Safety and Efficacy of Ibutilide in Cardioversion of Atrial Flutter and Fibrillation

Abstract

This article reviews the safety and efficacy of ibutilide for use in patients with atrial fibrillation and flutter. Ibutilide, a class III antiarrhythmic agent, is primarily used for conversion of atrial flutter and fibrillation and is a good alternative to electrical cardioversion. Ibutilide has a conversion rate of up to 75% to 80% in recent-onset atrial fibrillation and flutter; the conversion rate is higher for atrial flutter than for atrial fibrillation. It is also safe in the conversion of chronic atrial fibrillation/flutter among patients receiving oral amiodarone therapy. Ibutilide pretreatment facilitates transthoracic defibrillation and decreases the energy requirement of electrical cardioversion by both monophasic and biphasic shocks. Pretreatment with ibutilide before electrical defibrillation has a conversion rate of 100% compared with 72% with no pretreatment. Ibutilide is also safe and efficient in the treatment of atrial fibrillation in patients who have had cardiac surgery, and in accessory pathway-mediated atrial fibrillation where the conversion rate of ibutilide is as high as 95%. There is up to a 4% risk of torsade de pointes and a 4.9% risk of monomorphic ventricular tachycardia. Hence, close monitoring in an intensive care unit setting is warranted during and at least for 4 hours after drug infusion. The anticoagulation strategy is the same as for any other mode of cardioversion. In selected patient populations, cardioversion still remains the preferred management for atrial fibrillation and flutter, even though data suggest no survival advantage for rhythm control over rate control.1 Electrical cardioversion has been the most widely used and the most effective method to restore sinus rhythm in these atrial arrhythmias. However, chemical cardioversion is a good alternative for use in certain patient groups. Chemical cardioversion is less invasive, more cost-effective, and, unlike electrical cardioversion, it does not require sedation. Ibutilide-despite its efficacy, which is comparable or superior to other agents-is not widely used, mainly because of physician's lack of awareness about its safety and efficacy profile. This article reviews the safety and efficacy data of ibutilide and also compares it with other antiarrhythmics used for atrial fibrillation and flutter.Ibutilide, a class III antiarrhythmic drug that was approved by the Food and Drug Administration for This article was externally peer reviewed.

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…Należy je łączyć z lekiem kontrolującym częstość rytmu komór, by uniknąć przewodzenia zwalniających fal trzepotania do komór w stosunku 1:1. Ibutilid jest bardziej skuteczny w konwersji trzepotania przedsionków niż AF, natomiast wernakalant jest mniej skuteczny w konwersji typowego trzepotania przedsionków [996,997]. Kardiowersję elektryczną trzepotania przedsionków można wykonywać impulsami o mniejszej energii (50-100 J) niż w przypadku AF [998,999].…”

Atrial Fibrillation: Antiarrhythmic Therapy

“…Given intravenously, it cardioverts 30%-50% of AF within 1 hour, though is more effective with atrial flutter, with a 50%-80% conversion rate. 74 Dofetilide can be used for cardioversion in persistent AF, as demonstrated in the symptomatic atrial fibrillation investigative research on dofetilide (SAFIRE-D) trial. In SAFIRE-D, 325 patients with persistent AF or atrial flutter were randomized to dofetilide or placebo, with dosing based on renal function and QT prolongation.…”

Management of Arrhythmias in Heart Failure

“…Ibutilide (0.01 mg/kg iv with a second dose 10 min later if necessary) is approximately 50% effective at cardioversion; however, the risk of torsades de pointes increases to 11.4% compared to 3.6% in non-HF patients [ 63 ]. Class Ic agents flecainide and propafenone are contraindicated in the structural heart disease because of pro-arrhythmia and should not be used for chemical cardioversion.…”