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Make the diagnosis
Based on your diagnosis of this ECG*, would flecainide be suitable
as a first-line treatment strategy for this patient?
A. No, the ECG does not indicate the presence of AF
B. No, the ECG indicates AF and a history of myocardial infarction
C. Yes, the ECG indicates the presence of AF
(Answer will be discussed in the next newsletter)
*This ECG image is sourced from www.cardiophile.org and distributed according to a Creative
Commons Attribution-Noncommercial-Share Alike 3.0 Unported License
(http://creativecommons.org/licenses/by-nc-sa/3.0/)
Answer to the ECG published in Rhythm & Rate issue 5
According to this ECG, 1 should the patient be treated with flecainide?
Answer: 1 ‘The ECG is from a case of advanced hypertrophic cardiomyopathy
with AF. AF is suggested by the presence of irregular fibrillary waves. A
large amplitude in chest leads overlapping between the leads is evident
in the QRS complexes. Severe left ventricular hypertrophy is indicated by
deep S waves in anterior leads, tall R waves in lateral leads and gross ST
segment depression with T wave inversion in lateral leads. Left bundle
branch block is mimicked by an increase in the QRS width to approximately
120 ms. Development of atrial fibrillation leads to cardiac decompensation
in hypertrophic cardiomyopathy due to loss of atrial kick.’
Therefore, due to the presence of cardiomyopathy (indicated by severe
LV hypertrophy and left bundle branch block) and AF at the time of the
ECG recording the answer is ‘b) No, because the patient has atrial fibrillation
with comorbid advanced hypertrophic cardiomyopathy’. Treatment with
flecainide is contraindicated in this patient. 2
References
1. Cardiophile MD. Available at http://cardiophile.org/2009/01/hypertrophic-cardiomyopathy-with-atrial-fibrillation/,
accessed Feb 2011;
2. Tambocor® Summary of Product Characteristics 2009
Where to go for more information
MEDA: www.meda.se | European Society of Cardiology: www.escardio.org | Heart Rhythm Society: www.hrsonline.org
WHO prevention of cardiovascular disease guidelines: http://www.who.int/cardiovascular_diseases/guidelines/Pocket_GL_information/en/
index.html
Förskrivarinformation Tambocor
Produkt Beredningsform Styrka (mg) Antal (st)
Tambocor® Tablett 100 20, 100
Tambocor® Retard Depotkapsel 100 30
Tambocor® Retard Depotkapsel 200 30
Inital dos: Tambocor® 100 mg två gånger dagligen
Stegvis ökning: V ärde dag till maximalt 200 mg två gånger dagligen.
Underhållsbehandl: Pa ektiv dos med Tambocor® tabletter enligt ovan,
därefter kan patienten ställas på motsvarande dos Tambocor® Retard en
gång dagligen.
Kontakta oss gärna om ni har några frågor eller funderingar.
Vänliga hälsningar
Olle Karlsson
Medical Advisor
Medical Department Nordic Region, Meda AB
Tel: 08 630 19 32, Mob: 0733 16 94 51
E-post: olle.karlsson@meda.se
Meda AB, Besöksadress: Pipers väg 2 A, Box 906, 170 09 Solna. Telefon 08–630 19 00 • www.medasverige.se • arytmiguiden.se • info@meda.se
Tambocor ® ( ekainid) och Tambocor ® Retard ekainid):
Terapeutiska indikationer: Profylax och behandling av
livshotande ventrikulär takyarytmi. Profylax och behandling
av allvarliga supraventrikulära takyarytmier,
som inte svarat på annan behandling, hos patienter
med WPW-syndrom utan tecken på annan hjärtsjukdom
(i synnerhet utan tecken på vänsterkammarsvikt
och/eller fastställd koronarsjukdom). Profylax och
behandling av allvarliga symptomatiska paroxysmala
fö adder hos patienter utan strukturell
hjärtsjukdom (i synnerhet utan vänsterkammarsvikt
och/eller fastställd koronar-sjukdom) där annan behandling
inte haft ekt eller har gett oacceptabla
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Professor Paulus Kirchhof
T h e I n t e r n a tio nal New s lett e r
June 2012, Issue 6
Professor Paulus Kirchhof practices interventional cardiology at Sandwell and West Birmingham Hospitals NHS Trust in Birmingham,
UK, and is the Chair in Cardiovascular Medicine at the University of Birmingham. He is also aliated with the Department of
Cardiology and Angiology at the University of Münster, Germany. He graduated from Münster Medical School after studying Medicine
in Heidelberg, Germany, and at Georgetown University, USA. Among others, he sits on the steering committee of the German Atrial
Fibrillation competence NETwork (AFNET), chairs the Scientific Documents Committee of the European Heart Rhythm Association
(EHRA) and is a member of the European Society of Cardiology Committee for Practice Guidelines. His main research interests are atrial
fibrillation (AF) and cardiomyopathies ‘from molecule to man’, and he has published over 150 scientific papers in his field of expertise.
