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Hadova K, Kmecova J, Ochodnicka‐Mackovicova K, Kralova E, Doka G, Bies Pivackova L, Vavrinec P, Stankovicova T, Krenek P, Klimas J. Rapid changes of mRNA expressions of cardiac ion channels affected by Torsadogenic drugs influence susceptibility of rat hearts to arrhythmias induced by Beta-Adrenergic stimulation. Pharmacol Res Perspect 2023; 11:e01134. [PMID: 37715323 PMCID: PMC10504435 DOI: 10.1002/prp2.1134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 09/17/2023] Open
Abstract
Drug-induced long QT syndrome (LQTS) and Torsades de Pointes (TdP) are serious concerns in drug development. Although rats are a useful scientific tool, their hearts, unlike larger species, usually do not respond to torsadogenic drugs. Consequently, their resistance to drug-induced arrhythmias is poorly understood. Here, we challenged rats with rapid delayed rectifier current (Ikr)-inhibiting antibiotic clarithromycin (CLA), loop diuretic furosemide (FUR) or their combination (CLA + FUR), and examined functional and molecular abnormalities after stimulation with isoproterenol. Clarithromycin and furosemide were administered orally at 12-h intervals for 7 days. To evaluate electrical instability, electrocardiography (ECG) was recorded either in vivo or ex vivo using the Langendorff-perfused heart method under basal conditions and subsequently under beta-adrenergic stimulation. Gene expression was measured using real-time quantitative PCR in left ventricular tissue. Indeed, FUR and CLA + FUR rats exhibited hypokalemia. CLA and CLA + FUR treatment resulted in drug-induced LQTS and even an episode of TdP in one CLA + FUR rat. The combined treatment dysregulated gene expression of several ion channels subunits, including KCNQ1, calcium channels and Na+/K + -ATPase subunits, while both monotherapies had no impact. The rat with recorded TdP exhibited differences in the expression of ion channel genes compared to the rest of rats within the CLA + FUR group. The ECG changes were not detected in isolated perfused hearts. Hence, we report rapid orchestration of ion channel reprogramming of hearts with QT prolongation induced by simultaneous administration of clarithromycin and furosemide in rats, which may account for their ability to avoid arrhythmias triggered by beta-adrenergic stimulation.
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Affiliation(s)
- Katarina Hadova
- Department of Pharmacology and Toxicology, Faculty of PharmacyComenius University BratislavaBratislavaSlovakia
| | - Jana Kmecova
- Department of Pharmacology and Toxicology, Faculty of PharmacyComenius University BratislavaBratislavaSlovakia
- State Institute for Drug ControlBratislavaSlovakia
| | | | - Eva Kralova
- Department of Pharmacology and Toxicology, Faculty of PharmacyComenius University BratislavaBratislavaSlovakia
| | - Gabriel Doka
- Department of Pharmacology and Toxicology, Faculty of PharmacyComenius University BratislavaBratislavaSlovakia
| | - Lenka Bies Pivackova
- Department of Pharmacology and Toxicology, Faculty of PharmacyComenius University BratislavaBratislavaSlovakia
| | - Peter Vavrinec
- Department of Pharmacology and Toxicology, Faculty of PharmacyComenius University BratislavaBratislavaSlovakia
| | - Tatiana Stankovicova
- Department of Pharmacology and Toxicology, Faculty of PharmacyComenius University BratislavaBratislavaSlovakia
| | - Peter Krenek
- Department of Pharmacology and Toxicology, Faculty of PharmacyComenius University BratislavaBratislavaSlovakia
| | - Jan Klimas
- Department of Pharmacology and Toxicology, Faculty of PharmacyComenius University BratislavaBratislavaSlovakia
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Vlachos K, Georgopoulos S, Efremidis M, Sideris A, Letsas KP. An update on risk factors for drug-induced arrhythmias. Expert Rev Clin Pharmacol 2015; 9:117-27. [DOI: 10.1586/17512433.2016.1100073] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Agusala K, Oesterle A, Kulkarni C, Caprio T, Subacius H, Passman R. Risk prediction for adverse events during initiation of sotalol and dofetilide for the treatment of atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:490-8. [PMID: 25626340 DOI: 10.1111/pace.12586] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 11/24/2014] [Accepted: 12/21/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Inpatient antiarrhythmic drug initiation for atrial fibrillation is mandated for dofetilide (DF) and is often performed for sotalol (SL), particularly if proarrhythmia risk factors are present. Whether low-risk patients can be identified to safely allow outpatient initiation is unknown. METHODS A single-center retrospective cohort