Verapamil Versus Digoxin and Acute Versus Routine Serial Cardioversion Trial - VERDICT
The goal of the trial was to compare 1) acute (within 24 hours) versus routine serial electrical cardioversions (ECVs), and 2) verapamil versus digoxin for rate control before ECV among patients with persistent atrial fibrillation (AF).
Patients Enrolled: 144
Mean Follow Up: 18 months
Mean Patient Age: Mean age 65 years
Persistent AF without contraindication for oral anticoagulation
Current episode of AF that lasted >1 year; previous ECV unsuccessful; more than one previous ECV during the prior year; unstable angina pectoris; recent myocardial infarction or cardiac surgery within 4 weeks; current infection or thyroid disturbances; atrial flutter; concurrent untreated medical condition; unlikely to comply with protocol; heart failure, New York Heart Association functional class III or IV; current or previous treatment with amiodarone; or pacemaker
Patients were randomized in the month prior to ECV in a factorial design to 1) acute (within 24 hours) (n = 74) or routine serial electrical cardioversions (ECVs) (n = 70), and 2) verapamil (120-360 mg/day, n = 74) versus digoxin (0.125-0.25 mg/day, n = 70) for rate control before ECV. During the 4 weeks preceding and the 4 weeks following ECV, patients were treated with phenprocoumon or acenocoumarol.
Prior ECV had been performed in 18% of patients. Median duration of the current episode of AF was ~60 days, and total history of AF was ~120 days.
There was no difference in the primary endpoint of permanent AF by 18 months for the comparison of acute versus routine serial cardioversion (32% vs. 31%, p = 0.85). Patients in the acute group had more ECVs (median 3 vs. 2, p < 0.05; ≥3 ECVs 54% vs. 33%, p < 0.01). There was no difference in unsuccessful ECV or subacute recurrence of AF within 30 days between groups (58% for acute vs. 56% for routine serial, p = NS).
Use of beta-blocker therapy to maintain adequate rate control was higher in the digoxin group compared with the verapamil group (60% vs. 38%, p = 0.01). Spontaneous conversion occurred more frequently in the verapamil group (12% vs. 1% for digoxin, p = 0.01). There was no difference in the primary endpoint of permanent AF by 18 months for the comparison of digoxin versus verapamil (36% vs. 28%, p = 0.33). Patients in the digoxin group had more ECVs (median 3 vs. 2, p < 0.001; ≥3 ECVs 60% vs. 28%, p < 0.001).
Among patients with persistent AF, acute ECV was not associated with a difference in permanent AF by 18 months compared with routine serial ECVs; additionally, verapamil was not associated with a difference in permanent AF by 18 months compared with digoxin for rate control before ECV.
The latter strategy was based on the hypothesis that prevention of calcium overload by calcium antagonists would decrease intractability of AF by preventing remodeling processes. It is possible the lack of benefit observed with verapamil was due in part to the higher rate of beta-blocker use in the digoxin group needed for adequate rate control. As the authors point out, it is also possible that multiple episodes of AF increase remodeling, therefore interfering with the ability of calcium-lowering therapy to prevent remodeling.
Hemels ME, Van Noord T, Crijns HJ, et al. Verapamil versus digoxin and acute versus routine serial cardioversion for the improvement of rhythm control for persistent atrial fibrillation. J Am Coll Cardiol 2006;48:1001-9.
Keywords: Phenprocoumon, Digoxin, Electric Countershock, Verapamil, Calcium Channel Blockers
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