UNEXPECTED INSTANT DEATH FOLLOWING SUCCESSFUL CORONARY-ARTERY BYPASS GRAFT-SURGERY (AND OTHER CLINICAL SETTINGS) - ATRIAL-FIBRILLATION, QUINIDINE, PROCAINAMIDE, ET CETERA, AND INSTANT DEATH

Primum non nocere. Atrial fibrillation (AF) occurs commonly following coronary artery bypass graft surgery, although new onset atrial fibril lation in this setting is usually transient. When AF reverts or is con verted to sinus rhythm it is unlikely to recur, whether or not the pat ient takes preventive medication. As no benefit (and sometimes increas ed risk) associated with reduced mortality or morbidity in this settin g has been reported for antiarrhythmic agents, standard treatment shou ld consist of observation or control of ventricular response with an a ppropriate agent until AF relapses to sinus rhythm. If an antiarrhythm ic agent, especially a class I agent, is used because of persistent or recurrent AF in the early postoperative period, heart rhythm should b e monitored as long as the class I agent is administered and treatment initiated if an undesirable rhythm develops. Atrial fibrillation in o ther clinical settings in patients with structural heart disease prese nts a more difficult management problem. Class I agents are reported t o be associated with an increased risk of death, despite an efficaciou s effect of maintaining sinus rhythm. Amiodarone is reported to be wel l tolerated with respect to the cardiovascular system, but unacceptabl e noncardiac effects are reported. A safe amiodarone-like agent is gre atly needed. Atrial fibrillation in patients with no structural heart disease is not discussed in this presentation.