"Pill-In-The-Pocket" Antiarrhythmic drug therapy
Appropriate Candidates for PIP
  1. Symptomatic patients
  2. Sustained AF episodes (e.g. ≥ 2 hours)
  3. AF episodes that occur less frequently than monthly
  4. Absence of severe or disabling symptoms during an AF episode (e.g. fainting, severe chest pain, or breathlessness)
  5. Ability to comply with instructions, and proper medication use
Contraindication to PIP
  1. Significant structural heart disease (e.g. left ventricular systolic dysfunction [LVEF] < 50%, active ischemic heart disease, severe left ventricular hypertrophy)
  2. Abnormal conduction parameters at baseline (e.g. QRS duration > 120 msec, PR interval > 200 msec; or evidence of pre-excitation)
  3. clinical or electrocardiographic evidence of sinus node dysfunction/bradycardia or advanced AV block
  4. Hypotension (systolic BP < 100mmHg)
  5. Prior intolerance to any of the PIP-AAD medications
PIP Administration
Immediate release oral AV nodal blocker (one of diltiazem 60 mg, verapamil 80 mg, or metoprolol tartrate 25 mg) 30 minutes prior to the administration of a class Ic AAD (300 mg of flecainide or 600 mg of propafenone if ≥ 70 kg; 200 mg of flecainide or 450 mg of propafenone if < 70 kg)
Initial ED monitoring
  • Telemetry for at least 6 hours
  • Blood pressure monitoring every 30 minutes
  • 12-lead ECG monitoring every 2 hours
Determinants of initial treatment Failure
  1. AF persistence > 6 hours after PIP-AAD administration or electrical cardioversion required for termination
  2. Adverse events including symptomatic hypotension (systolic BP ≤ 90 mmHg), symptomatic conversion pauses (> 5 seconds), symptomatic bradycardia after sinus rhythm restoration, pro-arrhythmia (conversion to atrial flutter/tachycardia, or episodes of ventricular tachycardia), severe symptoms (dyspnea, presyncope, syncope), or a > 50% increase in QRS interval duration from baseline.
Instructions for subsequent use

Patients should take the AV nodal agent 30 minutes after the perceived arrhythmia onset, followed by the Class Ic AAD 30 minutes following the AV nodal agent.

Following AAD administration patients should rest in a supine or seated position for the next 4 hours, or until the episode resolves.

Patients should present to the emergency department in the event that:

  1. the AF episode did not terminate within 6-8 hours
  2. they felt unwell after taking the medication at home (e.g. a subjective worsening of the arrhythmia following AAD ingestion, or if they developed new or severe symptoms such as dyspnea, presyncope, or syncope)
  3. more than one episode occurred in a 24-hour period (patients were advised not to take a second PIP-AAD dose within 24 hours)
  4. if the AF episode was associated with severe symptoms at baseline (e.g. significant dyspnea, chest pain, pre-syncope, or symptoms of stroke), even in the absence of PIP-AAD use.