1
|
Maghrabi K, Uzun O, Kirsh JA, Balaji S, Von Bergen NH, Sanatani S. Cardiovascular Collapse with Intravenous Amiodarone in Children: A Multi-Center Retrospective Cohort Study. Pediatr Cardiol 2019; 40:925-933. [PMID: 30929065 DOI: 10.1007/s00246-019-02090-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 03/13/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine the incidence of cardiovascular collapse in children receiving intravenous (IV) amiodarone and to identify the population at risk. DESIGN A multicenter study of patients ≤ 18 years of age who received intravenous amiodarone between January 2005 and December 2015. A retrospective analysis was performed to identify patients who developed cardiovascular collapse (bradycardia and/or hypotension). RESULTS Of 456 patients who received amiodarone, cardiovascular collapse occurred in 47 patients (10%). Patient risk factors for collapse in a univariate analysis were as follows: age < 3 months (p = 0.04), depressed cardiac function (p < 0.001), blood pressure below 3rd percentile (p < 0.001), high lactate at baseline (p < 0.001). Administration risk factors included bolus administration (p = 0.04), and bolus administration over ≤ 20 min (p = 0.04). In multivariate analysis, age, baseline blood pressure less than 3rd percentile, and rapid bolus delivery were independent risk factors for cardiovascular collapse in the study group. The mortality rate was significantly higher in the collapse group (28% versus 8%). CONCLUSION We found an association between IV amiodarone administration and the risk of developing cardiovascular collapse in a significant subset of children. Extreme caution and careful hemodynamic monitoring is recommended when using IV amiodarone in this population, especially in young infants, hemodynamically compromised patients, and in patients receiving rapid amiodarone bolus administration.
Collapse
Affiliation(s)
- Khadijah Maghrabi
- Department of Pediatrics, Abdullah Bakhsh Children's Heart Center, King Abdulaziz University, PO Box 80215, Jeddah, 21589, Saudi Arabia.
| | - Orhan Uzun
- Department of Paediatric Cardiology, University Hospital Wales, Cardiff, UK
| | - Joel A Kirsh
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Forensic Services and Coroners Complex, Office of the Chief Coroner for Ontario, Toronto, Canada
| | - Seshadri Balaji
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | | | - Shubhayan Sanatani
- Children's Heart Centre, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
2
|
Dan GA, Martinez-Rubio A, Agewall S, Boriani G, Borggrefe M, Gaita F, van Gelder I, Gorenek B, Kaski JC, Kjeldsen K, Lip GYH, Merkely B, Okumura K, Piccini JP, Potpara T, Poulsen BK, Saba M, Savelieva I, Tamargo JL, Wolpert C, Sticherling C, Ehrlich JR, Schilling R, Pavlovic N, De Potter T, Lubinski A, Svendsen JH, Ching K, Sapp JL, Chen-Scarabelli C, Martinez F. Antiarrhythmic drugs–clinical use and clinical decision making: a consensus document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology (ESC) Working Group on Cardiovascular Pharmacology, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and International Society of Cardiovascular Pharmacotherapy (ISCP). Europace 2018; 20:731-732an. [DOI: 10.1093/europace/eux373] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 12/11/2017] [Indexed: 12/22/2022] Open
Affiliation(s)
- Gheorghe-Andrei Dan
- Colentina University Hospital, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
| | - Antoni Martinez-Rubio
- University Hospital of Sabadell (University Autonoma of Barcelona), Plaça Cívica, Campus de la UAB, Barcelona, Spain
| | - Stefan Agewall
- Oslo University Hospital Ullevål, Norway
- Institute of Clinical Sciences, University of Oslo, Søsterhjemmet, Oslo, Norway
| | - Giuseppe Boriani
- Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Martin Borggrefe
- Universitaetsmedizin Mannheim, Medizinische Klinik, Mannheim, Germany
| | - Fiorenzo Gaita
- Department of Medical Sciences, University of Turin, Citta' della Salute e della Scienza Hospital, Turin, Italy
| | - Isabelle van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bulent Gorenek
- Department of Cardiology, Eskisehir Osmangazi University, Büyükdere Mahallesi, Odunpazarı/Eskişehir, Turkey
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St. George’s, University of London, London, UK
| | - Keld Kjeldsen
- Copenhagen University Hospital (Holbæk Hospital), Holbæk, Institute for Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Centre For Cardiovascular Sciences, City Hospital, Birmingham, UK
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ken Okumura
- Saiseikai Akumamoto Hospital, Kumamoto, Japan
| | | | - Tatjana Potpara
- School of Medicine, Belgrade University; Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Magdi Saba
- Molecular and Clinical Sciences Research Institute, St. George’s, University of London, London, UK
| | - Irina Savelieva
- Molecular and Clinical Sciences Research Institute, St. George’s, University of London, London, UK
| | - Juan L Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense Madrid, Madrid, Spain
| | - Christian Wolpert
- Department of Medicine - Cardiology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | | | - Joachim R Ehrlich
- Medizinische Klinik I-Kardiologie, Angiologie, Pneumologie, Wiesbaden, Germany
| | - Richard Schilling
- Barts Heart Centre, Trustee Arrhythmia Alliance and Atrial Fibrillation Association, London, UK
| | - Nikola Pavlovic
- Department of Cardiology, University Hospital Centre Sestre milosrdnice, Croatia
| | | | - Andrzej Lubinski
- Uniwersytet Medyczny w Łodzi, Kierownik Kliniki Kardiologii Interwencyjnej, i Zaburzeń Rytmu Serca, Kierownik Katedry Chorób Wewnętrznych i Kardiologii, Uniwersytecki Szpital Kliniczny im WAM-Centralny Szpital Weteranów, Poland
| | | | - Keong Ching
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | | | | | - Felipe Martinez
- Instituto DAMIC/Fundacion Rusculleda, Universidad Nacional de Córdoba, Córdoba, Argentina
| | | |
Collapse
|
3
|
Modeling of Amiodarone Effect on Heart Rate Control in Critically Ill Patients with Atrial Tachyarrhythmias. Clin Pharmacokinet 2017; 55:991-1002. [PMID: 26946135 DOI: 10.1007/s40262-016-0372-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIMS Amiodarone is the gold-standard medication to control heart rate in critically ill patients with atrial tachyarrhythmias (ATs); however, effective doses and covariates influencing its efficacy remain unknown. We therefore performed pharmacodynamic modeling of heart rate reduction induced by amiodarone in these patients. METHODS AND RESULTS This observational study included 80 consecutive severely ill patients receiving amiodarone to treat ATs. A total of 1348 time-heart rate observations with 361 amiodarone dose administrations were analyzed during a period of up to 6 days after hospital treatment initiation using a nonlinear mixed-effect model. Pretreatment with amiodarone before intensive care administration, paroxysmal versus persistent AT, catecholamine infusion, and fluid and magnesium loading were among the covariates assessed in the model. In case of paroxysmal AT in a patient not pretreated with amiodarone, a 300 mg intravenous loading dose combined with an 800 mg oral dose on the first day, followed by 800 mg/day orally for 4 days was effective in achieving a heart rate between 80 and 115 bpm within the first day, and to maintain it during the next 4 days. Corresponding doses were twice as high in patients with persistent AT. Use of intravenous magnesium (p < 0.02) and fluid loading (p < 0.02) was associated with an earlier and greater heart rate decrease, while use of dobutamine had an opposite influence (p < 0.05). CONCLUSIONS In critically ill patients with AT, the dose of amiodarone required to control heart rate is influenced by the type of AT and by other easily measurable conditions which may allow better individualization of amiodarone dosing.
Collapse
|
4
|
Salem JE, Dureau P, Funck-Brentano C, Hulot JS, El-Aissaoui M, Aissaoui N, Urien S, Faisy C. Effectiveness of heart rate control on hemodynamics in critically ill patients with atrial tachyarrhythmias managed by amiodarone. Pharmacol Res 2017; 122:118-126. [PMID: 28610957 DOI: 10.1016/j.phrs.2017.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 05/03/2017] [Accepted: 06/09/2017] [Indexed: 11/19/2022]
Abstract
Atrial tachyarrhythmias (AT) are common in intensive care unit (ICU) patients and might contribute to hemodynamic instability if heart rate (HR) is persistently too rapid. We aimed to assess if HR control below 115 or 130bpm with amiodarone improves hemodynamics in ICU patients with AT. This observational study included 73 ICU patients with disabling AT receiving amiodarone for HR control. A total of 525 changes (mainly within 4-8h) in mean arterial pressure (MAP) and 167 changes in plasma lactate in response to HR variations above 115 or 130bpm were analyzed. Epinephrine, sedative drugs, fluid loading, use of diuretics, continuous renal replacement therapy and amiodarone dosing were among covariables assessed. Univariable analysis showed that HR variations above 115bpm were poorly correlated to change in MAP (r=0.11, p<0.01). Multivariable analysis showed that changes in MAP were still positively associated to HR variation (p<0.05) and to initiation or termination of epinephrine (p<0.05) or sedatives infusions (p<0.05). Changes in plasma lactate did not correlate to HR variations above 115bpm. When considering 130 bpm as a threshold, HR variations were not associated to changes in MAP or to changes in plasma lactate. Amiodarone dose was associated to HR decrease but not to MAP or plasma lactate increase. In ICU patients with AT, strict HR control below 115bpm or 130bpm with amiodarone does not improve hemodynamics. A prospective randomized trial assessing strict versus lenient HR control in this setting is needed.
