Letters to Editor

a β‑blocker or Calcium‑channel‑blocker should have been the first choice. Administration of amiodarone would never be a second choice for either of these purposes, since the patient was hemodynamically stable after administration of the first dose of diltiazem and was therefore a suitable candidate for initiation of an infusion of diltiazem. Esmolol could also have been chosen as a first or second line drug. It has been mentioned that in patients with adrenergically mediated lone AF, amiodarone should be chosen later in the sequence of drug therapy and is a less appealing selection due to its potential toxicity.[2] Therefore, the choice of amiodarone by the authors so early in the treatment was probably not justified. In cases of lone AF, amiodarone should only be chosen if β‑blockers and Ca‑channel‑blockers have been administered in the recommended dose and fail to achieve rate control and cardioversion.

Indira Malik Department of Anaesthesiology, GB Pant Hospital, New Delhi, India Address for correspondence: Dr. Indira Malik, F1/27, First Floor, Sector 11, Rohini, New Delhi - 110 085, India. E-mail: [email protected]

REFERENCES 1. Okuyan H, Altin C, Arihan O. Anaphylaxis during intravenous administration of amiodarone. Ann Card Anaesth 2013;16:229‑30. 2. Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/ AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology Foundation/ American Heart Association Task Force on practice guidelines. Circulation 2011;123:e269‑367. 3. Lévy S, Maarek M, Coumel P, Guize L, Lekieffre J, Medvedowsky JL, et al. Characterization of different subsets of atrial fibrillation in general practice in France: The ALFA study. The College of French Cardiologists. Circulation 1999;99:3028‑35. 4. Kopecky SL, Gersh BJ, McGoon MD, Whisnant JP, Holmes DR Jr, Ilstrup DM, et al. The natural history of lone atrial fibrillation. A population‑based study over three decades. N Engl J Med 1987;317:669‑74. 5. Clemo HF, Wood MA, Gilligan DM, Ellenbogen KA. Intravenous amiodarone for acute heart rate control in the critically ill patient with atrial tachyarrhythmias. Am J Cardiol 1998;81:594‑8. Access this article online Quick Response Code:

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Annals of Cardiac Anaesthesia    Vol. 17:1    Jan-Mar-2014

Authors’ reply The Editor, I thank the author for the supportive comments and criticisms to our article “anaphylaxis during intravenous administration of amiodarone”.[1] A trial fibrillation (AF) is the most common chronic cardiac arrhythmia occurring in 1‑2% of the general population.[2,3] AF is an independent risk factor for stroke; in fact, it increases the risk of stroke approximately fivefold.[4] In patients with AF, major mortality and morbidity are secondary to stroke and systemic embolism. The goals of management of acute AF are to relieve patients’ symptoms and to prevent thromboembolic complication especially stroke. Clinical evaluation of AF should include determination of the estimation of stroke risk and search for conditions that predispose to AF and for complications of the arrhythmia.[2,4] Many episodes of AF terminate spontaneously within the 1st h or days. Medical cardioversion is indicated in patients with recent‑onset AF who remain symptomatic despite adequate rate control. Pharmacological cardioversion may be initiated by a bolus administration of an antiarrhythmic drug. The conversion rate with antiarrhythmic drugs is lower than with direct current cardioversion, but does not require conscious sedation or anesthesia and may facilitate the choice of antiarrhythmic drug therapy to prevent recurrent AF. Several agents are available for pharmacological cardioversion.[4,5] The Task Force the European Society of Cardiology[4] for the Management of AF recommends intravenous flecainide or propafenone for cardioversion of recent‑onset AF when pharmacological cardioversion is preferred and there is no structural heart disease (Class I recommendation). In patients with recent‑onset AF and structural heart disease, intravenous amiodarone is recommended (Class I recommendation). Digoxin, verapamil, sotalol, metoprolol, other beta‑blocking agents and ajmaline are ineffective in converting recent onset AF to sinus rhythm and are not recommended (Class III recommendation).[4] Unfortunately, we did not have intravenous flecainide, propafenone or esmolol. Our patient was symptomatic even after rate control with administration of diltiazem. Therefore, we decided to administer amiodarone. Medical cardioversion was indicated in our patient, as she remained symptomatic even after adequate rate control. Therefore, amiodarone was administered for pharmacological cardioversion. It should be noted that The Task Force of the European Society of Cardiology has not considered metoprolol an effective drug for converting AF to sinus rhythm and not recommended.[4] 71

Letters to Editor

Hızır Okuyan, Cihan Altın, Okan Arıhan1 Department of Cardiology, Yenimahalle State Hospital, 1Department of Physiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey Address for correspondence: Dr. Hızır Okuyan, Yenibatı Mah, 2026 Cad, PK: 06370 Batıkent, Yenimahalle, Ankara, Turkey. E-mail: [email protected]

REFERENCES 1. Okuyan H, Altin C, Arihan O. Anaphylaxis during intravenous administration of amiodarone. Ann Card Anaesth 2013;16:229‑30. 2. Lloyd‑Jones DM, Wang TJ, Leip EP, Larson MG, Levy D, Vasan RS, et al. Lifetime risk for development of atrial fibrillation: The Framingham Heart Study. Circulation 2004;110:1042‑6. 3. Kannel WB, Benjamin EJ. Status of the epidemiology of atrial fibrillation. Med Clin North Am 2008;92:17‑40. 4. European Heart Rhythm Association, European Association for Cardio‑Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, Schotten U, et al. Guidelines for the management of atrial fibrillation: The task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010;31:2369‑429. 5. Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012;33:2719‑47.

Figure 1: Axial contrast-enhanced computed tomography of the chest shows the heterogeneously enhancing right paravertebral lesion (M) extending anteriorly. The arrow shows the displacement and compression of the vessel and Trachea (T). The esophagus depicted in the original case report is marked as E. The actual position of the esophagus is marked as small arrows (The figure is taken from the indexed case report and published with the permission of Medknow publications, India)

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In response to “Posterior mediastinal mass: Do we need to worry much ?” The Editor, We would like to put forth our view in response to “Posterior mediastinal mass: Do we need to worry much?” by Lalwani et al. [1] The article presents interesting facts. It introduces to the reader by stating that posterior mediastinal mass carries less anesthetic implications. The authors mention that these masses, with progression, can compress the vital structures including the trachea and the bronchus. The index 72

Figure 2: Axial contrast-enhanced computed tomography of the chest in an otherwise normal study. Note the contour and position of the trachea (T) and the esophagus (E)

patient has initially presented with pain, weakness and grade 1 dyspnea with hoarseness of voice. With the mention of the absence of orthopnea, non-productive cough, stridor etc. the authors, it seems, presumed that there is no airway compression. However, the given axial computed tomography image [Figure 1] shows evidence of airway compression. The scan clearly shows that the mass has started from the paravertebral region and extended anteriorly to push the esophagus and the trachea anteriorly. On comparison with a normal cross section image of the chest at this level, the displacement and loss of contour of the airway secondary to the compression by the mass is evident [Figure 2]. Even though, in the patient, there is lack of clinical evidence of the airway compression, the objective imaging evidence of airway compression should have warned Annals of Cardiac Anaesthesia    Vol. 17:1    Jan-Mar-2014

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In response to "Anaphylaxis during intravenous administration of amiodarone": is amiodarone the best choice for management of atrial fibrillation?

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