Primary care physicians are confronted with this problem on an almost daily basis and have to make decisions in the acute setting as well as for patients’ long term care. Professor Trappe’s article is thus enormously important and worth reading.
However, I think a few additional comments are warranted:
- It seems worth discussing, and readers did not receive a sufficiently clear answer, whether the available and reported study results even justify medical treatment of cardiac arrhythmia.
- The author’s explanations regarding dronedarone are euphemistic when he says that the current state of the evidence, after a relatively short period of observation of the effects of dronedarone, does not justify the prominent position accorded to this drug in the published guidelines. After the PALLAS trial was stopped (clinicaltrials.org), it seems obvious that this drug, which was initially provocatively advertised, does not provide a further, potential treatment option for permanent atrial fibrillation.
- I would have wished for a specialist cardiological assessment of the use of pulmonary vein isolation.
- I wonder which ethics committee gave approval for a substance such as vernakalant to be tested in at least three studies versus placebo (!) when effective alternative therapeutics are available, for which conversion rates of 40–60% in the acute setting have been described and confirmed. This expensive new drug cannot achieve any more than that, and it remains unclear whether it offers any additional advantages compared with flecainide or propafenone.
- In my opinion, it would have been important to mention for dabigatran the significantly increased risk of provoking myocardial infarction (Uchino K, Hernandez AV: Circulation 2011; 124: Abstract 15500), which should be an additional factor in the decision-making process.
Dr. med. Joachim Pries
Conflict of interest statement
The author declares that no conflict of interest exists.
|1.||Trappe HJ: Atrial fibrillation: established and innovative methods of evaluation and treatment. Dtsch Artzebl Int 2012; 109(1–2): 1–7.|