Controversies in the “pill in the pocket” approach to atrial fibrillation

Abstract

The efficacy of class I antiarrhythmic drugs in terminating atrial fibrillation (AF) has been proven. Both intravenous and oral administration of propafenone and flecainide restore sinus rhythm in a high percentage of cases [1][2][3][4][5]. Furthermore, in selected patients, the possibility of home self-administration of one of these drugs has been studied and is deemed safe for treating the sudden onset of heart palpitations [6]. Indeed, the recurrence of AF is responsible for a number of emergency department (ED) visits and hospital admissions. The ''pill in the pocket'' approach has proven to be effective in reducing this phenomenon. We report two cases we observed at our ED which could be the launching pad for both discussion and criticism about the ''pill in the pocket'' approach that is receiving increasing attention and ever-growing application in Italy. Case reportsCase 1 A 65-year-old man was admitted to our observation ward because of palpitations that had been going on for 6 h. He had a history of mild hypertension, treated with atenolol 100 mg and hydrochlorothiazide 12.5 mg. Over the last 2 years he had been hospitalized twice because of two episodes of AF which had required cardioversion with propafenone. During these previous admissions, severe cardiomyopathy, left ventricular dysfunction, severe valvular heart disease, and arrhythmic episodes other than atrial fibrillation had been ruled out. Two hours before being admitted to our ED he had taken 600 mg of propafenone as recommended, but after taking the medication his symptoms worsened. Blood pressure and physical examination were normal. Routine biochemical laboratory tests were normal as well. Electrocardiogram (ECG) showed a sinus rhythm with a variable heart rate (45-90 bpm) and a previously existing incomplete left bundle branch block, but transient sinus atrial blocks. The patient was monitored in the ED because he was symptomatic for pre-syncope. One hour after admission his ECG showed sinus arrest with a prolonged asystole (Fig. 1). The patient regained normal sinus rhythm after 24 h of complete drug wash-out. He was discharged after 48 h and sent to a cardiologist for a consult.Case 2 A 70-year-old woman with a history of hypertension, who was being treated with atenolol 50 mg, was brought to our ED because of palpitations. She realized that it could have been high rate AF because she had already had two previous transient episodes of arrhythmias, the first of which was treated by electrical cardioversion, and a second one which was treated by intravenous propafenone. Severe cardiomyopathy had been ruled out, and the physicians had advised the patient to take 425 mg of propafenone if AF recurred. She was also being treated with recommended dose of warfarin. Therefore, she had immediately taken this oral dose of propafenone, but nonetheless, she required medical evaluation in our ED. AF with a heart rate of approximately 200 bpm was observed at admission, but the patient showed no clinical signs of heart failure or any chest pain. Laborat...