Year : 2014  |  Volume : 17  |  Issue : 1  |  Page : 70--71

In response to "Anaphylaxis during intravenous administration of amiodarone" Is amiodarone the best choice for management of atrial fibrillation?

Indira Malik 
 Department of Anaesthesiology, GB Pant Hospital, New Delhi, India

Correspondence Address:
Indira Malik
F1/27, First Floor, Sector 11, Rohini, New Delhi - 110 085

How to cite this article:
Malik I. In response to "Anaphylaxis during intravenous administration of amiodarone" Is amiodarone the best choice for management of atrial fibrillation?.Ann Card Anaesth 2014;17:70-71

How to cite this URL:
Malik I. In response to "Anaphylaxis during intravenous administration of amiodarone" Is amiodarone the best choice for management of atrial fibrillation?. Ann Card Anaesth [serial online] 2014 [cited 2021 Jun 16 ];17:70-71
Available from:

Full Text

The Editor,

I read with interest the article, "Anaphylaxis during intravenous administration of amiodarone" by Okuyan et al. [1] Atrial fibrillation (AF) is described as uncoordinated atrial activation with consequent deterioration of atrial mechanical function. The ventricular response (VR) to AF depends upon the electrophysiological properties of the atrioventricular (AV) node and the level of vagal or sympathetic tone. A rapid, irregular, wide QRS complex tachycardia with AF suggests conduction over an accessory pathway or an underlying bundle branch block. Ventricular rates > 200/min suggest the presence of an accessory pathway. [2] Presence of AV block usually results in regular RR intervals. The term "lone AF" has been described as presence of AF in the absence of underlying heart disease and its incidence was reported to be 29.4%. [3] Lone AF may manifest as isolated or recurrent episodes or chronic AF. Risk of stroke and myocardial infarction without overt evidence of previous coronary artery disease has been reported with lone AF. [4]

Management of AF consists of three main goals: (1) Controlling the VR to AF; (2) restoring and maintaining sinus rhythm, and (3) prevention of thromboembolism. [2] Control of VR and maintenance of sinus rhythm are essential to prevent the complications of AF such as hypotension, heart failure and cardiomyopathy. The American College of Cardiology Foundation/American Heart Association/Heart Rhythm Society recommends intravenous β-blockers or non-dihydropyridine calcium-channel-blockers (verapamil or diltiazem) to slow the VR to AF in the acute setting in the absence of an accessory pathway as a class I recommendation (level of evidence B). [2] Amiodarone as a class I recommendation in presence of heart failure with AF without accessory pathway and a class IIa recommendation for control of heart rate in AF if other conventional therapies are unsuccessful or contraindicated (level of evidence C). While administering amiodarone caution should be exercised in patients with hypotension or heart failure. Other drugs such as quinidine, procainamide, disopyramide and ibutilide have been recommended as class IIb (level of evidence B). The guidelines also suggest that in cases of lone AF, a β-blocker may be tried first but flecainide; propafenone and sotalol are particularly effective. [2] Esmolol 0.5 mg/kg over 1 min followed by infusion at 0.05-0.2 mg/kg/min is preferred due to its quick onset of action and short term effects. Diltiazem 0.25 mg/kg followed by an infusion of 5-15 mg/h is also useful in the emergency scenario. However, both β-blockers and Calcium-channel-blockers are associated with the risk of hypotension, heart block and heart failure. Electrical cardioversion also is a class I recommendation in hemodynamically stable patients, only if the symptoms of AF are unacceptable. [2] β-blockers are contraindicated in patients with asthma. Amiodarone may be useful in critically ill patients who are refractory to conventional therapy. It may be considered an alternative therapy or last resort in cases where conventional therapy is unsuccessful. However, in view of its potential for causing severe extracardiac toxicity, the benefits outweigh the risks associated with its administration. [5]

In the case reported by the authors, the patient was apparently suffering from recurrent episodes of lone AF, as her hemodynamic profile, X-ray chest and left ventricular function were normal. As mentioned above, a β-blocker or Calcium-channel-blocker should have been the first choice. Administration of amiodarone would never be a second choice for either of these purposes, since the patient was hemodynamically stable after administration of the first dose of diltiazem and was therefore a suitable candidate for initiation of an infusion of diltiazem. Esmolol could also have been chosen as a first or second line drug. It has been mentioned that in patients with adrenergically mediated lone AF, amiodarone should be chosen later in the sequence of drug therapy and is a less appealing selection due to its potential toxicity. [2] Therefore, the choice of amiodarone by the authors so early in the treatment was probably not justified. In cases of lone AF, amiodarone should only be chosen if β-blockers and Ca-channel-blockers have been administered in the recommended dose and fail to achieve rate control and cardioversion.


1Okuyan H, Altin C, Arihan O. Anaphylaxis during intravenous administration of amiodarone. Ann Card Anaesth 2013;16:229-30.
2Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2011;123:e269-367.
3Lévy S, Maarek M, Coumel P, Guize L, Lekieffre J, Medvedowsky JL, et al. Characterization of different subsets of atrial fibrillation in general practice in France: The ALFA study. The College of French Cardiologists. Circulation 1999;99:3028-35.
4Kopecky SL, Gersh BJ, McGoon MD, Whisnant JP, Holmes DR Jr, Ilstrup DM, et al. The natural history of lone atrial fibrillation. A population-based study over three decades. N Engl J Med 1987;317:669-74.
5Clemo HF, Wood MA, Gilligan DM, Ellenbogen KA. Intravenous amiodarone for acute heart rate control in the critically ill patient with atrial tachyarrhythmias. Am J Cardiol 1998;81:594-8.