Eleven Things I Know About A-Fib Drug Therapy: Seldom a Lasting Cure

P. Kowey MD

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. (Summary of his 2014 American Heart Association (AHA) Scientific Session presentation.)

Fact #1 “An anti-arrhythmic drug is a poison administered in a therapeutic concentration.” Like most meds, anti-arrhythmic drugs, (AADs), are a trade-off between the unnatural and possible toxicity with the power to alleviate our A-Fib symptoms.

Fact #2 “Amiodarone is by far the most effective of the antiarrhythmics but is also the most toxic.” Amiodarone has never been reviewed or approved by the FDA for the treatment of A-Fib (this is called “off label” use).

Fact #3 “Doctors choose anti-arrhythmic drugs based on their relative chances of harm, not comparative efficacy.” That is. the least dangerous anti-arrhythmic first, rather than the drug most likely to suppress A-Fib.

Fact #4 “Anti-arrhythmic drug therapy is highly empiric (based on observable evidence), and exposure-related.” In practice, doctors don’t monitor how much of a drug is actually in a patient’s blood, but instead use a patient’s response to adjust dosage.

Fact #5 “Antiarrhythmic drugs require surveillance of varying intensity.” An example is Amiodarone which requires intense surveillance—lungs, thyroid, eyes, liver, skin and heart.

Fact #6 “Anti-arrhythmic drugs with multi-channel effects may be more effective than those that target single channels or receptors.” For instance, in one study, ‘Pill-In-The-Pocket’ didn’t reduce A-Fib symptoms but did significantly reduce emergency room visits and hospitalizations.

Fact #7 “Anti-arrhythmic drug therapy of A-Fib is imperfect.” It’s treatment without dealing with the underlying cause and not total eradication of symptoms.

Fact #8 “Anti-arrhythmic drug therapy can be creative.” Such as, a strategy like Pill-In-The-Pocket.

Fact #9 “Anti-arrhythmic drugs may supplement the effectiveness of other interventions like catheter ablation.” For instance, used during the 3 month blanking period following a catheter ablation.

Fact #10 “Taking anti-arrhythmic drugs does not preclude the need for stroke prevention.” For example, withdrawal of anti-coagulation therapy after a successful ablation.

Fact #11 “The holy grail is prevention.” But there is no proof that any treatment is conclusively effective.

Dr. Kowey’s Conclusions

• If doctors made better and more intelligent use of anti-arrhythmic drugs, patients would fare better and there’d be fewer ablations.

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

• Anti-arrhythmic 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 anti-arrhythmic 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 anti-arrhythmic 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, anti-arrhythmic drugs are toxic substances which aren’t meant to be in our bodies―so our bodies tend to reject them.