Collapse
Affiliation(s)
- Joe-Elie Salem
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France; INSERM, CIC-1421 and UMR ICAN 1166, F-75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, Faculty of Medicine, Department of Pharmacology and UMR ICAN 1166, F-75013 Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), France; Cardiology - Rythmology Unit, Pitié-Salpêtrière Hospital, Assistance Publique - Hôpitaux de Paris, F-75013 Paris, France.
| | - Pauline Dureau
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France; INSERM, CIC-1421 and UMR ICAN 1166, F-75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, Faculty of Medicine, Department of Pharmacology and UMR ICAN 1166, F-75013 Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), France
| | - Christian Funck-Brentano
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France; INSERM, CIC-1421 and UMR ICAN 1166, F-75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, Faculty of Medicine, Department of Pharmacology and UMR ICAN 1166, F-75013 Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), France
| | - Jean-Sébastien Hulot
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France; INSERM, CIC-1421 and UMR ICAN 1166, F-75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, Faculty of Medicine, Department of Pharmacology and UMR ICAN 1166, F-75013 Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), France
| | - Maria El-Aissaoui
- Critical Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Nadia Aissaoui
- Critical Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Saik Urien
- CIC-1419 INSERM, EAU-08 University Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Christophe Faisy
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France; INSERM, CIC-1421 and UMR ICAN 1166, F-75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, Faculty of Medicine, Department of Pharmacology and UMR ICAN 1166, F-75013 Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), France; CIC-1419 INSERM, EAU-08 University Paris Descartes Sorbonne Paris Cité, Paris, France
| |
Collapse
|
5
|
Otuki S, Hasegawa K, Watanabe H, Katsuumi G, Yagihara N, Iijima K, Sato A, Izumi D, Furushima H, Chinushi M, Aizawa Y, Minamino T. The effects of pure potassium channel blocker nifekalant and sodium channel blocker mexiletine on malignant ventricular tachyarrhythmias. J Electrocardiol 2016; 50:277-281. [PMID: 28238302 DOI: 10.1016/j.jelectrocard.2016.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with repetitive ventricular tachyarrhythmias - so-called electrical storm - frequently require antiarrhythmic drugs. Amiodarone is widely used for the treatment of electrical storm but is ineffective in some patients. Therefore, we investigated the efficacy of stepwise administration of nifekalant, a pure potassium channel blocker, and mexiletine for electrical storm. METHODS This study included 44 patients with repetitive ventricular tachyarrhythmias who received stepwise therapy with nifekalant and mexiletine for electrical storm. Nifekalant was initially administered, and mexiletine was subsequently added if nifekalant failed to control ventricular tachyarrhythmias. RESULTS Nifekalant completely suppressed recurrences of ventricular arrhythmias in 28 patients (64%), including 6 patients in whom oral amiodarone failed to control arrhythmias. In 9 of 16 patients in whom nifekalant was partially effective but failed to suppress ventricular arrhythmias, mexiletine was added. The addition of mexiletine prevented recurrences of ventricular tachyarrhythmias in 5 of these 9 patients (56%). There was no death associated with electrical storm. In total, the stepwise treatment with nifekalant and mexiletine was effective in preventing ventricular tachyarrhythmias in 33 of 44 patients (75%). There was no difference in cycle length of the ventricular tachycardia, QRS interval, QT interval, or left ventricular ejection fraction between patients who responded to antiarrhythmic drugs and those who did not. During follow-up, 8 patients had repetitive ventricular tachyarrhythmia recurrences, and the stepwise treatment was effective in 6 of these 8 patients (75%). CONCLUSIONS The stepwise treatment with nifekalant and mexiletine was highly effective in the suppression of electrical storm.
Collapse
Affiliation(s)
- Sou Otuki
- Department of Cardiovascular Biology and Medicine, Niigata University School of Medical and Dental Sciences, Niigata, Japan.
| | - Kanae Hasegawa
- Department of Cardiovascular Biology and Medicine, Niigata University School of Medical and Dental Sciences, Niigata, Japan
| | - Hiroshi Watanabe
- Department of Cardiovascular Biology and Medicine, Niigata University School of Medical and Dental Sciences, Niigata, Japan
| | - Goro Katsuumi
- Department of Cardiovascular Biology and Medicine, Niigata University School of Medical and Dental Sciences, Niigata, Japan
| | - Nobue Yagihara
- Department of Cardiovascular Biology and Medicine, Niigata University School of Medical and Dental Sciences, Niigata, Japan
| | - Kenichi Iijima
- Department of Cardiovascular Biology and Medicine, Niigata University School of Medical and Dental Sciences, Niigata, Japan
| | - Akinori Sato
- Department of Cardiovascular Biology and Medicine, Niigata University School of Medical and Dental Sciences, Niigata, Japan
| | - Daisuke Izumi
- Department of Cardiovascular Biology and Medicine, Niigata University School of Medical and Dental Sciences, Niigata, Japan
| | - Hiroshi Furushima
- Department of Cardiovascular Biology and Medicine, Niigata University School of Medical and Dental Sciences, Niigata, Japan
| | - Masaomi Chinushi
- Department of Cardiovascular Biology and Medicine, Niigata University School of Medical and Dental Sciences, Niigata, Japan
| | - Yoshifusa Aizawa
- Department of Cardiovascular Biology and Medicine, Niigata University School of Medical and Dental Sciences, Niigata, Japan
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Niigata University School of Medical and Dental Sciences, Niigata, Japan
| |
Collapse
|
6
|
Hashmi A, Keswani NR, Kim S, Graham DY. Hepatic Dysfunction in Patients Receiving Intravenous Amiodarone. South Med J 2016; 109:83-6. [PMID: 26840961 DOI: 10.14423/smj.0000000000000413] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Amiodarone is a commonly used antiarrhythmic drug. Hepatotoxicity following chronic oral administration occurs in 1% to 3% of patients. Hepatotoxicity following intravenous (IV) administration is infrequent but may be associated with dramatic increases in serum transaminases. We describe the incidence of liver toxicity among patients receiving IV amiodarone during a 5-year period. METHODS This was a single-center retrospective review of patients receiving IV amiodarone for any cause. The outcome measures were development of elevated serum transaminases and the relation of transaminitis to all-cause 30-day mortality. RESULTS A total of 1510 patients received amiodarone intravenously between 2005 and 2011; 77 (5%) developed elevated liver enzymes. Enzyme elevation was divided into mild (100-300 IU/L), moderate (300-1000 IU/L), and severe (>1000 IU/L). The median alanine aminotransferase was 189 (37-10,006) IU/L and aspartate aminotransferase was 253 (84-12,005) IU/L. The 30-day mortality among those with transaminitis was 22%; however, no patient died of amiodarone-related liver disease. CONCLUSIONS Amiodarone can cause severe elevation in liver enzymes. The incidence of severe transaminitis is low; deaths following IV amiodarone are rarely caused by drug-induced liver failure.
Collapse
Affiliation(s)
- Ali Hashmi
- From the Department of Medicine and Pharmacy Service, Michael E. DeBakey VA Medical Center, and Baylor College of Medicine, Houston, Texas
| | - Nicole R Keswani
- From the Department of Medicine and Pharmacy Service, Michael E. DeBakey VA Medical Center, and Baylor College of Medicine, Houston, Texas
| | - Sharon Kim
- From the Department of Medicine and Pharmacy Service, Michael E. DeBakey VA Medical Center, and Baylor College of Medicine, Houston, Texas
| | - David Y Graham
- From the Department of Medicine and Pharmacy Service, Michael E. DeBakey VA Medical Center, and Baylor College of Medicine, Houston, Texas
| |
Collapse
|
7
|
Abstract
INTRODUCTION Persistent foetal tachyarrythmias complicated by hydrops fetalis carry a poor prognosis, with foetal death reported in excess of a quarter despite treatment. We present our experience with direct intraperitoneal amiodarone administration in eight hydropic foetuses with resistant supraventricular tachycardia. METHODS Amiodarone was injected slowly into foetal peritoneal cavity under ultrasound guidance. All mothers were loaded with oral amiodarone before the procedure and maintained on it. The procedure was repeated guided by foetal rhythm. RESULT All eight cases had severe hydrops with a median foetal heart rate of 255 bpm (range 240-300 bpm), and the median gestational age was 27+1 weeks (range 21-33+3 weeks) at presentation. In six cases, the average time for supraventricular tachycardia to revert to sinus rhythm from the first procedure was 11.5 days. In one case, intravascular injection of amiodarone into the umbilical vein was performed before intraperitoneal injection, which resulted in conversion to sinus rhythm sustained until delivery. In the last case, supraventricular tachycardia and severe hydrops persisted and the baby was delivered 5 days later at 34 weeks' gestation. Hydrops resolved in five foetuses with a mean resolution time of 28.4 days. The mean gestational age at delivery was 34+5 days and seven of eight cases survived beyond the neonatal period with good postnatal outcomes. CONCLUSION Intraperitoneal administration of amiodarone is a relatively simple and effective strategy in refractory supraventricular tachycardia complicated by severe hydrops. The intraperitoneal route assures delivery of the drug to the severely hydropic foetus and enables a bolus dose to be delivered for sustained absorption.
Collapse
|
8
|
Slavik RS. Intravenous amiodarone for acute pharmacological conversion of atrial fibrillation in the emergency department. CAN J EMERG MED 2012; 4:414-20. [PMID: 17637159 DOI: 10.1017/s1481803500007922] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia seen in patients presenting to the emergency department (ED). Pharmacological conversion of atrial fibrillation to normal sinus rhythm (NSR) may be a feasible management strategy in selected patients. Recent guidelines have recommended intravenous amiodarone, a class III antiarrhythmic agent, for the conversion of AF to NSR. The purpose of this review is to examine the published evidence for the efficacy of IV amiodarone for the acute conversion of AF to NSR in the ED. Currently available data from 11 randomized, controlled trials and 3 meta analyses do not support the use of conventional doses of IV amiodarone for acute conversion in the ED. High dose IV or combined IV and oral administration may be effective as early as 8 hours in patients with recent-onset AF of <48 hour duration in patients without contraindications to these high dose regimens. There are no data to support the use of IV amiodarone for acute conversion in patients with an ejection fraction of <40% or clinical heart failure, so its use in these scenarios should be limited to symptomatic patients who are refractory to electrical conversion. More well-designed studies are required to determine the role of IV amiodarone for the acute conversion of AF in the ED.
