Abstract
Background: The management of permanent atrial fibrillation (PAF) consists primarily of long‐term anticoagulation with either aspirin or warfarin to prevent systemic embolization, and modulation of ventricular rate (VR) to improve cardiac function by prolonging the ventricular diastolic filling time.
Hypothesis: The effects of slow‐release formulations of gallopamil (100 mg b.i.d.), diltiazem (120 mg bid.), or verapamil (120 mg b.i.d.) on VR were evaluated in 18 patients with PAF without organic heart disease.
Methods: In all patients, each treatment was administered randomly, was compared with oral digoxin, and was assessed by 24‐h Holter monitoring during daily life and by a 6‐min walk ing test.
Results: There were no significant differences in mean and minimum VR recorded during 24‐h Holter monitoring among the four treatments. Peak heart rates recorded during the 6‐min walking test with digoxin treatment was 167 ± 12 beats/min. This was significantly reduced by gallopamil (149 ± 23 beats/ min, p = 0.01), diltiazem (142 ± 4 beats/min, p< 0.001), and verapamil (137 ± 30 beats/min, p < 0.001). There were no significant differences in peak VR during the walking test among the three calcium antagonists. Pauses of ≥ 3 s were observed in 3 of 18 (17%) patients who received digoxin (max 3.4 s) and in 5 of 18 (28%) patients who received diltiazem (max 3.4 s); p = NS. Periods of bradycardia < 30 beats/min were observed in 5 of 18 (28%) patients during digoxin treatment, and in 3 of 18(17%) patients during treatment with gallopamil, diltiazem, and verapamil; p = NS.
Conclusion: Gallopamil, diltiazem, or verapamil are superior to digoxin in controlling VR during mild exercise in patients with PAF without organic heart disease. The reduction of peak VR is obtainable without further slowing of resting VR. However, gallopamil appears to be the least effective calcium blocker at controlling resting and exercise VR; thus, there are no advantages over the other calcium blockers in its use in the clinical setting.
Keywords: atrial fibrillation, ventricular rate control, digoxin, calcium‐channel blockers
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References
- 1. Furberg C, Patsy B, Manolio T, Gardin JM, Smith VE, Rautahariu PM: Prevalence of atrial fibrillation in elderly subjects (The Cardiovascular Heart Study). Am J Cardiol 1994; 74: 236–241 [DOI] [PubMed] [Google Scholar]
- 2. Kannel WB, Abbot RD, Savage DD, McNamara PM: Epidemiologic features of chronic atrial fibrillation: The Framingham Study. N Engl J Med 1982; 306: 1018–1022 [DOI] [PubMed] [Google Scholar]
- 3. Stroke Prevention in Atrial Fibrillation Investigators : Stroke prevention in atrial fibrillation study: Final results. Circulation 1991; 84: 527–539 [DOI] [PubMed] [Google Scholar]
- 4. Zarowitz BJ, Gheorghiade M: Optimal heart rate control for patients with chronic atrial fibrillation: Are pharmacologic choices truly changing? Am Heart J 1992; 123: 1401–1403 [DOI] [PubMed] [Google Scholar]
- 5. Meijler FL: An “account” of digitalis and atrial fibrillation. J Am Coll Cardiol 1985; 5: 60A–68A [DOI] [PubMed] [Google Scholar]
- 6. David D, Segni ED, Klein HO, Kaplinsky E: Inefficacy of digitalis in the control of heart rate in patients with chronic atrial fibrillation: Beneficial effect of an added beta‐adrenergic agent. Am J Cardiol 1979; 44: 1378–1382 [DOI] [PubMed] [Google Scholar]
- 7. Beasley R, Smith DA, McHaffie DJ: Exercise heart rate at different serum digoxin concentration in patients with atrial fibrillation. Br Med J 1985; 290: 9–11 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Lang R, Klein HO, Weiss E, David D, Sarely P, Levy A, Guerrero J, Di Segni E, Kaplinsky E: Superiority of oral verapamil therapy to digoxin in treatment of chronic atrial fibrillation. Chest 1983; 83: 491–499 [DOI] [PubMed] [Google Scholar]
- 9. Pomfret SM, Beasley RW, Challenor W, Holgate T: Relative efficacy of oral verapamil and digoxin alone and in combination for the treatment of patients with chronic atrial fibrillation, Clin Sci 1988; 74: 351–357 [DOI] [PubMed] [Google Scholar]
- 10. Roth A, Harrison E, Mitani G, Cohen J, Rahimtoola SH, Elkayam U: Efficay and safety of medium‐ and high‐dose diltiazem alone and in combination with digoxin for control of heart rate at rest and during exercise in patients with chronic atrial fibrillation. Circulation 1986; 73: 316–324 [DOI] [PubMed] [Google Scholar]
- 11. Lewis RV, Laing E, Moreland TA, Service E, McDevitt G: A comparison of digoxin, diltiazem and their combination in the treatment of atrial fibrillation. Eur Heart J 1988; 9: 279–283 [DOI] [PubMed] [Google Scholar]
- 12. Bayer R, Kalusche D, Kaufmann R: Inotropic and electrophysiological actions of verapamil and D 600 in mammalian myocardium. III. Effects of the optical isomers on transmembrane action potentials. Naunyn‐Schmiedebergs Arch Phannacol 1975; 290: 81–97 [DOI] [PubMed] [Google Scholar]
- 13. Neuss H, Horn HG, Mitrovi V, Buss J, Schlepper M: Heart rate reduction in atrial fibrillation with a rapid ventricular response by gallopamil, a Ca‐antagonist. Z Cardiol 1982; 71: 334–339 [PubMed] [Google Scholar]
- 14. Lipkin DP, Scriven AJ, Crake T, Poole‐Wilson PA: Six minute walking test for assessing exercise capacity in chronic heart failure. Br Med J 1986; 292: 653–655 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Falk RH, Leavitt JI: Digoxin for atrial fibrillation: A drug whose time has gone? Ann Intern Med 1991; 114: 573–575 [DOI] [PubMed] [Google Scholar]
- 16. Corday E, Irvine DW: Disturbances of Heart Rate, Rhythm and Conduction, p. 207 Philadelphia: W.B. Saunders, 1961. [Google Scholar]
- 17. Singh BH, Nademanee K: Use of calcium antagonists for cardiac arrhythmias. Am J Cardiol 1987; 59: 153B–162B [DOI] [PubMed] [Google Scholar]
- 18. Billette J, Nadeau RA, Roberge F: Relation between the minimum RR interval during atrial fibrillation and the junctional refractory period of the AV junction. Cardiovasc Res 1974; 8: 347–351 [DOI] [PubMed] [Google Scholar]
- 19. Theisen K, Haute M, Peters J, Thiesen F, Jahrmarker H: Effects of the calcium antagonist diltiazem on atrioventricular conduction in chronic atrial fibrillation. Am J Cardiol 1985; 55: 98–102 [DOI] [PubMed] [Google Scholar]
- 20. Camm AJ, Martin A, Evans KE: Twenty‐four hour ambulatory monitoring: A survey of active elderly people In Proc Internat Symposium on Ambulatory Monitoring, p. 7 London: Academic Press, 1978. [Google Scholar]