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J R Soc Med. 2006 May; 99(5): 220.
PMCID: PMC1457752

Inadvertent toxic drug reaction in the management of atrial fibrillation

The choice of either sotalol or amiodarone for rhythm control was a feature of the management of a case presented by Leaver and Ho (March 2006 JRSM1) which was even more problematic than the inadvertent choice of adversely interacting drugs. Although amiodarone was the final choice of antiarrhythmic agent, presumably because of its superior efficacy in preventing relapse of atrial fibrillation (AF),2 it is a drug now known to be associated with relapse rates of the order of >90%.3,4 Accordingly, so long as the long-term antiarrhythmic management of AF involves drugs, which are not strikingly superior to amiodarone in their efficacy—even with the benefit of adjunctive electrical cardio-version3—the verdict from the AFFIRM study5 will prevail. In paraphrase, the verdict from AFFIRM is that failed rhythm control is a poor substitute for successful rate control.


1. Leaver S, Ho TB. Inadvertent toxic drug reaction in the management of atrial fibrillation. J R Soc Med 2006;99: 149-50 [PMC free article] [PubMed]
2. Singh BN, Singh SN, Reda SJ, et al. Amiodarone v sotalol for atrial fibrillation. N Engl J Med 2005;352: 1861-72 [PubMed]
3. Oral H, Pappone C, Chugh A, et al. Circumferential pulmonary—vein ablation for chronic atrial fibrillation. N Engl J Med 2006;354: 934-41 [PubMed]
4. Stabile G, Bertaglia E, Senatore G, et al. Catheter ablation treatment in patients with drug-refractory atrial fibrillation: a prospective, multicentre, randomised, controlled study (Catheter Ablation For the Cure of Atrial Fibrillation study). Eur Heart J 2006;27: 216-21 [PubMed]
5. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002;347: 1825-33 [PubMed]

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press