Collapse
Affiliation(s)
- Richard S Slavik
- Clinical Services Unit -- Pharmaceutical Sciences, Vancouver Hospital, Vancouver, British Columbia, Canada
| |
Collapse
|
9
|
SALERNO DAVIDM. Part IV: Class II, Class III, and Class IV Antiarrhythmic Drugs, Comparative Efficacy of Drugs, and Effect of Drugs on Mortality - A Review of Their Pharmaco kinetics, Efficacy, and Toxicity*. J Cardiovasc Electrophysiol 2008. [DOI: 10.1111/j.1540-8167.1991.tb01714.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
10
|
Cardiac Arrhythmias: Management of Atrial Fibrillation in the Critically Ill Patient. Crit Care Clin 2007; 23:855-72, vii. [DOI: 10.1016/j.ccc.2007.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
11
|
Marill KA, deSouza IS, Nishijima DK, Stair TO, Setnik GS, Ruskin JN. Amiodarone Is Poorly Effective for the Acute Termination of Ventricular Tachycardia. Ann Emerg Med 2006; 47:217-24. [PMID: 16492484 DOI: 10.1016/j.annemergmed.2005.08.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2005] [Revised: 08/16/2005] [Accepted: 08/23/2005] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE It is hypothesized that intravenous (IV) amiodarone is poorly effective for the acute termination of sustained monomorphic ventricular tachycardia because of the relatively slow onset of its Vaughn-Williams class III effect to prolong myocardial depolarization and the refractory period. This study is designed to determine the effectiveness and safety of IV amiodarone for the termination of sustained monomorphic ventricular tachycardia. METHODS A retrospective case series was collected at 4 urban university-affiliated hospitals from September 1996 to April 2005 after institutional review board approval with waiver of informed consent. Emergency department (ED) patients treated with IV amiodarone for ventricular tachycardia were identified by ED treatment and hospital pharmacy billing records, International Classification of Diseases, Ninth Revision discharge codes, and ECG characteristics. All consecutive patients who received at least 150 mg amiodarone in 15 minutes or less for spontaneous sustained monomorphic ventricular tachycardia were eligible for inclusion. Sustained monomorphic ventricular tachycardia was defined as a tachycardia with uninterrupted duration or rapid recurrence despite automatic internal cardiac defibrillator therapy for at least 5 minutes before amiodarone treatment, monomorphic morphology, rate greater than 120 beats/min, QRS duration greater than 120 ms, and subsequently determined to be ventricular tachycardia by ECG criteria (eg, atrioventricular dissociation), implanted device interrogation, or formal electrophysiology study. Measured outcomes included sustained termination of ventricular tachycardia within 20 minutes of initiation of amiodarone infusion and any documented adverse effects. Rates of successful termination and adverse effects and their 95% confidence intervals (CIs) were calculated. The presence or average values of potentially confounding predictors in patients with and without ventricular tachycardia termination after amiodarone were also calculated and compared. RESULTS Thirty-three patients were identified and included. Five patients received electrical therapy within 20 minutes of initiation of amiodarone infusion, and the response to amiodarone was unknown. Twenty-seven of the remaining 28 patients received 150 mg amiodarone, and the rate of successful ventricular tachycardia termination was 8 of 28, 29% (95% CI 13 to 49). Two of 33 patients, 6% (95% CI 1 to 20), required direct current cardioversion for presyncope or hypotension temporally associated with amiodarone treatment. CONCLUSION IV amiodarone, as currently administered, is relatively safe but ineffective for the acute termination of sustained ventricular tachycardia.
Collapse
|
12
|
Rätz Bravo AE, Drewe J, Schlienger RG, Krähenbühl S, Pargger H, Ummenhofer W. Hepatotoxicity during rapid intravenous loading with amiodarone: Description of three cases and review of the literature. Crit Care Med 2005; 33:128-34; discussion 245-6. [PMID: 15644659 DOI: 10.1097/01.ccm.0000151048.72393.44] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Atrial fibrillation is the most common arrhythmia after cardiac surgery. Amiodarone can effectively prevent and control postoperative atrial and ventricular fibrillation. Acute hepatic damage after intravenous amiodarone, which can be fatal, is not well recognized. We describe three cases of acute hepatocellular injury after intravenous amiodarone administration in critically ill patients. Another 25 published cases and six cases reported to the Swiss Pharmacovigilance Center (Swissmedic) are discussed. DESIGN This study consisted of a series of three case reports and review of the literature. SETTING : This study was conducted at an operative critical care unit at the University Hospital Basel, Switzerland. PATIENTS Three hemodynamically compromised patients after open heart surgery developed significant increases of transaminases (up to more than 100-fold of the upper limit of normal) shortly after the introduction of intravenous amiodarone. INTERVENTIONS AND MEASUREMENT: Cessation of intravenous amiodarone and of other potentially hepatotoxic drugs. RESULTS Liver parameters significantly improved or returned to normal in all three patients, even after start of oral amiodarone in two patients. CONCLUSIONS Amiodarone is a highly effective antiarrhythmic agent for the treatment and prevention of atrial and ventricular arrhythmias. Acute liver damage after intravenous amiodarone, possibly induced by the solubilizer polysorbate 80, is rare but potentially harmful. Amiodarone loading should therefore be adapted to the necessity of an immediate effect of the drug, and liver function should be monitored closely in critically ill patients. Oral maintenance therapy with amiodarone is possible, even in patients who developed liver disease during intravenous loading.
Collapse
Affiliation(s)
- Alexandra E Rätz Bravo
- Division of Clinical Pharmacology & Toxicology, University Hospital of Basel, CH-4031 Basel, Switzerland
| | | | | | | | | | | |
Collapse
|
13
|
Mayr AJ, Dünser MW, Ritsch N, Pajk W, Friesenecker B, Knotzer H, Ulmer H, Wenzel V, Hasibeder WR. High-dosage continuous amiodarone therapy to treat new-onset supraventricular tachyarrhythmias in surgical intensive care patients: an observational study. Wien Klin Wochenschr 2004; 116:310-7. [PMID: 15237656 DOI: 10.1007/bf03040901] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND New-onset supraventricular tachyarrhythmias (SVTA) are a complication contributing significantly to morbidity and mortality in surgical intensive care unit (SICU) patients. Although only few data on efficiency can be found in the literature, class III antiarrhythmics have become popular in the treatment of SVTA in critically ill patients. SETTING 12-bed general and surgical ICU in a university teaching hospital. DESIGN Observational, retrospective study. PATIENTS 131 SICU patients with SVTA (narrow-complex non-sinus tachyarrhythmias with heart rates > or = 100 bpm). INTERVENTION High-dosage amiodarone infusion according to an institutional protocol. MEASUREMENTS Hemodynamic data, acid-base status, and single organ functions were obtained in all patients before amiodarone infusion and at 12, 24, and 48 hours afterwards. Patients were divided into responders and nonresponders. Amiodarone infusion (mean dosage 24 h: 1625+/-528 mg; 48 h: 2708+/-895 mg) restored sinus rhythm in 54% of study patients within 12 h, in 64% within 24 h, and in 75% within 48 h. Heart rate, central venous pressure, and milrinone requirements significantly decreased in all patients; this was accompanied by a significant increase in stroke-volume index and mean arterial pressure. Serum concentrations of creatinine and bilirubin increased in all patients. CONCLUSION High-dosage continuous amiodarone infusion during a period of 48 hours resulted in restoration of SR in 75% of SICU patients with new-onset SVTA and moderate to severe multiple-organ dysfunction syndrome. A significant improvement in cardiocirculatory function was more pronounced in responders but could be demonstrated irrespective of restoration of sinus rhythm in all patients. Apart from a possibly amiodarone-mediated increase in concentrations of creatinine and bilirubin, no major drug-related adverse effects occurred during the observation period.
Collapse
Affiliation(s)
- Andreas J Mayr
- Division of General and Surgical Intensive Care Medicine, Department of Anesthesiology and Critical Care Medicine, Leopold-Franzens-University, Innsbruck, Austria.
| | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Cheung AT, Weiss SJ, Savino JS, Levy WJ, Augoustides JG, Harrington A, Gardner TJ. Acute circulatory actions of intravenous amiodarone loading in cardiac surgical patients. Ann Thorac Surg 2003; 76:535-41. [PMID: 12902100 DOI: 10.1016/s0003-4975(03)00509-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The duration, severity, and cause of hypotension after intravenous amiodarone has not been well characterized in anesthetized cardiac surgical patients. Because amiodarone is tolerated in patients with advanced cardiac disease, we hypothesized that left ventricular systolic performance is preserved despite hypotension during amiodarone loading. METHODS In a prospective double-blind trial, 30 patients undergoing coronary artery bypass graft (CABG) surgery were randomly assigned to receive intravenous amiodarone (n = 15) or placebo (n = 15). Cardiac output (CO), mixed venous oxygen saturation (SVO), arterial blood pressure (systolic blood pressure [SBP], diastolic blood pressure [DBP], mean arterial pressure [MAP]), pulmonary artery pressure, and central venous pressure (CVP) were recorded. Transesophageal echocardiographic left ventricular end-diastolic area (EDA), end-systolic area (ESA), fractional area change (FAC), and end-systolic wall stress (ESWS) were measured every 5 minutes. RESULTS Mean arterial pressure, SBP, and DBP decreased over time after drug administration in both groups (p < 0.05). At 6 minutes, amiodarone decreased the MAP by 14 mm Hg (p = 0.004) and placebo decreased the MAP by 4 mm Hg. The change in MAP, SBP, and DBP between groups was statistically different for the first 15 minutes after drug administration. Hypotension requiring intervention occurred in 3 of 15 after amiodarone and 0 of 15 after placebo (p = 0.22). The mean heart rate was 11.5 beats per minute less after amiodarone (p < 0.02), but pulmonary artery pressure, CVP, SVO, and FAC were not different between groups. CONCLUSIONS Intravenous amiodarone decreased heart rate and caused a significant, but transient decrease in arterial pressure in the first 15 minutes after administration. Left ventricular performance was maintained suggesting that selective arterial vasodilation was the primary cause of drug-induced hypotension.
