CARDIOVERSION FARMACOLOGICA PDF

The Framingham Study. N Engl J Med ; Petersen P, Godtfredsen J: Atrial fibrillation-a review of course and prognosis. Acta Med Scand ; ; JAMA ;

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The journal, published since , is the official publication of the Spanish Society of Cardiology and founder of the REC Publications journal family. Articles are published in both English an Spanish in its electronic edition. The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two receding years. CiteScore measures average citations received per document published.

Read more. SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact.

SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field. Patients with AF have a greater morbidity and mortality, and an increased risk of embolic events, which leads to a high percentage of permanent disability in survivors of stroke The recovery and maintenance of sinus rhythm has several potential benefits: an improved functional capacity and hemodynamic situation, relief of symptoms and reduction of the risk of embolism.

For that reason, this is one of the main goals of cardiologists when treating patients with AF. Traditionally, two types of cardioversion have been described, external electrical and pharmacological Recently, internal electrical cardioversion has been introduced into clinical practice and its initial results have been much better than those of external cardioversion, although its use is still not very widespread due to its greater technical complexity The recent development of defibrillators that can deliver a bi-phase rectilinear pulses as opposed to the traditional mono-phase pulses has also helped to improve the success rate with reduce the energy applied Although both classic types of cardioversion, pharmacological and external electrical, have been shown to be effective in restoring sinus rhythm, we have found no large studies comparing the effectiveness of both strategies.

On the other hand, both techniques have advantages and disadvantages. Pharmacological cardioversion 7,17 PCV is generally recommended in AF of less than 48 h evolution in patients with good hemodynamic tolerance and no relevant structural heart disease, with or without ventricular dysfunction, as well as in persistent AF as an alternative to electrical cardioversion ECV.

Both require clinical monitoring of the patient, although it must be stricter in the case of ECV, which is carried out under deep sedation.

The aims of the present study are a to compare the effectiveness and safety of both strategies in the case of chronic or persistent AF, and b to identify clinical or echocardiographic markers related with successful cardioversion. The present prospective study included consecutive patients who were selected in two provincial hospitals Hospital General de Alicante and Hospital General de Elche between February and January Patients had chronic or persistent AF of more than 48 h evolution and were candidates for the recovery of sinus rhythm by elective cardioversion according to the criterion of the cardiologist.

This is a comparative study of experimental nature without randomization. Most of the patients came from the outpatient clinics and, to a lesser extent, directly from the emergency area. Hemodynamically unstable patients who required urgent electrical cardioversion were excluded. Two main treatment groups were created, one assigned to synchronized external ECV, which was constituted by patients selected exclusively from the Hospital General de Alicante patients , and the other was assigned to PCV with quinidine and formed by patients selected from the Hospital General de Elche 86 patients.

Thirteen patients assigned to the pharmacological group without success, then assigned to a second attempt at CV by electrical discharge, which was performed at the same hospital. All patients signed an informed consent form before CV was performed.

The duration of the arrhythmia was determined by considering the time of onset of symptoms or of the abrupt deterioration of previously existing symptoms. In patients in whom the exact moment of onset of symptoms In every case, oral anticoagulation with acenocoumarol was begun at least 3 weeks before cardioversion, maintaining a stable range of anticoagulation, with INR 2.

Most patients took medication to control heart rate, basically beta-blockers, calcium antagonists, and digoxin, in a regimen established by the cardiologist responsible for the patient. All patients were hospitalized the day before cardioversion and underwent a differential blood count, basic biochemistry, and chest radiograph, as well as an electrocardiogram that confirmed the persistence of AF. In all patients, an echocardiographic study was made Hewlett-Packard Sonos , Andover, Massachusetts with M-mode bidimensional analysis to determine the ventricular diameters, wall thickness septum and posterior wall , and size of the left atrium in the longitudinal parasternal plane.

In addition, the existence of structural valve anomalies and significant cardiac valve disease was evaluated by continuous pulsed color Doppler study. ECV was carried out under deep sedation with diazepam and etomidate i. It began with a discharge of , or joules according to the criterion of the cardiologist in charge of cardioversion with the defibrillator paddles in standard anteroapical position.

If the first discharge was ineffective, shocks were repeated at progressively higher energies up to a maximum of 4 shocks , , and joules, respectively. PCV was carried out with quinidine sulfate, administering an oral dose of mg every 6 h the first 2 days, followed by a mg dose every 6 h for 48 h more, which was discontinued when sinus rhythm was restored.

The presence of a stable sinus rhythm was defined as success after the procedure and before releasing the patient. After cardioversion, the anticoagulation state of the patient was recorded, as estimated by the INR value. These records were completed by a physician not involved in the cardioversion process, and done after the procedure. The anticoagulation level was considered adequate when the INR was 2. Patients were followed-up for a month after cardioversion to detect delayed embolic events Techniques: total quinidine dose and days of treatment in the pharmacological group; number of discharges, maximum and total energy in the electrical group; duration of hospital stay and complications in both groups.

Clinical variables: Age, sex, history of previous AF, time since onset of AF in weeks , presence of hypertension, and body mass index. Echocardiographic variables: Size of left atrium, presence of structural heart disease, shortening fraction, left ventricular ejection fraction, and cardiac mass. The qualitative variables are expressed as percentages and the quantitative ones are expressed as mean and standard deviation. The normal distribution of the quantitative variables analyzed was confirmed by the Kolmogorov-Smirnov test.

To analyze the different variables, parametric tests were used. The chi-square test was used to compare two qualitative variables. To determine the association between quantitative and qualitative variables, the Student t test was used.

