Sotalol is a commonly prescribed
antiarrhythmic drug (AAD) used for maintaining sinus rhythm in patients with
atrial fibrillation (AF). Although randomized studies have found that
sotalol can significantly delay time to AF recurrence, its association with mortality is less clear, particularly among those with
coronary artery disease. We examined outcomes of 2,838 patients with
coronary artery disease and AF. Using Cox proportional hazards modeling, landmark analysis, and time-dependent covariates for
drug therapy, we compared cumulative survival among patients treated with
sotalol (n = 226),
amiodarone (n = 856), or no AAD (n = 1,756). Median follow-up was 4.2 years (interquartile range [IQR] 2.0-7.4). The median age was 68 years (IQR 60-75). Compared with those treated with
amiodarone or no AAD, patients treated with
sotalol were less likely to be black (6% vs 13% vs 13%) and have a previous
myocardial infarction (35% vs 51% vs 48%) or a left ventricular ejection fraction <40% (13% vs 26% vs 21%). In follow-up, persistence of
sotalol was limited; 97% of patients treated with
sotalol were treated for <25% of the follow-up period. In adjusted analysis accounting for time on
therapy,
sotalol use was associated with an increased risk of all-cause death compared with no drug (hazard ratio 1.53, 95% confidence interval 1.19 to 1.96, p = 0.0009), but a decreased risk of death compared with
amiodarone (hazard ratio 0.72, 95% confidence interval 0.55 to 0.91, p = 0.0141). In conclusion,
sotalol therapy was more frequently used in patients with fewer co-morbidities, often discontinued early in follow-up, and was associated with increased mortality compared with no AAD but decreased mortality relative to
amiodarone.