Collapse
Affiliation(s)
- Albert T Cheung
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania 19104-4283, USA.
| | | | | | | | | | | | | |
Collapse
|
15
|
Chevalier P, Durand-Dubief A, Burri H, Cucherat M, Kirkorian G, Touboul P. Amiodarone versus placebo and class Ic drugs for cardioversion of recent-onset atrial fibrillation: a meta-analysis. J Am Coll Cardiol 2003; 41:255-62. [PMID: 12535819 DOI: 10.1016/s0735-1097(02)02705-5] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This meta-analysis compared amiodarone with placebo and class Ic drugs for the cardioversion of recent-onset atrial fibrillation (AF), defined as lasting less than seven days. BACKGROUND Despite the lack of trials that support its efficacy convincingly, amiodarone is widely used for conversion of recent-onset AF. METHODS We searched Medline and EMBASE databases, as well as the Cochrane Controlled Trials Register for randomized trials on recent-onset AF comparing amiodarone to placebo or class Ic drugs. Data were combined according to a fixed effect model. The primary end point was the rate of conversion at 24 h. To study time-dependency of the drugs, efficacy at 1 to 2 h, 3 to 5 h, 6 to 8 h, and at 24 h was analyzed. RESULTS We found six studies randomizing amiodarone versus placebo (595 patients) and seven studies versus class Ic drugs (579 patients). There was no significant difference between amiodarone and placebo at 1 to 2 h, but significant efficacy was found after 6 to 8 h (relative risk [RR] 1.23, p = 0.022) and at 24 h (RR 1.44, p < 0.001). Efficacy with amiodarone was inferior to class Ic drugs for up to 8 h (RR 0.67, p < 0.001) but no difference was seen at 24 h (RR 0.95, p = 0.50). There were no major adverse effects. CONCLUSIONS Amiodarone is superior to placebo for cardioversion of AF, and even though the onset of conversion is delayed, its efficacy is similar at 24 h compared with class Ic drugs. These results favor amiodarone as a reasonable alternative for patients with recent AF in whom class Ic and other, more rapidly acting antiarrhythmic drugs cannot be used.
Collapse
Affiliation(s)
- Philippe Chevalier
- Département de cardiologie et de soins intensifs, Hôpital Louis Pradel, Lyon, France.
| | | | | | | | | | | |
Collapse
|
16
|
Rousseau MF, Massart PE, van Eyll C, Etienne J, Ahn S, Ghadanfar M, Friedrich T, Pouleur H. Cardiac and hemodynamic effects of intravenous dofetilide in patients with heart failure. Am J Cardiol 2001; 87:1250-4. [PMID: 11377349 DOI: 10.1016/s0002-9149(01)01514-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This study assesses the effects of dofetilide, a new selective Ikr blocker with class III properties, on left ventricular function and hemodynamics of heart failure and compares these effects with those of placebo and amiodarone. Because available antiarrhythmic drugs may depress myocardial performance, an invasive hemodynamic study was performed to assess the safety of this agent. Hemodynamic and angiographic data were obtained at baseline and after 30 minutes of double-blind infusion of dofetilide (8 microg/kg; n = 12), placebo (n = 12), or amiodarone (5 mg/kg; n = 6) in heart failure patients (New York Heart Association class II or III, ejection fraction <35%). Intravenous dofetilide preserved the inotropic indexes and the end-systolic volume index despite a slight but significant decrease in heart rate, whereas intravenous amiodarone increased end-diastolic and end-systolic volume indexes. Amiodarone induced a negative inotropic effect illustrated by a rightward shift of the pressure-volume loop and a reduction in pressure-derived indexes of contractility. Intravenous dofetilide acutely prolonged QT interval more than intravenous amiodarone; however, dofetilide did not slow the overall relaxation rate and reduced QT dispersion. In an acute setting, compared with intravenous amiodarone, intravenous dofetilide preserves cardiac function offering a hemodynamic advantage to treat arrhythmias in patients with impaired left ventricular function.
Collapse
Affiliation(s)
- M F Rousseau
- Division of Cardiology, University of Louvain, Brussels, Belgium.
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Bicer S, Schwartz D, Nakayama T, Hamlin R. Hemodynamic and Electrocardiographic Effects of Graded Doses of Amiodarone in Healthy Dogs Anesthetized with Morphine/Alpha Chloralose. J Vet Intern Med 2000. [DOI: 10.1111/j.1939-1676.2000.tb01505.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
18
|
Kreiss Y, Sidi Y, Gur H. Efficacy and safety of intravenous amiodarone in recent-onset atrial fibrillation: experience in patients admitted to a general internal medicine department. Postgrad Med J 1999; 75:278-81. [PMID: 10533631 PMCID: PMC1741237 DOI: 10.1136/pgmj.75.883.278] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We examined the efficacy and safety of intravenous amiodarone in 20 unselected patients with recent-onset atrial fibrillation who were admitted to a general internal medicine department during a 6-month period. The treatment protocol included a loading dose of 1200 mg intravenous amiodarone in 24 hours, after which amiodarone treatment was continued orally. Eleven of the 20 patients (55%) converted to sinus rhythm within 48 hours of intravenous amiodarone treatment and were discharged in sinus rhythm, while 9/20 (45%) patients failed to convert during hospitalisation. Six patients (30%) failed to convert to sinus rhythm even after one further month of oral treatment. There was one death and a high frequency (25%) of thrombophlebitis during hospitalisation. The in-hospital non-convertors had a significantly lower ejection fraction and initial low ventricular response rate than the convertors. In conclusion, the acute conversion rate by intravenous amiodarone was at best modest. It is suggested that intravenous amiodarone is probably more effective in patients with rapid recent-onset atrial fibrillation and good left ventricular function.
Collapse
Affiliation(s)
- Y Kreiss
- Department of Medicine C, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | | | | |
Collapse
|
19
|
Kowey PR, Marinchak RA, Rials SJ, Bharucha D. Pharmacologic and pharmacokinetic profile of class III antiarrhythmic drugs. Am J Cardiol 1997; 80:16G-23G. [PMID: 9354408 DOI: 10.1016/s0002-9149(97)00710-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Cardiac arrhythmias frequently respond only to drugs that have as their predominant electrophysiologic effect the prolongation of repolarization and refractoriness. According to the Singh-Vaughan Williams classification, these drugs are known as class III agents. In the last few years, interest has increased in the development of class III antiarrhythmic drugs as alternatives to sodium channel blocking agents, which mainly affect cardiac conduction. Much of this interest results from a perceived danger of using drugs with sodium channel blocking properties, particularly in patients with ischemic heart disease, based on the results of the Cardiac Arrhythmia Suppression Trial (CAST) and several other trials. This article is a review of the pharmacology, including the pharmacokinetics and pharmacodynamics, of the most commonly used and investigated class III antiarrhythmic drugs. As will be seen from the discussion, each of these drugs has novel pharmacology that makes it applicable in specific clinical situations. Their putative effects on various arrhythmogenic mechanisms and their efficacy in treating specific target arrhythmias will be addressed.
Collapse
Affiliation(s)
- P R Kowey
- Division of Cardiovascular Diseases, Lankenau Hospital and Medical Research Center, Wynnewood, Pennsylvania 19096, USA
| | | | | | | |
Collapse
|
20
|
Stambler BS, Beckman KJ, Kadish AH, Camm JA, Ellenbogen KA, Perry KT, VanderLugt JT. Acute hemodynamic effects of intravenous ibutilide in patients with or without reduced left ventricular function. Am J Cardiol 1997; 80:458-63. [PMID: 9285658 DOI: 10.1016/s0002-9149(97)00395-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Many antiarrhythmic agents have adverse hemodynamic effects which limit their use in patients with impaired ventricular function or during tachyarrhythmias. Ibutilide is an intravenous, selective class III antiarrhythmic agent that is effective for conversion of atrial fibrillation or flutter. This multicenter, randomized, placebo-controlled, dose-ranging study evaluated the effects of intravenous ibutilide on hemodynamic parameters during invasive monitoring in 47 patients with or without reduced left ventricular ejection fraction (LVEF) > 35% or < or = 35%. Patients received either placebo or ibutilide as a 10-minute loading and a 30-minute maintenance infusion using 1 of the following dosing regimens: placebo then placebo (n = 12); 0.01 then 0.002 mg/kg (n = 12); 0.02 then 0.004 mg/kg (n = 12); or 0.03 then 0.006 mg/kg (n = 11). Ibutilide significantly increased QT and QTc intervals in a dose-related manner with mean increases ranging from 51 to 99 ms, but did not alter the PR interval or QRS duration. During ibutilide infusion, a few small but statistically significant changes from baseline in several hemodynamic variables were present. However, the changes in cardiac output, pulmonary artery or capillary wedge pressures, blood pressure, or heart rate in patients receiving ibutilide were not significantly different from the changes in patients receiving placebo. Thus, ibutilide did not cause clinically important adverse hemodynamic effects, even in patients with depressed ventricular function. One patient developed 2 episodes of nonsustained torsades de pointes during ibutilide. These results demonstrate that with careful monitoring for proarrhythmia, ibutilide can be used safely from a hemodynamic standpoint in the acute treatment of arrhythmias, even in patients with reduced ventricular function.
