We report the case of a 46-year-old man who developed syncope, a widened QRS interval, and depressed left ventricular systolic function during propafenone therapy for atrial fibrillation. These acute findings may have been consequent to an increased dosage of propafenone combined with heavy alcohol consumption that led to decreased metabolism of propafenone. In addition, propafenone is known to interfere with liver function, although this patient’s test results showed scant evidence of liver abnormalities.
Yet another possible factor is the genetic spectrum in the metabolism of propafenone and other class I antiarrhythmic agents. When propafenone is prescribed, we recommend advising patients that alcohol consumption and interactions with other drugs can lead to increased levels of the antiarrhythmic agent, with resultant toxicity that can lead to adverse cardiovascular effects. Patients taking propafenone should also undergo periodic liver function testing. Finally, attention should be paid to voluntary or official recalls of specific antiarrhythmic medications that are of unreliable quality or potency.
Cardiovascular risk factor control is inadequate in many high-risk patients. Although many provider-directed educational interventions attempt to address this issue by enhancing provider self-efficacy, a link between greater self-efficacy and better patient outcomes has not been established. Primary care providers (PCPs) in outpatient clinics of a large Veteran’s Administration (VA) facility were asked to complete 4 subscales assessing self-efficacy and attitudes related to cardiovascular prevention (CVP).
Using a cross-sectional study design, responses were linked with process and CVP outcomes related to blood pressure (BP) and low-density lipoprotein-cholesterol (LDL-C) control and the Framingham Risk Score (FRS), a summary measure of risk factor control, in diabetic patients observed by participating PCPs between December 1, 2004 and December 31, 2005. Multivariable, multilevel models assessed associations between these patient outcomes and provider self-efficacy and CVP-related attitudes, after accounting for patient characteristics, including baseline risk factor control, provider characteristics, and patient clustering within provider practices. Fifty-nine PCPs (86%) providing care to 1495 patients with diabetes completed the survey. Mean scores for provider efficacy and CVP-related attitudes were moderate to high. Higher self-efficacy scores were associated with initiation of medications in previously untreated individuals with inadequate BP or lipid control at baseline. Despite adequate power, however, multilevel models demonstrated neither consistent nor substantive associations between providers’ self-efficacy and CVP-related attitudes and patient outcome measures. These findings underscore the need for interventions to enhance cardiovascular risk factor control that look beyond educational strategies to address a broader range of factors with potential influence on patient outcomes and the delivery of preventive care.