Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, Canada.
Lower Mainland Pharmacy Services, Vancouver General Hospital, Vancouver, Canada.
Heart Rhythm. 2018 Jan;15(1):9-16. doi: 10.1016/j.hrthm.2017.10.002.
For patients with symptomatic, sustained atrial fibrillation (AF), a "pill-in-the-pocket" antiarrhythmic drug (PIP-AAD) strategy has been proposed to reduce emergency department (ED) use.
To assess the clinical utility of a protocolled PIP-AAD approach within contemporary practice.
Consecutive patients who hemodynamically tolerated symptomatic, sustained AF were prospectively managed with the PIP-AAD strategy. All patients were given an atrioventricular nodal blocker 30 minutes prior to a single oral dose of a class Ic antiarrhythmic drug. If the initial PIP-AAD in the ED was efficacious and tolerated, PIP-AADs were given out of hospital for subsequent sustained AF episodes. Usage and complications were systematically recorded.
During a median follow-up period of 565 days, 43 of 80 patients presented to the ED for initial PIP-AAD. Sinus rhythm was restored without complication in 30 of 43 patients. The reasons for initial PIP-AAD failure were inefficacy (6 patients), significant hypotension (4 patients), conversion to flutter necessitating cardioversion (2 patients), and syncopal conversion pause (1 patient). For the 30 patients with successful initial PIP-AAD, 159 out-of-hospital PIP-AAD treatments occurred (mean 5.3 ± SD 1.3 per patient). Compared with ED visits in the period prior to PIP-AAD initiation, there was a significant reduction in visits (2.6 ± 3.0 vs. 0.4±0.9 ED visits per patient, P < .001) and the need for cardioversion (2.3 ± 3.1 vs. 0.0 ± 0.2 treatments per patient, P < .001). Adverse events associated with out-of-hospital PIP-AAD include presyncope (3 of 30 patients), syncope necessitating pacemaker implantation (1 patient), and conversion to flutter (1 patient).
Out-of-hospital PIP-AAD can be an effective for highly selected patients; however, the rates of treatment failure and adverse events are clinically relevant, which limits the widespread application of a PIP-AAD approach.
对于有症状、持续性心房颤动（AF）的患者，提出了一种“口袋里的药丸”抗心律失常药物（PIP-AAD）策略，以减少急诊科（ED）的使用。
评估在当代实践中，一种经过方案设计的 PIP-AAD 方法的临床实用性。
连续有症状、持续性 AF 且血流动力学稳定的患者前瞻性地接受 PIP-AAD 策略治疗。所有患者在单次口服 Ic 类抗心律失常药物前 30 分钟给予房室结阻滞剂。如果 ED 初始 PIP-AAD 有效且可耐受，则在院外给予 PIP-AAD 用于后续持续性 AF 发作。系统记录使用情况和并发症。
在中位随访 565 天期间，80 例患者中有 43 例因初始 PIP-AAD 就诊 ED。43 例患者中有 30 例成功恢复窦性心律，无并发症。初始 PIP-AAD 失败的原因包括无效（6 例）、显著低血压（4 例）、转为需要电复律的扑动（2 例）和心搏暂停（1 例）。对于 30 例初始 PIP-AAD 成功的患者，发生了 159 例院外 PIP-AAD 治疗（每位患者平均 5.3 ± 1.3 次）。与 PIP-AAD 启动前的 ED 就诊相比，就诊次数显著减少（每位患者 2.6 ± 3.0 次 vs. 0.4 ± 0.9 次，P <.001），电复律需求减少（每位患者 2.3 ± 3.1 次 vs. 0.0 ± 0.2 次，P <.001）。院外 PIP-AAD 相关的不良事件包括晕厥前兆（30 例患者中的 3 例）、需要起搏器植入的晕厥（1 例）和转为扑动（1 例）。
院外 PIP-AAD 对高度选择的患者可能是有效的；然而，治疗失败和不良事件的发生率具有临床意义，限制了 PIP-AAD 方法的广泛应用。