Collapse
Affiliation(s)
- B S Stambler
- West Roxbury Veterans Affairs Medical Center and Harvard Medical School, Massachusetts 02132, USA
| | | | | | | | | | | | | |
Collapse
|
21
|
Vadiei K, Troy S, Korth-Bradley J, Chiang ST, Zimmerman JJ. Population pharmacokinetics of intravenous amiodarone and comparison with two-stage pharmacokinetic analysis. J Clin Pharmacol 1997; 37:610-7. [PMID: 9243354 DOI: 10.1002/j.1552-4604.1997.tb04343.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The disposition of amiodarone, an antiarrhythmic agent was evaluated after a single intravenous infusion (5 mg/kg over 15 minutes) in patients of various ages and with various degrees of renal function and left ventricular function. The plasma concentration-time data were obtained from three clinical studies with similar protocols. The data were analyzed by nonlinear mixed-effects modeling (NONMEM) to estimate the population pharmacokinetic parameters of amiodarone and to determine the significant demographic covariates affecting these parameters. The pharmacokinetic parameters of amiodarone (weight-corrected) also were calculated using two-stage analysis and were compared with the results obtained from the mixed-effects analysis. The population plasma concentration-time profile of amiodarone was best described by a four-compartment model. Demographic covariates (i.e., creatinine clearance and ejection fraction) did not improve the final pharmacostatistical model significantly. The results from the two-stage analysis showed no significant relationship between amiodarone pharmacokinetic parameters and age, gender, renal function, or ejection fraction. The results from one study, however, demonstrated that advanced age (> or = 65 years) resulted in reduced amiodarone clearance coupled with a prolonged elimination half-life. No such correlation was detected with NONMEM analysis, which may be partly attributable to the small number of elderly patients. Overall, the results from NONMEM analysis validated the results obtained from the two-stage analysis.
Collapse
Affiliation(s)
- K Vadiei
- Medical Affairs Department, Wyeth-Ayerst Laboratories, Philadelphia, PA 19101, USA
| | | | | | | | | |
Collapse
|
22
|
Abstract
Intravenous amiodarone was approved in 1995 for the treatment of malignant and resistant ventricular arrhythmia. Although it is an "old drug," much has been learned recently about this complex drug and its application in a variety of cardiac arrhythmias. The objectives of this review were to summarize what is known about intravenous amiodarone, including its pharmacologic and electrophysiologic effects, to review its efficacy for the treatment of patients with highly malignant ventricular arrhythmia and to provide specific information about its clinical use for this and other indications. The studies that were reviewed were selected on the basis of time published (from 1983 to 1995) and the completeness of information provided regarding patient clinical characteristics, drug dosing and methods of evaluation, efficacy analyses, long-term follow-up and complications. The full data from the three controlled trials that formed the basis of the drug's approval are contained in published reports that were also extensively reviewed. Intravenous amiodarone has demonstrable efficacy for the treatment of frequently recurrent destabilizing ventricular tachycardia and ventricular fibrillation, with suppression rates of 63% to 91% in uncontrolled trials. The three pivotal trials confirmed these findings and demonstrated a dose-response relation, with at least comparable efficacy to bretylium, a drug with a similar indication. The safety profile has also been well described; cardiovascular adverse effects are the most frequent, especially hypotension. Intravenous amiodarone is a useful addition to the drugs available for the treatment of patients with very severe ventricular arrhythmia. Its use in patients with other rhythm disorders appears promising, but final recommendations must await development of definitive data from ongoing clinical trials.
Collapse
Affiliation(s)
- P R Kowey
- Division of Cardiovascular Diseases, Lankenau Hospital and Medical Research Center, Wynnewood, Pennsylvania 19096, USA
| | | | | | | |
Collapse
|
23
|
Kennedy JA, Unger SA, Horowitz JD. Inhibition of carnitine palmitoyltransferase-1 in rat heart and liver by perhexiline and amiodarone. Biochem Pharmacol 1996; 52:273-80. [PMID: 8694852 DOI: 10.1016/0006-2952(96)00204-3] [Citation(s) in RCA: 158] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The mechanism of the anti-anginal effect of perhexiline is unclear but appears to involve a shift in cardiac metabolism from utilization of fatty acid to that of carbohydrate. We tested the hypothesis that perhexiline inhibits the enzyme carnitine palmitoyltransferase-1 (CPT-1), which controls access of long chain fatty acids to the mitochondrial site of beta-oxidation. Perhexiline produced a concentration-dependent inhibition of CPT-1 in rat cardiac and hepatic mitochondria in vitro, with half-maximal inhibition (IC50) at 77 and 148 mumol/L, respectively. Amiodarone, another drug with anti-anginal properties, also inhibited cardiac CPT-1 (IC50 = 228 mumol/L). The rank order of potency for inhibition was malonyl-CoA > 4-hydroxyphenylglyoxylate (HPG) = perhexiline > amiodarone = monohydroxy-perhexiline. Kinetic analysis revealed competitive inhibition of cardiac and hepatic CPT-1 by perhexiline with respect to palmitoyl-CoA but non-competitive inhibition with respect to carnitine. Curvilinear Dixon plots generated "apparent inhibitory constant (Ki)" values for perhexiline, which indicated a greater sensitivity of the cardiac than the hepatic enzyme to inhibition by perhexiline. Perhexiline inhibition of CPT-1, unlike that of malonyl-CoA and HPG, was unaffected by pretreatment with the protease nagarse. These data establish for the first time that two agents with proven anti-anginal effects inhibit cardiac CPT-1. This action is likely to contribute to the anti-ischaemic effects of both perhexiline and amiodarone.
Collapse
Affiliation(s)
- J A Kennedy
- Department of Cardiology, Queen Elizabeth Hospital, University of Adelaide, Woodville, South Australia
| | | | | |
Collapse
|
24
|
Abstract
OBJECTIVE To review the clinical pharmacology, pharmacokinetics, and clinical efficacy and safety of intravenous amiodarone. DATA IDENTIFICATION Articles were identified through a computer search of the English-language literature using MEDLINE (KR Information OnDisc) and the search term amiodarone. Additional articles were identified through examination of the bibliographies of the articles initially retrieved. STUDY SELECTION Relevant or representative animal studies, clinical trials, and case reports were selected for evaluation. Particular emphasis was placed on studies pertaining to the use of intravenous amiodarone in treatment-refractory ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT). DATA EXTRACTION The literature was assessed for adequate description of patients, study methodologies (e.g., study design, number of patients), and outcomes. DATA SYNTHESIS Amiodarone is an unusual class III antiarrhythmic that produces each of the four main types of antiarrhythmic action in addition to other effects, such as vasodilatory, selective antithyroid, and other activities that may be therapeutically relevant. Amiodarone pharmacokinetics demonstrate extensive interpatient variability and are characterized by wide tissue distribution (steady-state volume of distribution 40-84 L/kg), slow total body clearance (90-158 mL/h/kg), long terminal elimination half-life (20-47 d), and extensive hepatic metabolism. The onset of maximal antiarrhythmic effect is a function of both amiodarone dosage and time. The high plasma concentrations achieved with intravenous dosing do not fully replicate the electrophysiologic effects observed following long-term oral administration, particularly with respect to class III activity. Available data suggest that intravenous amiodarone is associated with an efficacy rate of 50% or more in treatment-refractory VT/VF, and has a relatively rapid (2-24 h) onset of action. The drug is relatively well tolerated, but close hemodynamic, electrocardiographic, and hepatic function monitoring are required. The value of using amiodarone serum concentrations to guide therapy remains uncertain. CONCLUSIONS Intravenous amiodarone is an effective, relatively safe antiarrhythmic for the treatment of recurrent, hemodynamically unstable VT/VF refractory to other drug therapy in the acute care setting.
Collapse
Affiliation(s)
- M S Chow
- School of Pharmacy, University of Connecticut, Hartford, USA
| |
Collapse
|
25
|
Perry JC, Fenrich AL, Hulse JE, Triedman JK, Friedman RA, Lamberti JJ. Pediatric use of intravenous amiodarone: efficacy and safety in critically ill patients from a multicenter protocol. J Am Coll Cardiol 1996; 27:1246-50. [PMID: 8609351 DOI: 10.1016/0735-1097(95)00591-9] [Citation(s) in RCA: 152] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The purpose of this study was to analyze the efficacy and safety of intravenous amiodarone in young patients with critical, drug-resistant arrhythmias. BACKGROUND Intravenous amiodarone has been investigated in adults since the early 1980s. Experience with the drug in young patients is limited. A larger pediatric study group was necessary to provide responsible guidelines for the drug's use before its market release. METHODS Eight centers obtained institutional approval of a standardized protocol. Other centers were approved on a compassionate use basis after contacting the primary investigator (J.C.P). RESULTS Forty patients were enrolled. Standard management in all failed. Many patients had early postoperative tachyarrhythmias (25 of 40), with early successful treatment in 21 (84%) of 25. Twelve patients had ventricular tachyarrhythmias: seven had successful therapy, and six died, none related to the drug. Eleven patients had atrial tachyarrhythmias: 10 of 11 had immediate success, but 3 later died. Fourteen patients had junctional ectopic tachycardia, which was treated with success (sinus rhythm or slowing, allowing pacing) in 13 of 14, with no deaths. Three other patients had supraventricular tachycardias, with success in two and no deaths. The average loading dose was 6.3 mg/kg body weight, and 50% of patients required a continuous infusion. Four patients had mild hypotension during the amiodarone bolus. One postoperative patient experienced bradycardia requiring temporary pacing. There were no proarrhythmic effects. Deaths (9 [23%] of 40) were not attributed to amiodarone. CONCLUSIONS Intravenous amiodarone is safe and effective in most young patients with critical tachyarrhythmia. Intravenous amiodarone can be lifesaving, particularly for postoperative junctional ectopic tachycardia, when standard therapy is ineffective.
