficial here??) 25 mg to take PRN "when in atrial fib for longer than 30 minutes"

I was under the impression that atrial fib can many times be asymptomatic and while come patients can identify when they are in atrial fib through a pulse check, some events go unnoticed... and it only takes ~48 hrs to form a thrombus... which also begs the question... should a CHADS2 score be involved somewhere here to determine proper level of anticoagulation?

Does anyone have any experience with the pill in the pocket method for controlling atrial fib or have any recommendations/literature to back it up or cut it down? Perhaps in PAF the risks of daily rate control medications outweigh the benefits?

I appreciate it! Thanks!

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[Instatewaiter]

Pill in the pocket is usually with propafenone or flecanide.

There is argument regarding AC. I would say there is probably enough AF you don't feel to warrant AC in a population with high enough risk

 

[muzzlenose]

I agre with instatewaiter. Pill in the pocket actually refers to using flecainide (sometimes propafenone) which are class IC antiarrhythmic drugs. Coronary artery disease must be absent as the CAST trial showed increased mortality using these drugs to suppress PVCs post MI. So to use a real "pill in the pocket" approach, a stress test must be done excluding coronary disease and the first attempt to use these drugs must be made in the hospital monitored as they can at times be proarrhythmic. Lastly, recall that these drugs MUST AT ALL TIMES be used with an AV blocking agent like a beta-blocker or CCB in order to prevent atrial fibrillation from turning into atrial flutter and conducting to the ventricles 1:1 which can cause very fast ventricular rates (250-300).