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Stimulation in Atrial Fibrillation To the Editor: Zhuang et al1 showed well that slowing the ventricular rate by atrioventricular nodal vagal stimulation (AVN-VS) improved hemodynamics during atrial fibrillation (AF). This gave better hemodynamic responses than slowing the ventricular rate by atrioventricular nodal ablation with right ventricular pacing, which caused adverse effects that the authors cited. The authors then wrongly concluded, “. . .we believe that this novel strategy (AVN-VS) might be applicable in some patients, eg, postoperative patients with AF.” However, atrial fibrillation after surgical operations, especially cardiac operations, is peculiar because it is self-limiting. This arrhythmia commonly starts on the second or third postoperative day, and it reverts to regular sinus rhythm in a few days if the fast ventricular rate is slowed. The ventricular rate can be slowed promptly and safely by giving intravenous digoxin, 15 to 19 micrograms per kg of lean body weight,2,3 using the dosing calculations of Roger Jelliffe et al.4 Digoxin stimulates the vagus nerve actively. -blockers can be used in addition to digoxin. Many doctors are rightly reluctant to estimate these higher digoxin doses because estimating can cause toxicity. In contrast, the calculations by Jelliffe et al of doses for dangerous drugs, including digoxin, are used in more than 100 institutions and are available (Laboratory of Applied Pharmacokinetics, University of Southern California, Los Angeles, Calif. contact@lapk.org). AVN-VS is an effective treatment. However, doctors should give postoperative patients the benefits of digoxin therapy controlled by the same calculations of doses that they use for other dangerous drugs, such as aminoglycosides. This costs less money and is less disturbing to the patients than other treatments.

Inappropriate Use of Atrioventricular Nodal Vagal Stimulation in Atrial Fibrillation