Verapamil versus digoxin and acute versus routine serial cardioversion for the improvement of rhythm control for persistent atrial fibrillation.
OBJECTIVE
The VERDICT (Verapamil Versus Digoxin and Acute Versus Routine Serial Cardioversion Trial) is a prospective, randomized study to investigate whether: 1) acutely repeated serial electrical cardioversions (ECVs) after a relapse of atrial fibrillation (AF); and 2) prevention of intracellular calcium overload by verapamil, decrease intractability of AF.


BACKGROUND
Rhythm control is desirable in patients suffering from symptomatic AF.


METHODS
A total of 144 patients with persistent AF were included. Seventy-four (51%) patients were randomized to the acute (within 24 h) and 70 (49%) patients to the routine serial ECVs, and 74 (51%) patients to verapamil and 70 (49%) patients to digoxin for rate control before ECV and continued during follow-up (2 x 2 factorial design). Class III antiarrhythmic drugs were used after a relapse of AF. Follow-up was 18 months.


RESULTS
At baseline, there were no significant differences between the groups, except for beta-blocker use in the verapamil versus digoxin group (38% vs. 60%, respectively, p = 0.01). At follow-up, no difference in the occurrence of permanent AF between the acute and the routine cardioversion groups was observed (32% [95% confidence intervals (CI)] 22 to 44) vs. 31% [95% CI 21 to 44], respectively, p = NS), and also no difference between the verapamil- and the digoxin-randomized patients (28% [95% CI 19 to 40] vs. 36% [95% CI 25 to 48] respectively, p = NS). Multivariate Cox regression analysis revealed that lone digoxin use was the only significant predictor of failure of rhythm control treatment (hazard ratio 2.2 [95% CI 1.1 to 4.4], p = 0.02).


CONCLUSIONS
An acute serial cardioversion strategy does not improve long-term rhythm control in comparison with a routine serial cardioversion strategy. Furthermore, verapamil has no beneficial effect in a serial cardioversion strategy.
Hemels
Martin E W
ME
Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
Van Noord
Trudeke
T
Crijns
Harry J G M
HJ
Van Veldhuisen
Dirk J
DJ
Veeger
Nic J G M
NJ
Bosker
Hans A
HA
Wiesfeld
Ans C P
AC
Van den Berg
Maarten P
MP
Ranchor
Adelita V
AV
Van Gelder
Isabelle C
IC
D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy* / Q000628:therapy*; D002118:Calcium / Q000378:metabolism; D004077:Digoxin / Q000627:therapeutic use*; D004554:Electric Countershock; D005260:Female; D006470:Hemorrhage; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011788:Quality of Life; D012008:Recurrence; D013923:Thromboembolism; D016896:Treatment Outcome; D014700:Verapamil / Q000627:therapeutic use*
D000889:Anti-Arrhythmia Agents; D004077:Digoxin; D014700:Verapamil; D002118:Calcium