Collapse
Affiliation(s)
- J C Perry
- Children's Hospital San Diego, California, USA
| | | | | | | | | | | |
Collapse
|
26
|
Stambler BS, Gottlieb SS, Singh BN, Ramanathan KB, Ogilby JD, Ellenbogen KA. Hemodynamic effects of intravenous sematilide in patients with congestive heart failure: a class III antiarrhythmic agent without cardiodepressant effects. J Am Coll Cardiol 1995; 26:1679-84. [PMID: 7594103 DOI: 10.1016/0735-1097(95)00376-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES This study sought to evaluate the hemodynamic effects of intravenous sematilide hydrochloride, a selective class III antiarrhythmic agent, in patients with heart failure and left ventricular systolic dysfunction. BACKGROUND Class I antiarrhythmic agents, which primarily slow conduction, can depress ventricular function, particularly in patients with heart failure. In contrast, pure class III agents, which selectively prolong repolarization, do not adversely affect hemodynamic variables in animal models, but there are no data evaluating their hemodynamic effects in humans. METHODS In 39 patients with congestive heart failure and a left ventricular ejection fraction < 40%, hemodynamic and electrocardiographic measurements were obtained at baseline, after a loading dose and during a maintenance infusion of intravenous sematilide using either a low (0.75 then 0.3 mg/min) or high dose (1.5 then 0.6 mg/min) regimen. The study had an 80% power to detect clinically meaningful differences in hemodynamic variables. RESULTS Both low (n = 20) and high (n = 19) dose sematilide infusions produced dose-dependent increases in QT interval (5 +/- 8% [mean +/- SD] and 18 +/- 10%, respectively) and corrected QT interval (4 +/- 8% and 14 +/- 10%), and high dose sematilide decreased heart rate by 7 +/- 10% (all p < 0.025 vs. baseline). Neither dose regimen had a statistically significant effect on any other hemodynamic variable, including mean arterial, right atrial, pulmonary artery and pulmonary capillary wedge pressures; cardiac index, stroke volume, systemic and pulmonary vascular resistances; and left ventricular stroke work index. Sematilide showed no adverse hemodynamic effects in patients with left ventricular ejection fraction < or = 25% or > 25% and in patients with cardiac index < 2 or > or = 2 liters/min per m2. Sustained polymorphic ventricular tachycardia (n = 1) and excessive QT prolongation (n = 4) were seen during the high dose. CONCLUSIONS Sematilide, in the doses administered, prolonged repolarization but did not alter hemodynamic variables in patients with heart failure. These data suggest that class III antiarrhythmic agents, which selectively prolong repolarization, are not cardiodepressant but may be proarrhythmic in humans, especially at high doses.
Collapse
Affiliation(s)
- B S Stambler
- Division of Cardiology, Medical College of Virginia, Richmond, USA
| | | | | | | | | | | |
Collapse
|
27
|
Scheinman MM. Parenteral antiarrhythmic drug therapy in ventricular tachycardia/ventricular fibrillation: evolving role of class III agents--focus on amiodarone. J Cardiovasc Electrophysiol 1995; 6:914-9. [PMID: 8548112 DOI: 10.1111/j.1540-8167.1995.tb00367.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
More effective intravenous antiarrhythmic agents are required for treatment of patients with refractory malignant ventricular arrhythmias. More recently, a great deal of interest has been focused on use of intravenous amiodarone for these patients. Uncontrolled early studies showed that intravenous amiodarone was effective in 42% to 81% of treated patients. Recent large cooperative trials have documented the efficacy of intravenous amiodarone in these patients and have shown an efficacy comparable to bretylium in patients with refractory sustained ventricular tachycardia or fibrillation.
Collapse
Affiliation(s)
- M M Scheinman
- Department of Medicine, University of California, San Francisco 94143-1354, USA
| |
Collapse
|
28
|
Terada Y, Mitsui T, Yoshimura Y, Osaka M, Mihara W. Amiodarone for ventricular tachycardia after coronary artery bypass grafting. Ann Thorac Surg 1995; 60:1155. [PMID: 7574979 DOI: 10.1016/0003-4975(95)97586-c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
|
29
|
Mickleborough LL, Maruyama H, Mohamed S, Rappaport DC, Downar E, Butany J, Sun Z. Are patients receiving amiodarone at increased risk for cardiac operations? Ann Thorac Surg 1994; 58:622-9. [PMID: 7944681 DOI: 10.1016/0003-4975(94)90717-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Amiodarone therapy has been implicated as a risk factor for cardiothoracic surgical procedures. In patients undergoing map-guided surgical procedures for the treatment of ventricular tachycardia, we compared the perioperative course of those receiving long-term amiodarone therapy (n = 36) versus that in those not receiving the drug (n = 31). The two groups were similar with respect to age, sex, presenting symptoms, functional class, extent of coronary artery disease, presence of a ventricular aneurysm, technique of ventricular tachycardia ablation, cross-clamp or pump time, the number of vessels grafted, the operative fluid balance, and a need for intraaortic balloon pump or inotropic agent support. In 5 patients receiving amiodarone, epinephrine was required to maintain a normal systemic vascular resistance and adequate arterial pressure. Postoperatively, 6 patients (17%) on amiodarone therapy suffered acute respiratory failure. In spite of aggressive therapy, 3 of these patients died. Only 1 patient not receiving amiodarone died of a stroke. We conclude that amiodarone therapy in patients undergoing open heart operations is associated with an increased risk of severe pulmonary complications (p = 0.03 by Fisher's exact test). Amiodarone therapy should be withheld in patients with ventricular tachycardia until they have been assessed as candidates for possible surgical intervention.
Collapse
|
30
|
Gottlieb SS, Riggio DW, Lauria S, Peters RW, Shorofsky SR, Cines M, Froman D, Gold MR. High dose oral amiodarone loading exerts important hemodynamic actions in patients with congestive heart failure. J Am Coll Cardiol 1994; 23:560-4. [PMID: 8113534 DOI: 10.1016/0735-1097(94)90736-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The purpose of this study was to use invasive monitoring to analyze the hemodynamic effects of both a large single dose and a 48-h loading regimen of amiodarone in patients with severe heart failure. BACKGROUND Amiodarone is frequently used as an antiarrhythmic agent in patients with congestive heart failure, but the impact of this agent on cardiac function remains controversial. Recent successful experience with a rapid oral load of amiodarone makes invasive testing of the hemodynamic effects of oral amiodarone in such patients now feasible. METHODS After baseline hemodynamic assessment (using balloon-tipped pulmonary artery catheters) and electrocardiographic measurements, 16 patients received 12.5 mg/kg body weight of amiodarone orally. Hemodynamic measurements were obtained hourly for 4 h. Patients then received this dose an additional seven times over the next 2 days. Hemodynamic variables and QRS, QT and PR intervals were measured after 48 h of treatment. RESULTS Vasodilation was seen between 1 and 3 h after drug administration. Systemic vascular resistance decreased 326 +/- 135 dynes.s.cm-5, cardiac index increased 0.24 +/- 0.08 liters/min per m2 and mean arterial pressure decreased 6 +/- 3 mm Hg (mean +/- SEM, all p < 0.05). After 48 h of amiodarone administration, heart rate decreased 23 +/- 3 beats/min (p < 0.005), stroke volume increased 9 +/- 3 ml (p < 0.005), cardiac index decreased 0.23 +/- 0.09 ml/min per m2 (p < 0.05), pulmonary capillary wedge pressure increased 4 +/- 1 mm Hg (p < 0.01), right atrial pressure increased 3 +/- 1 mm Hg (p < 0.005) and QT and PR intervals were markedly prolonged (p < 0.01). CONCLUSIONS Although the first dose caused vasodilation, a complete loading regimen of amiodarone produced a decreased heart rate with elevated filling pressures and decreased cardiac index.
Collapse
Affiliation(s)
- S S Gottlieb
- Department of Medicine, University of Maryland School of Medicine, Baltimore 21201
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Russo AM, Beauregard LM, Waxman HL. Oral amiodarone loading for the rapid treatment of frequent, refractory, sustained ventricular arrhythmias associated with coronary artery disease. Am J Cardiol 1993; 72:1395-9. [PMID: 8256733 DOI: 10.1016/0002-9149(93)90186-g] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
To evaluate the efficacy and safety of oral amiodarone in the treatment of recurrent, sustained, refractory ventricular arrhythmias, rapid high-dose oral loading was used to treat 12 critically ill patients with frequent, sometimes incessant, sustained ventricular arrhythmias refractory to 2 to 6 antiarrhythmic agents. Presenting arrhythmias included sustained monomorphic ventricular tachycardia and ventricular fibrillation associated with cardiac arrests in 6 patients. Patients experienced 2 to 10 episodes (mean 5 +/- 2) of sustained ventricular arrhythmias over a mean period of 6.2 +/- 5.0 days (range 1 to 14) before oral amiodarone was initiated at 1,200 to 1,400 mg/day. This included at least 1 to 4 episodes (mean 2.2 +/- 1.1) within 24 hours before amiodarone. One to 4 antiarrhythmic drugs were administered concurrently during amiodarone loading. Sustained ventricular arrhythmias no longer occurred after a mean of 5.2 days (range 1 to 22) with amiodarone. Arrhythmias were controlled in 4 patients within 24 hours, 5 patients within 48 hours, 7 patients within 4 days and 10 patients within 6 days. Patients experienced a mean of 0.6 +/- 0.8 episodes within 24 hours after amiodarone. Nine patients survived to hospital discharge. No patient had significant adverse effects during high-dose loading. In conclusion, high-dose oral amiodarone loading, when added to previously unsuccessful conventional antiarrhythmic therapy, is safe and often rapidly effective for at least short-term control of frequent, refractory, sustained ventricular arrhythmias.