study was performed on patients initiated with DF or SL. Risk factors for adverse events (AEs), defined as any arrhythmia or electrocardiogram change requiring dose reduction or cessation, were identified. RESULTS Of 329 patients, 227 (69%) received SL and 102 (31%) DF. The cohort had a mean age of 63 ± 13 years; 70% of patients were male and had a baseline QTc of 440 ± 37 ms. A total of 105 AEs occurred in 92 patients: QTc prolongation or ventricular tachyarrhythmia in 70 patients (67% of AEs), bradyarrhythmias in 35 patients (33% of AEs), with some experiencing both AE types. Ventricular arrhythmias were seen in 23 patients (7%) and torsades de pointes in one (0.3%). Total AE rates were similar between drugs (P = 0.09); however, DF patients had more QTc prolongation or ventricular arrhythmias (P = 0.001). In SL patients, there were no predictors for QTc prolongation or ventricular proarrhythmia. In DF patients, higher baseline QTc interval (odds ratio = 1.64/25 ms, P = 0.01) was an independent predictor of QTc prolongation or ventricular proarrhythmias. For patients without proarrhythmia risk factors, overall AE rate was 26%. CONCLUSIONS In conclusion, AEs are common during DF and SL initiation but rarely severe in hospitalized inpatients. Baseline QTc predicts AEs for DF patients only and AE are common even in "low-risk" patients. These results support in-hospital drug initiation for all DF and SL patients.
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Affiliation(s)
- Kartik Agusala
- From Northwestern University, Feinberg School of Medicine, Chicago, Illinois
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Abstract
Underlying causes of ventricular tachycardia (VT) or complex ventricular arrhythmias (VA) should be treated if possible. Antiarrhythmic drugs should not be administered to treat asymptomatic individuals with complex VA and no heart disease. Beta-blockers are the only antiarrhythmic drugs that have been documented to reduce mortality in patients with VT or complex VA. Radiofrequency catheter ablation of VT has been beneficial in treating selected patients with arrhythmogenic foci of monomorphic VT. The automatic implantable cardioverter-defibrillator (AICD) is the most effective treatment for patients with life-threatening VT or ventricular fibrillation. Patients with AICDs should be treated with biventricular pacing, not with dual-chamber rate-responsive pacing at a rate of 70/min. Patients with AICDs should also be treated with beta-blockers, statins, and angiotensin-converting enzyme inhibitors or angiotensin blockers.
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Lynch JJ, Wilson AW, Hernandez LE, Nelson RA, Marsh KC, Cox BF, Mittelstadt SW. Dose-response effects of sotalol on cardiovascular function in conscious, freely moving cynomolgus monkeys. Br J Pharmacol 2008; 154:1439-45. [PMID: 18516073 DOI: 10.1038/bjp.2008.206] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND AND PURPOSE The non-selective beta-adrenoceptor antagonist, D,L-sotalol (sotalol) is commonly employed as a positive control during preclinical cardiovascular safety pharmacology testing, mainly because of its ability to prolong QT interval duration. However, no information appears in the literature, except in abstract form, regarding the dose-response effects of sotalol in unanesthetized monkeys. The current study was conducted to determine the dose- and plasma-response effects of orally administered sotalol on cardiovascular function in conscious non-human primates. EXPERIMENTAL APPROACH Male cynomolgus monkeys were implanted with telemetry devices and the effects of sotalol hydrochloride (5, 10 and 30 mg kg(-1) of body weight, p.o.) on arterial blood pressure, heart rate, body temperature and electrocardiogram waveform were continuously monitored for 6 h after dosing. Blood was sampled for the measurement of plasma concentrations of sotalol. KEY RESULTS Sotalol dose dependently decreased heart rate and prolonged RR, PR, QT and corrected QT intervals, while having little or no effects on the QRS complex, arterial pressure or body temperature, over the dose range tested. When the data were related to plasma concentrations of sotalol, it was clear that the cardiovascular effects occurred in a similar pattern and to a comparable degree as those reported in human studies. CONCLUSIONS AND IMPLICATIONS The current study helps demonstrate the validity of utilizing telemetry-instrumented non-human primates for the cardiovascular safety pharmacology assessment of drugs prior to first-in-human testing, and its findings may serve as a reference source for the dose- and plasma-response effects of orally administered sotalol in conscious monkeys.
