CORRECT USE OF PROPAFENONE
| INDICATIONS
AND CLINICAL USE |
| SUPRAVENTRICULAR
ARRHYTHMIAS
|
 RECENT ONSET ATRIAL FIBRILLATION
|
Conversion
to sinus rhythm |
| |
Propafenone
has shown to be particularly effective in
converting atrial fibrillation of recent onset to
sinus rhythm (Table 2). |
TABLE
2
Efficacy of intravenous
Propafenone in converting atrial fibrillation of
recent onset to sinus rhythm
|
| |
Ref.
|
Ps Number
|
Efficacy
N° (%)
|
Time to
Conversion
|
| Capucci,
1987 |
12
|
22
|
10 (45)
|
< 1 hour
|
| Connolly,
1987 |
13
|
12
|
6 (50)
|
5 - 10 min
|
| Carerj,
1989 |
14
|
14
|
7 (50)
|
16 + 10 min
|
| Suttorp,
1990 |
15
|
20
|
11 (55)
|
16 + 10 min
|
| Bianconi,
1991 |
16
|
158
|
140 (66)
|
26 + 17 min
|
| Negrini,
1991 |
17
|
18
|
16 (89)
|
1.7 hour
|
| Lavanga,
1991 |
18
|
60
|
44 (73)
|
10 min
|
| Rostagno,
1991 |
19
|
239
|
124 (45)
|
< 1 hour
|
| Gentili,
1992 |
20
|
50
|
35 (70)
|
22 + 6 min
|
| Margheri,
1992 |
21
|
42
|
24 (57)
|
< 2 hour
|
| Tisi, 1992 |
22
|
73
|
58 (79)
|
?
|
| Palmieri,
1992 |
23
|
349
|
230 (66)
|
49 + 46 min
|
| Bellandi,
1993 |
24
|
98
|
89 (91)
|
2.5 + 2.7 hour
|
| Baldi, 1994
|
25
|
24
|
12 (43)
|
14 + 13 min
|
| Berti, 1994
|
26
|
25
|
15 (60)
|
< 1 hour
|
| Total |
|
1204
|
785 (65)
|
range
5 min - 1.7 hours
|
As with
other drugs, more recent the onset of the arrhythmia
higher the drug’s efficacy.
In patients who do not convert to sinus rhythm a
reduction in the ventricular rate is usually observed.(18)
Although
the percentage success obtained with Propafenone seems
greater in lone atrial fibrillation, results not
significantly different have been achieved in the
treatment of atrial fibrillation in patients with
underlying heart disease.(18)
|
Prevention
of recurrence |
| |
The
major studies reported in the literature
concerning prevention of paroxysmal atrial
fibrillation or maintenance of sinus rhythm after
cardioversion of chronic atrial fibrillation are
reported in Table 3. |
TABLE
3
Efficacy of Propafenone for the
prevention of recurrence of chronic or paroxysmal
atrial fibrillation
|
| |
Ref.
|
Dose
mg/day
|
Ps
Number
|
Follow
up
(months)
|
Efficacy
N° (%)
|
| Bounhoure,
1985 |
27
|
600 - 900
|
20
|
6
|
15
|
75
|
| Kerr, 1988 |
28
|
300 - 1200
|
53
|
9
|
34
|
64
|
| Hammill,
1988 |
29
|
600 - 1200
|
47
|
18.6
|
30
|
53
|
| Connolly,
1989 |
30
|
450 - 900
|
18
|
?
|
4
|
22
|
| Porterfield,
1989 |
31
|
450 - 1200
|
26
|
15.6
|
12
|
46
|
| Antman,
1990 |
32
|
450 - 900
|
109
|
5.6
|
43
|
39
|
| Nobile,
1990 |
33
|
450 - 900
|
40
|
13
|
27
|
67
|
| Lopez, 1991 |
34
|
671 + 187
|
21
|
9
|
12
|
56
|
| Kyles, 1991 |
35
|
701 + 235
|
81
|
30
|
31
|
38
|
| Richiardi,
1992 |
36
|
450 - 900
|
102
|
12
|
49
|
48
|
| Sirinelli,
1992 |
37
|
450 - 900
|
65
|
7.8
|
43
|
66
|
| Tarquini,
1993 |
38
|
450 - 900
|
33
|
21
|
23
|
70
|
| Bellandi,
1993 |
24
|
450
|
89
|
12
|
69
|
78
|
| Reimond,
1993 |
39
|
450 - 900
|
50
|
12
|
15
|
30
|
| Chimienti,
1994 |
40
|
450 - 900
|
82
|
12
|
52
|
63
|
| Total |
|
300 - 1200
|
836
|
6 - 30
|
459
|
55
|
In a
placebo controlled cross-over study with each treatment
period lasting up to 60 days, the recurrence rate of
arrhythmia during treatment with Propafenone was
approximately one-fifth of that observed during placebo
administration.(41)
ATRIAL FLUTTER
Propafenone,
as other antiarrhythmic drugs, is not particularly
effective in the conversion of atrial flutter to sinus
rhythm, with success rates varying from 33 to 55% (Table
4).
