Doctors & patients are saying about 'A-Fib.com'...


"A-Fib.com is a great web site for patients, that is unequaled by anything else out there."

Dr. Douglas L. Packer, MD, FHRS, Mayo Clinic, Rochester, MN

"Jill and I put you and your work in our prayers every night. What you do to help people through this [A-Fib] process is really incredible."

Jill and Steve Douglas, East Troy, WI 

“I really appreciate all the information on your website as it allows me to be a better informed patient and to know what questions to ask my EP. 

Faye Spencer, Boise, ID, April 2017

“I think your site has helped a lot of patients.”

Dr. Hugh G. Calkins, MD  Johns Hopkins,
Baltimore, MD


Doctors & patients are saying about 'Beat Your A-Fib'...


"If I had [your book] 10 years ago, it would have saved me 8 years of hell.”

Roy Salmon, Patient, A-Fib Free,
Adelaide, Australia

"This book is incredibly complete and easy-to-understand for anybody. I certainly recommend it for patients who want to know more about atrial fibrillation than what they will learn from doctors...."

Pierre Jaïs, M.D. Professor of Cardiology, Haut-Lévêque Hospital, Bordeaux, France

"Dear Steve, I saw a patient this morning with your book [in hand] and highlights throughout. She loves it and finds it very useful to help her in dealing with atrial fibrillation."

Dr. Wilber Su,
Cavanaugh Heart Center, 
Phoenix, AZ

"...masterful. You managed to combine an encyclopedic compilation of information with the simplicity of presentation that enhances the delivery of the information to the reader. This is not an easy thing to do, but you have been very, very successful at it."

Ira David Levin, heart patient, 
Rome, Italy

"Within the pages of Beat Your A-Fib, Dr. Steve Ryan, PhD, provides a comprehensive guide for persons seeking to find a cure for their Atrial Fibrillation."

Walter Kerwin, MD, Cedars-Sinai Medical Center, Los Angeles, CA


Antiarrhythmics

Eleven Things I Know About A-Fib Drug Therapy by Dr. Peter Kowey

Peter R. Kowey MD 2.150 pix at 96 res

Dr. Peter R. Kowey

Dr. Peter Kowey, American Heart Association (AHA) Scientific Sessions, November 17, 2014, Chicago, IL

Report by Steve S. Ryan, PhD

This is my only report from the November 2014 meeting of the American Heart Association. Unlike the annual (Boston) AF Symposium, the AHA had only a few sessions on Atrial Fibrillation.
About Dr. Peter Kowey: An internationally respected expert in heart rhythm disorders. His research has led to the development of dozens of new drugs and devices for treating a wide range of cardiac diseases.  Note: In his disclosure statement, he lists being a consultant for most of the major pharmaceutical companies.

Dr. Kowey’s first point is a sobering statement about today’s antiarrhythmic drugs (AADs).

Fact #1 “An antiarrhythmic drug is a poison administered in a therapeutic concentration.”

(Like most meds, antiarrhythmic drugs, (AAD), are a trade-off. We trade the unnaturalness and possible toxicity of AADs in the hope that they will alleviate our A-Fib symptoms and keep our A-Fib from getting worse. But AADs are unnatural substances not normally found in our body. Our body has a tendency to react to them like they were toxins.)

Fact #2 Amiodarone is by far the most effective of the antiarrhythmics but is also the most toxic.

The “protean toxicity” of amiodarone is grossly underappreciated by practicing doctors. The average GP or cardiologist often doesn’t understand how severely amiodarone can affect people and often don’t monitor patients closely enough.

Amiodarone has never been reviewed or approved by the FDA for the treatment of A-Fib (this is called “off label” use).

Though doctors use the 200 mg dose, the best dosage is unknown. The degree and rate amiodarone is absorbed into the circulation (bioavailability) can range widely from 15% to 85%.

An antiarrhythmic drug is a poison administered in a therapeutic concentration.

Back to top

Fact #3 We choose antiarrhythmic drugs based on their relative chances of harm, not comparative efficacy.

Doctors usually start out by prescribing the least dangerous antiarrhythmic first or the least likely to have bad side effects in a particular patient, rather than the drug most likely to suppress A-Fib.