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Affiliation(s)
- J J Lynch
- Department of Integrative Pharmacology, Global Pharmaceutical Research and Development, Abbott Laboratories, Abbott Park, IL 60064-6119, USA.
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Philips DA, Bauch TD. Rapid correction of hypokalemia in a patient with an implantable cardioverter-defibrillator and recurrent ventricular tachycardia. J Emerg Med 2008; 38:308-16. [PMID: 18375090 DOI: 10.1016/j.jemermed.2007.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2006] [Revised: 02/13/2007] [Accepted: 03/22/2007] [Indexed: 01/02/2023]
Abstract
We present the case of a 74-year-old man with non-ischemic dilatated cardiomyopathy and an implantable cardioverter-defibrillator presenting with a serum potassium of 2.6 mmol/L, recurrent unstable ventricular tachycardia, and multiple defibrillations. Administration of a rapid bolus of 20 mEq KCL solution via central venous access, followed by an additional total of 80 mEq (orally and intravenously [i.v.]) over the next 2 h, resulted in immediate resolution of his recurrent unstable dysrhythmia without toxic side effects. Guidelines for rapid correction of hypokalemia quote a maximum safe administration of 20 mEq i.v./h. In addition to discussing the clinical relevance and physiologic interactions of the variables leading to this patient's presentation, we discuss the successful termination of his sustained recurrent ventricular dysrhythmia by rapid potassium repletion above currently recommended rates. The patient we present is representative of a growing population, given medical and technological advances over the years. Potassium boluses may be reasonable in such circumstances, particularly in patients with ICDs.
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Affiliation(s)
- David A Philips
- Department of Cardiology, Brooke Army Medical Center, San Antonio, Texas 78209, USA
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Hoppe UC, Haverkamp W, Breithardt G, Borggrefe M. Infarct related artery patency: relation to serial electropharmacological studies and outcome in patients with previous myocardial infarction and ventricular tachyarrhythmias. Pacing Clin Electrophysiol 2000; 23:854-62. [PMID: 10833706 DOI: 10.1111/j.1540-8159.2000.tb00855.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Evidence suggests that infarct related artery (IRA) patency may improve survival after acute myocardial infarction, which is thought to be partially due to a lower incidence of malignant ventricular tachyarrhythmias. However, little is known about the effect of IRA patency on antiarrhythmic drug response and long-term outcome in patients with previous infarction who already experienced sustained ventricular tachyarrhythmias. A total of 152 patients with remote myocardial infarction and documented ventricular tachycardia (VT) or ventricular fibrillation (VF) underwent coronary angiography and programmed ventricular stimulation before and after oral administration of d,l-sotalol (240-640 mg/day). D,l-sotalol suppressed inducibility of VT/VF in 37 (25.2%) patients. The IRA was patent in 38.1% of all patients. There was no significant difference in the frequency of drug response between patients with patent or occluded IRAs (26.8% vs 24.2%, P = 0.87). In patients with a patent IRA, d,l-sotalol tended to be more effective in the absence of a left ventricular aneurysm, although this difference did not reach statistical significance (P = 0.38). Ejection fraction and collateral blood flow had no effect on drug response in the presence or absence of IRA patency. During follow-up (13.0 +/- 19.9 months) of 29 patients discharged on oral d,l-sotalol, 3 patients experienced symptomatic VT and 4 sudden death. Arrhythmia recurrence and death of all cause (n = 6) and cardiac death (n = 4) were independent of IRA patency status. IRA patency had no effect on short-term drug response to d,l-sotalol in patients with remote myocardial infarction and documented VT/VF. Long-term outcome of patients with sustained ventricular tachyarrhythmias is independent of IRA patency status. In contrast to a previous report, outcome of electropharmacological testing was not predicted by the patency of the IRA.