TABLE 4
Efficacy of intravenous
Propafenone in the conversion of atrial flutter
of recent onset
|
|
|
Ref.
|
Duration
|
Ps
Number
|
Efficacy
N° (%)
|
| Bianconi,
1989 |
42
|
< 15
days
|
15
|
5
|
33
|
| Suttorp,
1990 |
15
|
?
|
5
|
2
|
40
|
| Rostagno,
1991 |
19
|
< 24
hours
|
3
|
1
|
33
|
| Tisi, 1992 |
22
|
< 3 days
|
9
|
5
|
55
|
| Total |
|
|
32
|
13
|
41
|
PAROXYSMAL
SUPRAVENTRICULAR TACHYCARDIA
Propafenone,
administered intravenously (2mg/kg), has proved effective
in interrupting both junctional nodal re-entrant
tachycardia and atrioventricular re-entrant tachycardias
in a high percentage of cases (83%), and it was able to
prevent the arrhythmia recurrence in 70% of patients
(Table 5).
TABLE 5
Efficacy
of intravenous Propafenone in the management of
paroxysmal supraventricular tachycardia during
electrophysiological studies
|
|
|
|
Arrhythmia
Interruption |
|
|
|
Ref. |
AVRT |
AVNRT |
Total |
Prevention
of reinduction |
| Walleffe,
1983 |
4 |
6/7 |
4/5 |
10/12 |
7/12 |
| Breithardt,
1984 |
43 |
-- |
-- |
-- |
6/15 |
| Shen, 1986 |
44 |
9/14 |
3/3 |
12/17 |
-- |
| Fauchier,
1986 |
45 |
6/7 |
7/10 |
13/17 |
8/17 |
| Ludmer,
1987 |
46 |
10/11 |
-- |
10/11 |
-- |
| Hammil,
1987 |
47 |
6/8 |
6/6 |
12/14 |
11/12 |
| Dubuc, 1989 |
48 |
14/15 |
-- |
14/15 |
-- |
| Total |
|
51/62 |
20/24 |
71/86 |
32/46 |
| |
|
82% |
83% |
83% |
70% |
AVRT =
atrioventricular reentrant tachycardia
AVNRT = atrioventricular nodal reentrant tachycardia
WOLFF-PARKINSON-WHITE
SYNDROME
Propafenone,
because of its pronounced effect in slowing conduction
through the anomalous pathways and in increasing their
refractory period, is particularly suitable for the
treatment of arrhythmias associated with the
Wolff-Parkinson-White syndrome (WPW) in patients who are
haemodynamically stable.
In a study(43),
43 patients with WPW were treated with Propafenone and
followed-up for 2-3 years. The patients previously had
frequent episodes of supraventricular tachycardia,
associated with syncope in 14 of them.
Benign or potentially malignant
arrhythmias
A number
of placebo controlled studies have shown that Propafenone
abolishes or significantly reduces premature ventricular
beats and episodes of non-sustained ventricular
tachycardia in 60-85% of patients. (49-57)
Propafenone
has been shown to be useful in controlling ventricular
arrhythmias induced by exercise and in the treatment of
ventricular arrhythmias associated with mitral valve
prolapse.(58)
Propafenone
is suitable for the treatment of symptomatic ventricular
arrhythmias provided antiarrhythmic therapy is advisable
on the basis of the symptoms and the underlying
cardiopathy.
Malignant
ventricular arrhythmias
The use of
Propafenone in the treatment of malignant ventricular
arrhythmias should be carefully assessed in the
individual patient through invasive (Electrophysiological
Study) or non-invasive means (Holter, exercise test).
In such
patients, as with other antiarrhythmic agent, the risk of
drug-induced proarrhythmia is higher. (59)
Ventricular
arrhythmias in myocardial infarction
Because of
limited experience the use of Propafenone in acute
myocardial infarction is not recommended.
In
patients with previous myocardial infarction Propafenone
should be limited to the treatment of life-threatening
arrhythmias after a careful assessment of the risk:
benefit ratio.
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