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Nifekalant-Magnesium Cocktail for Chemical Cardioversion of Atrial Flutter: A Multicenter Pilot Study

Akinori Sairaku1,2, Michitaka Amioka3, Yoshikazu Watanabe4

  • 1Department of Cardiology, National Hospital Organization Higashihiroshima Medical Center, Higashihiroshima, Japan.

Pacing and Clinical Electrophysiology : PACE
|May 21, 2026
PubMed
Abstract

Insights

This pilot study found that combining nifekalant with magnesium sulfate successfully converted atrial flutter (AFL) in nearly half of patients. This nifekalant-magnesium combination appears feasible and safe for AFL chemical cardioversion.

Area of Science:

  • Cardiology
  • Electrophysiology
  • Pharmacology

Background:

  • Pharmacologic cardioversion for atrial flutter (AFL) is challenging, especially for elderly or frail patients unsuitable for ablation.
  • Nifekalant is effective for AFL but carries risks of QT prolongation and torsades de pointes (TdP).
  • Magnesium sulfate may reduce the risk of TdP associated with nifekalant.

Purpose of the Study:

  • To evaluate the feasibility and safety of using intravenous magnesium sulfate followed by nifekalant for chemical cardioversion of symptomatic persistent AFL.
  • To assess the efficacy of this combination therapy in terminating AFL within 60 minutes.
  • To identify factors associated with successful AFL termination.

Main Methods:

  • A multicenter, investigator-initiated pilot study involving 86 patients with symptomatic persistent AFL.
  • Patients received intravenous magnesium sulfate followed by nifekalant.
  • Primary outcome was AFL termination within 60 minutes; safety outcomes, including TdP, were monitored. Multivariable logistic regression was used to identify predictive factors.

Main Results:

  • Atrial flutter terminated in 42 patients (48.8%).
  • Successful cardioversion was achieved within 20 minutes in 80% of responders.
  • Larger left atrial diameter was linked to a lower chance of termination. Adverse events were rare (2.3%) and included sinus pauses and transient hypotension; no TdP occurred.

Conclusions:

  • The combination of nifekalant and magnesium sulfate shows potential as a feasible and safe option for chemical cardioversion of AFL.
  • Further investigation in larger clinical trials is warranted to confirm these findings.
  • This approach may offer an alternative for patients who are not candidates for catheter ablation.
Keywords:
atrial flutterchemical cardioversionmagnesium sulfatenifekalanttorsades de pointes

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