[Outpatient treatment of recurrent atrial fibrillation with the "pill-in-the-pocket" approach: practical aspects].

In patients with not very frequent episodes of atrial fibrillation (AF), highly symptomatic for palpitation, hemodynamically well tolerated but long enough to require emergency room (ER) intervention, the best outpatient treatment appears to be the "pill-in-the-pocket" approach. In several studies, in-hospital administration of flecainide or propafenone in a single oral loading dose has been shown to be effective and superior to placebo in terminating recent-onset AF. Recently, a multicenter Italian study has been carried out to evaluate the feasibility and the safety of self-administered oral loading of flecainide or propafenone in terminating AF of recent onset outside the hospital. Either flecainide or propafenone were administered orally to restore sinus rhythm in 268 patients with mild heart disease or none, who came to the ER with AF of recent onset that was hemodynamically well tolerated. Of these patients, 21% were excluded from the study because of treatment failure or side effects. During a mean follow-up of 15 months, 94% of the arrhythmic episodes were interrupted by the oral loading of flecainide or propafenone; the mean time to resolution of symptoms was about 2 hours. Adverse effects were reported during one or more arrhythmic episodes by 7% of the patients, including atrial flutter at a rapid ventricular rate in 1 patient. The numbers of monthly visits to the ER and hospitalizations were 90% lower during follow-up than the year before enrollment. These results show that in a selected, risk-stratified population of patients with recurrent AF, the "pill-in-the-pocket" treatment is feasible and safe, with a high rate of compliance by patients, a low rate of adverse effects, and a marked reduction in ER visits. Some recommendations on the practical use of this type of treatment are given.