Collapse
Affiliation(s)
- A M Russo
- University of Medicine and Dentistry of New Jersey/Robert Wood Johnson Medical School, Camden
| | | | | |
Collapse
|
32
|
Satoh H. Arrhythmogenic actions of class III antiarrhythmic drugs in spontaneously beating rabbit sino-atrial node cells. GENERAL PHARMACOLOGY 1993; 24:1435-42. [PMID: 8112516 DOI: 10.1016/0306-3623(93)90431-v] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
1. Arrhythmogenic actions induced by class III antiarrhythmic drugs (amiodarone, bretylium and sotalol) in spontaneously beating rabbit sino-atrial node cells were investigated by using a two microelectrode voltage-clamp technique. 2. Amiodarone (10(-6) mol/l) caused a negative chronotropic effect. Dysrhythmias at 10(-5) mol/l occurred in 3 out of 10 preparations. Amiodarone elicited a transient inward current. After wash out, the regular rhythm was resumed and the transient inward current also disappeared. 3. Bretylium (10(-5) mol/l) also induced dysrhythmias more often (in 5 of 11 preparations). Sotalol (10(-5) mol/l) caused dysrhythmias in only 1 of 10 preparations. 4. Changes in the cytosolic Ca2+ concentration in single sino-atrial node cells were monitored with fura-2, a Ca(2+)-sensitive fluorescent dye. Amiodarone (3 x 10(-5) mol/l) and bretylium (10(-5) mol/l) elevated the cytosolic Ca2+ level significantly, but sotalol even at 10(-3) mol/l did not affect it. 5. These results indicate that class III antiarrhythmic drugs possess arrhythmogenic actions, probably resulting from elevation of cellular Ca2+ concentration due to direct and indirect actions.
Collapse
Affiliation(s)
- H Satoh
- Department of Pharmacology, Nara Medical University, Japan
| |
Collapse
|
33
|
Complications of acute myocardial infraction. Curr Probl Cardiol 1993. [DOI: 10.1016/0146-2806(93)90002-j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
34
|
Gøtzsche LB, Pedersen EM, Keld D, Paulsen PK. Reduced cardiac reserve in amiodarone-treated pigs after cardiopulmonary bypass and cardioplegic arrest. J Am Coll Cardiol 1992; 20:236-41. [PMID: 1607531 DOI: 10.1016/0735-1097(92)90165-j] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
An animal model was designed for blinded study to elucidate whether cardiac pump failure after heart surgery in amiodarone-treated patients is due to interference between the drug and the surgical procedures. Seventeen adult pigs were treated with amiodarone for 30 days (study animals, 1,400 mg/day, n = 9; untreated control animals, n = 8) followed by exposure to cardiopulmonary bypass and topical cold cardioplegic arrest (Bretschneiders solution) for 60 min. Apart from 1 g of calcium, no inotropic agents were administered. Cardiac reserve was tested by ventricular pacing (200 beats/min for 30 min or until exhaustion). No difference in hemodynamic status was observed between the treated and the untreated group before pacing. Pacing duration in the amiodarone-treated pigs was 10 +/- 3 versus 22 +/- 4 min in control pigs (p less than 0.05). Only one amiodarone-treated pig survived 30 min of pacing compared with five control pigs (11% vs. 63%, p less than 0.05). The following variables differed significantly in the two groups during pacing: cardiac output, left ventricular pressure, arterial pressure and peak positive and negative first derivative of left ventricular pressure (dP/dt). Most marked were the changes in peak positive dP/dt, indicating a compromised systolic function. The two groups did not differ in preload or afterload at any time during the experiments.
Collapse
Affiliation(s)
- L B Gøtzsche
- Institute of Experimental Clinical Research, Skejby University Hospital, Aarhus, Denmark
| | | | | | | |
Collapse
|
35
|
Gill J, Heel RC, Fitton A. Amiodarone. An overview of its pharmacological properties, and review of its therapeutic use in cardiac arrhythmias. Drugs 1992; 43:69-110. [PMID: 1372862 DOI: 10.2165/00003495-199243010-00007] [Citation(s) in RCA: 114] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Amiodarone, originally developed over 20 years ago, is a potent antiarrhythmic drug with the actions of all antiarrhythmic drug classes. It has been successfully used in the treatment of symptomatic and life-threatening ventricular arrhythmias and symptomatic supraventricular arrhythmias. In patients with left ventricular dysfunction amiodarone does not usually produce any clinically significant cardiodepression and the drug has relatively high antiarrhythmic efficacy. Preliminary studies indicate that amiodarone may have a beneficial effect on mortality and survival in certain groups of patients with ventricular arrhythmias, an action probably related to both its antiarrhythmic and antifibrillatory effects. The adverse effect profile of amiodarone is diverse, involving the cardiac, thyroid, pulmonary, hepatic, gastrointestinal, ocular, neurological and dermatological systems. Interstitial pneumonitis and hepatitis are potentially fatal, but the vast majority of adverse events are less serious, and some may be dose dependent. Pretreatment monitoring, regular assessments and the use of minimum effective doses are, therefore, necessary. Thus, with appropriate monitoring to control its well recognised adverse effects amiodarone has an important place as an effective 'broad spectrum' antiarrhythmic drug which has, so far, been used when other treatments have proved ineffective. More recent preliminary data also suggest that it may also have a beneficial effect in the prevention of sudden death in some patients.
Collapse
Affiliation(s)
- J Gill
- Adis International Limited, Chester, UK
| | | | | |
Collapse
|
36
|
Frumin H, Behrens S, Martyn R, Goldberg MJ, Rubenfire M, Kerin N. Hemodynamic effects of antiarrhythmic drugs. J Clin Pharmacol 1991; 31:1070-80. [PMID: 1753011 DOI: 10.1002/j.1552-4604.1991.tb03674.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- H Frumin
- Department of Medicine, Sinai Hospital, Detroit, MI 48235
| | | | | | | | | | | |
Collapse
|
37
|
Abstract
Amiodarone is a unique antiarrhythmic agent originally developed as a vasodilator. Classified electrophysiologically as a Type III antiarrhythmic, it also has both nonspecific antisympathetic and direct, fast channel-membrane effects. Hemodynamic effects of orally administered amiodarone (a negative inotropic agent) are usually negligible, and are usually compensated for by induced vasodilation. Effects on thyroid and hepatic function may help to explain some of the unique pharmacologic as well as toxicologic effects of the drug. Amiodarone is poorly bioavailable (20-80%) and undergoes extensive enterohepatic circulation before entry into a central compartment. The principal metabolite, mono-n-desethyl amiodarone is also an antiarrhythmic. From this central compartment, it undergoes extensive tissue distribution (exceptionally high tissue/plasma partition coefficients). The distribution half-life of amiodarone out of the central compartment to peripheral and deep tissue compartments (t1/2 alpha) may be as short as 4 hours. The terminal half-life (t1/2 beta) is both long and variable (9-77 days) secondary to the slow mobilization of the lipophilic medication out of (primarily) adipocytes. A pharmacokinetically based loading scheme is described, and data suggesting a role for routine amiodarone plasma levels are presented.
Collapse
|
38
|
Affiliation(s)
- D G Waller
- Clinical Pharmacology Group, Southampton General Hospital
| |
Collapse
|
39
|
Remme WJ, Kruyssen HA, Look MP, van Hoogenhuyze DC, Krauss XH. Hemodynamic effects and tolerability of intravenous amiodarone in patients with impaired left ventricular function. Am Heart J 1991; 122:96-103. [PMID: 2063768 DOI: 10.1016/0002-8703(91)90764-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Acute hemodynamic effects and tolerability of intravenous amiodarone, 5 mg/kg administered over 5 minutes, were compared in patients with coronary artery disease and either a normal (left ventricular [LV] ejection fraction greater than or equal to 45%, n = 10, group N) or impaired LV function (ejection fraction less than 45%, n = 9, group L). Amiodarone reduced systemic vascular resistence and LV and aortic pressures in both groups (13%, 18%, and 13%, respectively [group N], and 15%, 17%, and 15%, respectively [group L]) over the short term. Heart rate initially increased (18%, group L, and 10% group N), but was followed by a late 6% decrease in group N only, and by a progressive reduction in contractility (Vmax), together with a rise in LV end-diastolic pressure (19% and 38%, respectively [group N] and 17% and 58%, respectively [group L]; all values p less than 0.05 versus control). Coronary flow increased significantly by 20% (group N) and 31% (group L), but only during amiodarone administration, accompanied by a 26% and 25% reduction in myocardial oxygen extraction in groups N and L, respectively. Stroke work decreased in both groups (20% [group N] and 19% [group L], p less than 0.05 versus control). In contrast, cardiac output only improved (10%) in patients with impaired ventricular function. Significant side effects did not occur. Thus relatively high dosages of intravenous amiodarone are well tolerated and improve cardiac pump function in patients with an impaired, but not with a normal cardiac function. However, the tendency to increase LV end-diastolic pressures necessitates careful monitoring in patients in whom preexisting LV filling pressure may be elevated.
