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Rate Control and Sinus Rhythm Maintenance in Atrial Fibrillation
National Trends in Medication Use, 1980-1996
Randall S. Stafford, MD, PhD;
Deborah C. Robson, BS;
Bismruta Misra, MPH;
Jeremy Ruskin, MD;
Daniel E. Singer, MD
Arch Intern Med. 1998;158:2144-2148.
Background Little is known about national patterns of pharmacological treatment of atrial fibrillation, in particular, use of medications for ventricular rate control and for restoration and maintenance of sinus rhythm.
Methods We analyzed 1555 visits by patients with atrial fibrillation to randomly selected office-based US physicians included in National Ambulatory Medical Care surveys conducted in 1980, 1981, 1985, and 1989 through 1996. To determine national trends, we evaluated the proportion of atrial fibrillation visits with reported use of rate control medications (digoxin and antiarrhythmics in classes II and IV) and sinus rhythm medications (classes IA, IC, and III).
Results The use of rate control agents decreased from 79% of atrial fibrillation visits in 1980-1981 to 62% in 1994-1996. Declining use was noted for both digoxin (76% in 1980-1981 to 53% in 1994-1996) and  -blockers (19%-13%). After their introduction, the use of verapamil hydrochloride and diltiazem hydrochloride increased to 15% of atrial fibrillation visits in 1994-1996. Sinus rhythm agent use decreased from 18% of visits in 1980-1981 to 4% in 1992-1993 and then rose to 13% in 1994-1996. The use of class IA agents declined from 18% in 1980-1981 to 3.5% in 1992-1993 and then increased to 8% in 1994-1996. Quinidine remained the most widely used sinus rhythm medication, despite its declining share of this category. Newly available sotalol hydrochloride and amiodarone hydrochloride were used in 3.6% of visits in 1994-1996.
Conclusions Despite changes in the treatment of atrial fibrillation, digoxin remains the dominant rate control medication. Medications for sinus rhythm maintenance are not widely used. Quinidine use declined prominently in the 1980s, possibly because of concerns about proarrhythmic effects. The use of sinus rhythm agents, however, is now rising.
From the General Medicine Division (Drs Stafford and Singer and Mss Robson and Misra) and the Cardiac Unit (Dr Ruskin), Massachusetts General Hospital, Medical Services and Department of Medicine, Harvard Medical School; and the Department of Epidemiology, Harvard School of Public Health (Dr Singer), Boston, Mass. Dr Stafford is now also with the Institute for Health Policy, Massachusetts General Hospital.
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