Fact #4 Antiarrhythmic drug therapy is highly empiric, but exposure-related.

For example, in practice doctors don’t use plasma monitoring to determine how much of an antiarrhythmic is actually in a patient’s blood.

In clinical practice most doctors don’t continually adjustment dosage based on patient response.

Fact #5 Antiarrhythmics drugs require surveillance of varying intensity.

• Amiodarone requires intense surveillance—lungs, thyroid, eyes, liver, skin, heart. (For more see my article, Amiodarone: Most Effective and Most Toxic.)

• Flecainide/Propafenone: check for ischemic effects (swelling)

• Sotalol/Dofetilide: check for renal function

• Sotalol: monitor kidneys as 100% is renally eliminated

Fact #6 Antiarrhythmic drugs with multi-channel effects may be more effective than those that target single channels or receptors.

Dr. Kowey discussed Vanoxerine which is a dopamine transporter antagonist developed for Parkinson’s and depression but is being studied for A-Fib conversion.

In one study, ‘Pill-In-The-Pocket’ didn’t reduce A-Fib symptoms but did significantly reduce emergency room visits and hospitalizations.

Fact #7 Antiarrhythmic drug therapy of A-Fib is imperfect.

The goal is palliation (treatment without dealing with the underlying cause) and not total eradication of symptoms.

Fact #8 Antiarrhythmic drug therapy can be creative.

Instead of taking an antiarrhythmic drug on a continuous basis, one can instead use a strategy like Pill-In-The-Pocket. The A-Fib patient only takes an antiarrhythmic drug at the time of an A-Fib attack (or as a booster—taking more of an AAD at the time of an A-Fib episode).

In one study, Pill-In-The-Pocket didn’t reduce A-Fib symptoms but did significantly reduce emergency room visits and hospitalizations.

Back to top

Fact #9 Antiarrhythmic drugs may supplement the efficacy of other interventions like catheter ablation.

After a catheter ablation during the 3 month blanking period, patients are often given an antiarrhythmic drug to help their heart ‘learn’ to beat normally again, to prevent their heart from slipping back into A-Fib.

About the 3 month blanking period, Dr. Kowey says “the rationale for which is unknown.” (But it generally takes that long for the scarring from an ablation to heal and for the heart to return to normalcy.)

There haven’t been any clinical trials to guide the choice of drug and dose during the 3 month blanking period.

The concept of “enhanced efficacy” has not been grounded or tested.

Fact #10 Taking antiarrhythmic drugs does not obviate the need for stroke prevention.

There is an inadequate data to form a firm conclusion regarding withdrawal of anticoagulation after a successful ablation. (For more see the FAQs question #15: “I’ve had a successful Pulmonary Vein Ablation to cure my A-Fib. Do I still need to be on blood thinners like Coumadin or aspirin?”

Some studies indicate that anticoagulants can be stopped 3-6 months after a successful Pulmonary Vein Ablation. As Dr. John Mandrola says, “and if there is no A-Fib, there is no benefit from anticoagulation.”)

Abundant data prove the prevalence of silent A-Fib.

Dr. Kowey stated that there is an unwarranted assumption regarding the relationship between A-Fib appendage function and clot. (But some studies indicate that 90%-95% of A-Fib clots come from the Left Atrial Appendage (LAA), that closing off the LAA does reduce A-Fib stroke risk.)

After a successful Pulmonary Vein Ablation…and if there is no A-Fib, there is no benefit from anticoagulation. -Dr. John Mandrola

Fact #11 The holy grail is prevention.

But there is no proof that any treatment is conclusively effective in this regard. Dr. Kowey discussed the new drug in development ‘LCZ696’ by Novartis AG which shows promise in preventing A-Fib.

Dr. Kowey’s Conclusions

• If doctors made better and more intelligent use of antiarrhythmic drugs, patients would fare better and we would do fewer ablations.

• Intelligent use requires an in-depth knowledge of pharmacology and familiarity with all aspects of clinical use, especially dosing.