To study possible confusion variables, a multiple logistic regression model was made. A P of less than 0. The clinical and echocardiographic characteristics of the study population, overall and by assigned treatment groups, are described in Table 1. The groups were similar in clinical and echocardiographic characteristics. A tendency was found towards a greater incidence of hypertension, larger left atrium, and greater ejection fraction in the pharmacological group and more previous episodes of paroxysmal AF in the electrical group, although none of them reached statistical significance.

No significant differences were found between intervention groups pharmacological to electrical , in previous drug treatment, or when comparing the successful or unsuccessful CV groups. In Figure 1 are shown the percentages of success achieved after cardioversion, overall and by treatment groups. No statistically significant differences were found in the variables analyzed between the groups with successful and failed cardioversion Table 2.

There were no differences in the presence and number of previous episodes of AF, or the presence of hypertension or structural heart disease, including the presence of mitral valve disease. The same analysis was repeated separately in both the pharmacological and electrical groups, comparing the subgroups of successful and unsuccessful cardioversion in each group, but no significant difference was found between the variables analyzed.

Since the duration of AF had a very large standard deviation, a cut-off point was established at the average value 8 weeks. In both the overall group and ECV subgroup, patients with a duration of AF of less than 8 weeks had a higher rate of conversion to sinus rhythm P P. Success rate after cardioversion. Electrical cardioversion after failed pharmacological cardioversion.

Next to the sectors is indicated the absolute number of patients. This indicates that conversion was achieved most often after the first discharge and progressively decreased with the number of discharges administered.

In 55 patients, cardioversion began at J and was effective in In 76 patients, cardioversion began at J and was effective in In spite of this, no embolic complications were found during the acute phase or the next month of follow-up. Only 2 patients presented arrhythmic complications during the cardioversion process: an episode of bradycardia that required pharmacological treatment in the electrical group and a torsade des pointes in the group treated with quinidine.

Current recommendations for the treatment of persistent AF 9,14,25,26 indicate that we should try to recover sinus rhythm by external or pharmacological electrical cardioversion if the clinical profile of the patient allows. However, this recommendation is being debated and a discussion is underway as to which of the following two options is best: cardioversion and aggressive efforts to maintain sinus rhythm, or control of heart rate in the presence of baseline AF.

Another current topic of debate is the potential benefit, in terms of improved quality of life, of recovering sinus rhythm in persistent or chronic AF. Until these studies conclude, most authors 8, 21, 30 feel that an attempt must be made to recover sinus rhythm, PCV being most useful in patients with paroxysmal AF of less than 48 h evolution. From this time on, its effectiveness greatly diminishes Our results confirm a high rate of effectiveness for the conversion to sinus rhythm of patients with persistent AF the mean duration of the arrhythmia in our group was 25 weeks.

The success rate was similar with both strategies but, since it was not a randomized study, a critical analysis must be made to compare the effectiveness of the two strategies. The rates of conversion to sinus rhythm buy ECV that we obtained were similar to those seen in previously published series The differences between studies in the success rates of quinidine seem to be due to differences in the groups analyzed, fundamentally the time since onset of AF which suggests that quinidine is less beneficial in AF of less than 48 h evolution 37 and the different pharmacological regimes used.

The meta-analysis of Coplen et al indicates a higher incidence of death with quinidine versus placebo Nevertheless, this study has important limitations because the groups of patients were very heterogeneous and had a higher incidence of baseline heart disease. A recent meta-analysis 45 that analyzed the long-term use of this drug found a low mortality rate, similar to that obtained with drugs considered safer. Therefore, the main problem of proarrhythmia fundamentally in the form of torsade des pointes and sudden death with quinidine seems to be limited to the first days of treatment, especially in the subgroup of patients with depressed systolic function.

In addition, this side effect is not dose-dependent, the appearance of which depends on individual drug tolerance idiosyncratic reaction. In our group we found a success rate similar to that obtained with ECV, and a very low rate of arrhythmic complications, only one case of torsade des pointes in 86 patients treated 1.

We must emphasize that, of all clinical and echocardiographic parameters analyzed, only duration of AF of less than 8 weeks was predictive of successful cardioversion, both overall and in the ECV subgroup 46, No differences were found in the PCV subgroup, possibly due to the high success rate and size of the sample.

Nevertheless, it was not possible to identify subgroups of patients who benefit more from one strategy than the other.

This could be related with a sample size that was too small to find significant differences, or with the possibility that the factors traditionally implicated in the reappearance of AF age, hypertension, systolic dysfunction, left atrial size are not directly related with the immediate success of c ardioversion.

Likewise, the practical absence of relevant structural heart disease, as indicated by the echocardiographic parameters within normal range in our group, could explain these findings. Nevertheless, the number of patients who benefited from a fourth shock is low 2 of 35 patients in our group.

The success rate was greater with higher initial discharges. In patients in which cardioversion began with J, the failure rate was very high and a new discharge was required, thus increasing the final total energy. Nevertheless, when the initial discharge was J, the success rate was greater and the total energy applied was less than in those that began with J. These findings justify the present tendency to initiate electrical cardioversion at J 30, If after 2 days of failed treatment, it is advisable to continue with ECV, which reduces the hospital stay.

In this subgroup, the rate of conversion was high, so the failure of one technique does not seem to predict the failure of the other and it seems justified to attempt ECV after a preliminary failure. In our study, PCV was not attempted in any patient in which ECV had failed, which is why results cannot be extrapolated to the other treatment.

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The journal, published since , is the official publication of the Spanish Society of Cardiology and founder of the REC Publications journal family. Articles are published in both English an Spanish in its electronic edition. The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two receding years. CiteScore measures average citations received per document published.

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