Collapse
Affiliation(s)
- W J Remme
- Cardiovascular Research Foundation "Sticares," Rotterdam, The Netherlands
| | | | | | | | | |
Collapse
|
40
|
Vig PJ, Yallapragada PR, Kodavanti PR, Desaiah D. Modulation of calmodulin properties by amiodarone and its major metabolite desethylamiodarone. PHARMACOLOGY & TOXICOLOGY 1991; 68:26-33. [PMID: 1848930 DOI: 10.1111/j.1600-0773.1991.tb01203.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Long-term amiodarone therapy is invariably associated with some side effects. Although its mechanism of action, as an antiarrhythmic drug is well understood, the side effect profile of amiodarone is not yet established. To determine possible mechanisms, the interaction of amiodarone and its major metabolite desethylamiodarone with calmodulin was investigated, since calmodulin is known to regulate Ca2+ transport, cell proliferation and the enzymes involved in signal transduction and nucleotide metabolism. The interaction between the drugs and calmodulin was studied by monitoring intrinsic tyrosine fluorescence of calmodulin and by using a fluorescent probe, N-phenyl-1-naphthylamine (NPN). 14C-Chlorpromazine displacement studies were conducted to differentiate the specific binding sites. The effect on the biological activity of calmodulin was determined with calmodulin dependent phosphodiesterase and Ca2(+)-ATPase. The dansyl calmodulin was used as fluorescent probe to study the effect of these drugs on complex formation between calmodulin and phosphodiesterase. Both amiodarone and desethylamiodarone decreased tyrosine fluorescence of calmodulin with IC50 of 4.9 and 4.4 microM respectively and these interactions were Ca2(+)-dependent. NPN fluorescence was also affected in a concentration dependent manner. These drugs also displaced bound 14C-chlorpromazine from calmodulin and the effect was biphasic. However, desethylamiodarone was more potent than amiodarone. The binding of 3H-amiodarone to calmodulin was modified by a variety of compounds, one class of compounds decreased and the other increased 3H-amiodarone binding to calmodulin. Only, desethylamiodarone inhibited the phosphodiesterase activation by calmodulin with IC50 of 13.2 microM without changing the basal enzyme.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- P J Vig
- Department of Neurology, University of Mississippi Medical Center, Jackson 39216
| | | | | | | |
Collapse
|
41
|
Rosalion A, Snow NJ, Horrigan TP, Noon DL, Mostow ND. Amiodarone versus bretylium for suppression of reperfusion arrhythmias in dogs. Ann Thorac Surg 1991; 51:81-5. [PMID: 1985582 DOI: 10.1016/0003-4975(91)90455-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Reperfusion arrhythmias are an important complication of interventions to limit infarct size. Recently, amiodarone has been shown to be rapidly effective in suppressing sustained, incessant ventricular tachycardia and ventricular fibrillation in this setting. This study evaluated the time course of arrhythmia suppression and comparative efficacy of amiodarone versus bretylium in a canine model of reperfusion arrhythmias. Of 23 dogs subjected to a Harris two-stage coronary artery ligation followed by release, 18 demonstrated clinically significant ventricular arrhythmias and received either intravenous amiodarone, 5 mg/kg (9 dogs), or intravenous bretylium, 5 mg/kg (9 dogs). Direct-current shocks for sustained ventricular tachycardia or ventricular fibrillation were administered as necessary. Amiodarone rapidly suppressed sustained ventricular tachycardia and ventricular fibrillation in this model with no dog in the amiodarone-treated group requiring cardioversion after completion of the 15-minute infusion versus 4 of 9 dogs in the bretylium-treated group (p less than 0.05). Amiodarone was more effective than bretylium in suppressing episodes of sustained ventricular tachycardia/ventricular fibrillation, episodes of nonsustained ventricular tachycardia, and premature ventricular complexes. The blood pressure and heart rate decreased more after amiodarone administration than after bretylium administration. We conclude that, in the canine reperfusion arrhythmia model, amiodarone is rapidly effective in suppressing ventricular arrhythmias and is more effective than bretylium.
Collapse
Affiliation(s)
- A Rosalion
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio 44109
| | | | | | | | | |
Collapse
|
42
|
Intravenous amiodarone bolus versus oral quinidine for atrial flutter and fibrillation after cardiac operations. J Thorac Cardiovasc Surg 1990. [DOI: 10.1016/s0022-5223(19)36909-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
43
|
Gembruch U, Manz M, Bald R, Rüddel H, Redel DA, Schlebusch H, Nitsch J, Hansmann M. Repeated intravascular treatment with amiodarone in a fetus with refractory supraventricular tachycardia and hydrops fetalis. Am Heart J 1989; 118:1335-8. [PMID: 2589171 DOI: 10.1016/0002-8703(89)90028-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- U Gembruch
- Department of Prenatal Diagnosis and Therapy, University of Bonn., FRG
| | | | | | | | | | | | | | | |
Collapse
|
44
|
Perkins MW, Dasta JF, Reilley TE, Halpern P. Intraoperative complications in patients receiving amiodarone: characteristics and risk factors. DICP : THE ANNALS OF PHARMACOTHERAPY 1989; 23:757-63. [PMID: 2683418 DOI: 10.1177/106002808902301003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This article reviews amiodarone's adverse cardiovascular properties, concentrating on those in surgical patients, and evaluates several potential risk factors. Amiodarone has negative inotropic and chronotropic properties as well as peripheral vasodilating properties that may manifest as bradycardia, reduced cardiac output, and hypotension. These reactions are clinically important during surgery, because of resistance to pharmacologic resuscitation and an increased mortality rate. Potential risk factors include ventricular dysfunction, rapid infusion rate, hypocalcemia, cardiopulmonary bypass, general anesthesia, concurrent negative inotropic or chronotropic drugs, and an elevated serum amiodarone or desethylamiodarone concentration. The following measures may decrease the risk of intraoperative adverse reactions in amiodarone-treated patients. The serum calcium concentration should be at the physiologic level and the serum amiodarone and digoxin concentrations should be in the therapeutic range. Negative inotropic and chronotropic agents should be discontinued when possible. A temporary cardiac pacemaker may prevent intraoperative hypotension due to bradycardia. Amiodarone may be discontinued before surgery to minimize the risk of intraoperative complications, but this decision should balance the potential for amiodarone-associated intraoperative complications against the risk of arrhythmia recurrence and the delay of surgery.
Collapse
Affiliation(s)
- M W Perkins
- College of Pharmacy, Ohio State University, Columbus
| | | | | | | |
Collapse
|
45
|
Ochi RP, Goldenberg IF, Almquist A, Pritzker M, Milstein S, Pedersen W, Gobel FL, Benditt DG. Intravenous amiodarone for the rapid treatment of life-threatening ventricular arrhythmias in critically ill patients with coronary artery disease. Am J Cardiol 1989; 64:599-603. [PMID: 2782249 DOI: 10.1016/0002-9149(89)90486-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This study examined the effectiveness of intravenous amiodarone for rapid control and prevention of recurrent life-threatening ventricular tachyarrhythmias associated with cardiovascular collapse. In 22 critically ill patients with coronary artery disease (mean ejection fraction 27 +/- 13%), recurrent ventricular tachyarrhythmias proved refractory to 3.7 +/- 1.1 (mean +/- standard deviation) conventional antiarrhythmic drugs. In the 24-hour period before intravenous amiodarone treatment, patients experienced 2.4 +/- 2.3 (range 1 to 9) episodes of life-threatening ventricular tachycardia, ventricular fibrillation or both, requiring 4.0 +/- 3.9 direct current cardioversions. Within the 24 hours after initiation of intravenous amiodarone therapy (900 to 1,600 mg/day), 20 of 22 patients remained alive and had 1.1 +/- 1.6 episodes of life-threatening ventricular arrhythmias, requiring 1.9 +/- 3.1 direct current cardioversions. In the second 24-hour period, there were 19 survivors and life-threatening arrhythmias were reduced to 0.4 +/- 0.7 episode/patient requiring 0.4 +/- 0.9 direct current cardioversion. Overall, arrhythmias were controlled in 11 of 22 (50%) patients within the first 24 hours, and in 14 of 22 (64%) in the second 24 hours. Intravenous amiodarone therapy was well tolerated. Twelve patients were discharged from the hospital and 8 remained alive at a mean follow-up of 22 +/- 14 months. Thus, in critically ill patients, intravenous amiodarone may be useful for rapid control of spontaneous, refractory, life-threatening ventricular tachyarrhythmias.
Collapse
Affiliation(s)
- R P Ochi
- Minneapolis Heart Institute, Minnesota 55407
| | | | | | | | | | | | | | | |
Collapse
|
46
|
|
47
|
Singh BN, Venkatesh N, Nademanee K, Josephson MA, Kannan R. The historical development, cellular electrophysiology and pharmacology of amiodarone. Prog Cardiovasc Dis 1989; 31:249-80. [PMID: 2642623 DOI: 10.1016/0033-0620(89)90033-9] [Citation(s) in RCA: 87] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- B N Singh
- Department of Cardiology, Wadsworth VA Hospital, Los Angeles, CA 90073
| | | | | | | | | |
Collapse
|
48
|
Raddino R, Poli E, Pelà G, Gargano M, Manca C. Inhibitory actions of amiodarone on the isolated rabbit heart and aorta. GENERAL PHARMACOLOGY 1989; 20:313-7. [PMID: 2744397 DOI: 10.1016/0306-3623(89)90265-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
1. The inhibitory actions of amiodarone on the isolated rabbit heart and aorta have been studied. 2. Amiodarone inhibited vasopressin- and ergonovine-induced coronary spasm, starting from a concentration of 10(-7) M which did not affect myocardial contractility to 10(-4) M, which decreased myocardial contractility. 3. Sinus node activity was largely unaffected even when the highest dose of 10(-4) M was used. 4. Amiodarone did not modify the smooth muscle contraction in rabbit aorta strips precontracted with noradrenaline or potassium. 5. Comparison with other inhibitors of the cardiovascular system (alpha- and beta-blockers, nitrates, calcium entry blockers) points out a peculiar pharmacological profile of amiodarone and indicates some doubts about its presumed anti-adrenergic properties.
Collapse
Affiliation(s)
- R Raddino
- Cattedra di Cardiologia, Università di Brescia e di Parma, Italy
| | | | | | | | | |
Collapse
|
49
|
Kadish A, Morady F. The use of intravenous amiodarone in the acute therapy of life-threatening tachyarrhythmias. Prog Cardiovasc Dis 1989; 31:281-94. [PMID: 2642624 DOI: 10.1016/0033-0620(89)90034-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- A Kadish
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | | |
Collapse
|
50
|
Franklin JO. Intravenous Amiodarone: Emergency Therapy for Refractory Life-Threatening Ventricular Arrhythmias. Proc (Bayl Univ Med Cent) 1989. [DOI: 10.1080/08998280.1989.11929691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|