Well, since we're going to talk about rhythm.control, let's talk about our drug choices,.and let me just in no particular order talk.about the drugs..So, you have a drug like dofetilide..Dofetilide can markedly prolong the .QT interval in some patients..This is the reason it's mandated .to start in the hospital..There's a lot of literature on all these drugs,.so I've treated hundreds of .people with drugs for afib..I'm going to give you some of my .own personal experiences..Dofetilide has a unique property for me.when I have a patient who has a .slow heart rate when they're in normal rhythm..Most of the other antiarrhythmic drugs kind.of pile on because their ionic effects.also affect the sinus node, .so it gets slower and slower,.and you get an issue of should I need a .pacemaker now to keep the heart rate up..Dofetilide doesn't do it that much, so it's.one of the drugs that I use.to try to get out of that conundrum..It also has a wonderful ability to actually.cardiovert the patient..In our experience, 40 to 50 percent of people.will be spontaneously cardioverted,.and you can avoid a direct shock cardioversion..But, you have to watch for drug-drug interactions..That's a big thing..I like to use that drug when I'm looking to.get cardiovert a patient.when I have a patient with a slow sinus rate..They can't have a thick ventricle, but they.can have coronary disease,.and they can have even heart failure..So, that's a drug that I sort of look at. in that situation..Sotalol is another common drug I use..It's both a beta blocker and an antiarrhythmic..And, at the lower doses, there tend to be.a little more beta blocker effects..So, if you have somebody whose heart rate.is 45 to 50 when they're in normal rhythm,.I'm just telling you, you're not going .to get away with sotalol,.because if you give sotalol, now they're .going to be 35 to 40 beats a minute,.and they're just not going to feel good..Now, maybe you could add a pacemaker, that's.a brady-tachy syndrome,.and now you can advance the dose..The problem is, you use too little .of it, it doesn't work,.and then you say, \"ahh, .the drugs don't work.\".Well, the drug isn't working because you didn't.use the appropriate dose, but I get it..But, if a person has reasonable sinus rates,.and they have a normal heart,.I often will start it as an outpatient .if they're not in atrial fib..I know that some people don't like to do that,.so if you don't, you can start it in the hospital..But, I don't start it as an outpatient at.120 milligrams twice a day..I start low, like 80 milligrams twice a day..I either have them come back for an ECG or.I have them send me in rhythm strips..If they do fine, and they're keeping.a normal rhythm, I stop..If not, I might up the dose..Dronedarone?.It's an interesting drug in my experience..It's safe to use as an outpatient in multiple.situations, not heart failure,.but I've used it in coronary disease..It's an interesting drug because, for me,.it's like a yes or no drug..I do not know why this is so, but in my own.experience, it either has a remarkable ability.to suppress someone's afib, or it does almost.nothing, and you usually figure that out.within the first week or two of using the drug..The patient will call and say, .\"nothing's happening, Dr. P.\".and I say, \"okay, we'll switch .to something else.\".Or, I'll call them, or they'll call me and say, .\"Wow, I don't have any more episodes!\".I'm not exactly sure why that happens, but.at least in my experience,.it's almost like a switch..It either works, or it doesn't work..Then, you have the drugs like .flecainide and propafenone..They're kind of similar in my experience..They're excellent drugs..I use them mostly in patients who have, almost.in fact exclusively in patients who have normal hearts..I also want to make sure those patients have.a beta blocker.or calcium channel blockers,.so they don't go real fast.if they go into atrial fib or flutter..But, they're safe to start as an outpatient,.if you're in normal rhythm..They don't have a lot of drug-drug interactions,.and they're quite successful..And, I sometimes will start flecainide even.at low doses, at 50 milligrams twice a day..It's amazing to see how some people .are so sensitive to the drug.that you can get away with a really low dose..Last of all, you have amiodarone..So, amiodarone is the kingpin of drugs. in the fact of effectiveness;.it's also the kingpin in side effects..So, amiodarone has multiple ways .it can affect atrial fib..It affects a lot of different channels .in the heart. It's extremely effective..It can be started safely as an .outpatient in almost any situation..The downside of amiodarone?.It does have a lot of drug-drug interactions..You have to check what else patients are on .— warfarin, certain statins —.you've got to be aware of that..And, it can have a three to five percent chance.of causing toxicity to the lungs, liver, and thyroid..So, you can see, you have a lot of choices..You've got to know the drugs, you got to know.the patient, you got to know the doses,.but you can usually, with a little time and effort.with each patient,.pick the best one-two-punch for that patient..And, if that's not working, in my experience,.if you fail a couple of drugs,.you might as well go on to ablation, .unless you haven't tried amio..If you fail one or two of the non-amio drugs,.my experience has been.the third one's not going to work, and. either go amiodarone or ablation..But don't forget, ablation could also be used.as an upfront therapy..