Let’s talk
1. What do you think are the advantages of controlling the heart rhythm versus the
frequency of heart beat?
There are several conceptual advantages of maintaining sinus rhythm (SR),
eg reduction in AF-associated mortality and cardiovascular (CV) risk factors.
Although there are presently no data to support these hypotheses, there are a
few large trials underway. A landmark study coordinated by AFNET and EHRA to
address this issue is the Early prevention of Atrial fibrillation for Stroke prevention
Trial (EAST) which has started to enrol 3000 patients in 11 EU nations. 1 This study
is investigating if early rhythm control therapy (administered directly after AF
diagnosis) can reduce AF-associated CV complications with a reported outcome
expected within the next 5 years.
2. What are the benefits of early AF management?
Epidemiological studies show excess mortality clustered within the first year of
AF diagnosis. Furthermore, the early period of AF is a window of opportunity
to potentially prevent further AF-related complications, and to more eectively
and safely maintain SR. Early therapy could therefore prevent AF-related atrial
remodelling, and help to reduce AF-related complications. Again, we do not
yet have data that demonstrate these benefits in patients undergoing rhythm
control therapy, but it is tempting to speculate that they would exist.
3. What are the main factors that you consider when choosing a pharmacological
agent for AF management?
Anti-arrhythmic drugs remain an important means to maintain SR even though
catheter ablation is becoming increasingly available. The two main types of
anti-arrhythmic drug therapy are short-term pharmacological cardioversion
of AF and long-term maintenance of SR. We know from clinical experience that
pharmacological cardioversion works best in patients with recent onset of AF
(

What’s in the literature?
Pharmacological conversion of recent atrial fi brillation: a randomized,
placebo-controlled study of three antiarrhythmic drugs
Balla I et al. Anadolu Kardiyol Derg 2011;11:600–606
Objective:
To compare the e cacy and safety of the oral administration of three
anti-arrhythmic drugs – amiodarone, fl ecainide and propafenone – in
cardioversion in patients with recent onset of AF (within 48 hours).
Design:
This randomised prospective, placebo-controlled, single-blind study included
160 patients; 40 patients per treatment group. The treatment groups involved
one of: single oral doses of amiodarone (30 mg/kg of body weight), fl ecainide
(3 mg/kg of body weight), propafenone (8.5 mg/kg of body weight), or
placebo. E cacy and safety were assessed at the time of drug ingestion, 3, 6,
12 and 24 hours following drug intake by 12-lead ECGs.
The primary endpoint of the study was the rate of conversion 24 hours after
drug intake.
Key fi ndings:
The primary endpoint was achieved by 87.5% of patients treated with
fl ecainide, 85% treated with amiodarone, 85% treated with propafenone, and
17.5% of patients in the placebo group (Figure A). A greater proportion of
patients receiving fl ecainide and propafenone converted to SR within 6 hours
after drug intake compared with amiodarone and placebo. Amiodarone
showed the highest e cacy beyond 6 hours (Figure A). No signifi cant
adverse events (SAEs) occurred with any of the drug treatments. Additional
independent predictors of conversion of AF to SR are shown in Figure B.
Figure B: Predictors of AF conversion to SR
Adjusted odds ratio (95% CI)
3
2.5
2
1.5
1
0.5
aOR: 0.34;
p