• Antiarrhythmic therapy is not perfect, but it can improve quality of life and functionality for a significant percentage of A-Fib patients.

Editors Comments:
Dr. Kowey’s statement that “an antiarrhythmic drug is a poison administered in a therapeutic concentration” should set off alarm bells for patients. In the US, we’ve been conditioned to think “ if we’re sick, just take a pill”. But today’s antiarrhythmic drugs have poor success rates (often under 50%), often have unacceptable side effects, and when they do work they tend to lose their effectiveness over time. In general, antiarrhythmic drugs are toxic substances which aren’t meant to be in our bodies―so our bodies tend to reject them.
Antiarrhythmic drugs are certainly better than living a life in A-Fib. They are useful for many patients. But as Dr. Kowey states, they are “palliative” (without dealing with the underlying cause) and are seldom a lasting cure for A-Fib.
Reference for this Article

Back to top

Return to Index of Articles: Drug Therapies

Last updated: Sunday, February 15, 2015

FAQs A-Fib Drug Therapy: Amiodarone & Toxic Side Effects

 FAQs A-Fib Drug Therapy: Amiodarone

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

4. I’ve been on amiodarone for over a year. It works for me and keeps me out of A-Fib. But I’m worried about the toxic side effects. What should I do?”

You are correct to be concerned about toxic effects. Amiodarone is considered one of the most effective antiarrhythmic meds, but it’s also one of the most toxic. It may affect your lungs, eyes, thyroid, liver, skin, heart, and nervous system.

Also, amiodarone has a long half-life. It is retained in the body for up to 45 days after the drug has been discontinued.

(Be advised that a newer drug dronedarone (brand name Multaq) is now on the market and may be a good substitute for amiodarone. Dronedarone may not be quite as effective as amiodarone, but is much safer. However, some studies indicate that dronedarone may have problems.)

If you are taking amiodarone, you should by monitored and tested frequently and scrupulously for damage to your organ systems (your doctor may already be doing this). You should keep copies of any tests. What’s important is not so much whether you are within a “normal” range, but whether your measurements are going up and how fast. Note: it’s important that baseline values for organ systems should be documented before you start taking amiodarone.

Contact your doctor immediately if, after taking amiodarone, you experience any new symptoms such as: coughing, wheezing, shortness of breath, visual changes, skin rash, pain, tingling or weakness in the arms or legs, fever, rapid heart beat, fatigue, lethargy, unusual weight gain, swelling, hair loss, cold or heat intolerance, lightheadedness or fainting.

The recommended maintenance dose of amiodarone is 200 mg/day. A possible toxic level of amiodarone may be 400 mg daily for more than two months, or a low dose for more than two years.

For a more in depth discussion, see Amiodarone: Most Effective and Most Toxic.

 Thanks to Lee Abdullah for this question.

Resources:

Jessurun, G. and Crijns, H. “Amiodarone pulmonary toxicity—Dose and duration of treatment are not the only determinants of toxicity.” BMJ, 1997, Volume 314, Number 7081, 619. http://www.bmj.com/content/314/7081/619.full

Jessurun, G. and Crijns, H. “Amiodarone pulmonary toxicity—Dose and duration of treatment are not the only determinants of toxicity.” BMJ, 1997, Volume 314, Number 7081, 619. http://www.bmj.com/content/314/7081/619.full

Return to FAQ Drug Therapies

Follow Us
facebook - A-Fib.comtwitter - A-Fib.comlinkedin  - A-Fib.compinterest  - A-Fib.comYouTube: A-Fib Can be Cured!  - A-Fib.com


A-Fib.com is a
501(c)(3) Nonprofit



Your support is needed. Every donation helps, even just $1.00.



A-Fib.com top rated by Healthline.com for fourth year 2014  2015  2016  2017

A-Fib.com Mission Statement
We Need You

Mug - Seek your cure - Beat Your A-Fib 200 pix wide at 300 resEncourage others
with A-Fib
click to order

Home | The A-Fib Coach | Help Support A-Fib.com | A-Fib News Archive | Tell Us What You think | Press Room | GuideStar Seal | HON certification | Disclosures | Terms of Use | Privacy Policy