Amiodarone as a first-line drug in the treatment of atrial fibrillation: the protagonist viewpoint.

The endpoint of pharmacologic therapy in patients with recurrent paroxysmal atrial fibrillation or in patients with chronic atrial fibrillation successfully cardioverted is to prevent recurrences. Recent studies have cautioned against the use of sodium channel blockers (class I agents) in terms of safety. A number of patients with atrial fibrillation have coronary artery disease and the use of class I agents may be of concern, as suggested by the CAST trial. Recently a concern was also raised, regarding the safety of quinidine following cardioversion of atrial fibrillation. In patients with congestive heart failure on antiarrhythmic therapy, the SPAF trial has shown an increase in cardiac mortality and arrhythmic deaths. In this review a case is made in favor of the use of low-dose amiodarone as a first-line agent in patients with atrial fibrillation. Amiodarone is a potent antiarrhythmic agent with little if any negative inotropic effect and, therefore, is the agent of choice in patients with heart failure. In patients with coronary artery disease, the antianginal properties may be useful, and recent studies have shown a decrease in sudden death in the amiodarone group. Therefore, a number of advantages do exist in favor of the use of amiodarone as a first-line drug, at least in selected indications.