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Affiliation(s)
- U C Hoppe
- Department of Cardiology and Angiology, Westfälische Wilhelms-University, Münster, Germany
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Reiffel JA. The importance of considering trial design when interpreting clinical trial results. J Cardiovasc Pharmacol Ther 2000; 5:17-25. [PMID: 10687670 DOI: 10.1177/107424840000500103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In recent decades, clinical trials have played an increasingly important role in determining how we practice. Trial results proving that a clinical finding poses risk have led to interventions that try to reduce risk. Clinical trials proving that a particular therapy provides better outcome than another therapy have changed the therapies we now use. Unfortunately, the results of clinical trials are too often affected by biases or design issues that may overtly or covertly alter the results or the way they should really be used. In addition, these biases and design and analysis issues are rarely evident in the abstract sections or key figures and tables in the publications reporting the trials, which may be all the busy physician either reads or remembers. METHODS AND MATERIALS This manuscript discusses the issues involved in optimally understanding clinical trial design and interpretation so that practitioners can better understand how to intelligently read and apply trial results to clinical practice. CONCLUSIONS Clinical trial results can not be properly applied without consideration of trial design features and intertrial comparisons.
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Affiliation(s)
- J A Reiffel
- Department of Medicine, Columbia Presbyterian Campus, NY Presbyterian Hospital, and Columbia University, New York, USA
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Abstract
OBJECTIVE To review the prognosis and management of ventricular arrhythmias (VA) in persons with and without heart disease, with emphasis on older adults. DATA SOURCES A computer-assisted search of the English language literature (MEDLINE database) followed by a manual search of the bibliographies of pertinent articles. STUDY SELECTION Studies on the prognosis and management of VA in persons with and without heart disease were screened for review. Studies in older persons and recent studies were emphasized. DATA EXTRACTION Pertinent data were extracted from the reviewed articles. Emphasis was placed on studies involving older persons. Relevant articles were reviewed in depth. DATA SYNTHESIS Available data on the prognosis and management of VA in persons with and without heart disease, with emphasis on studies in older persons, were summarized. CONCLUSIONS Ventricular arrhythmias in older persons without heart disease should not be treated with antiarrhythmic drugs, nor should Class I antiarrhythmic drugs be used to treat VA in older persons with heart disease. Beta-blockers should be used to treat complex VA in older persons with ischemic or nonischemic heart disease without contraindications to beta-blockers. Amiodarone should be reserved for life-threatening ventricular tachyarrhythmias in older persons who cannot tolerate or who do not respond to beta-blockers. Angiotensin-converting enzyme inhibitors should be used to treat older persons with heart failure, an anterior myocardial infarction, or a left ventricular ejection fraction < or = 40%. If older persons have life-threatening recurrent ventricular tachycardia (VT) or ventricular fibrillation (VF) resistant to antiarrhythmic drugs, invasive intervention should be performed. The automatic implantable cardioverter-defibrillator is recommended in older persons who have medically refractory sustained VT or VF.
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Affiliation(s)
- W S Aronow
- Hebrew Hospital Home, Bronx, New York 10475, USA
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Mewis C, Kühlkamp V, Mermi J, Bosch RF, Seipel L. Long-term reproducibility of electrophysiologically guided therapy with sotalol in patients with ventricular tachyarrhythmias. J Am Coll Cardiol 1999; 33:1989-95. [PMID: 10362204 DOI: 10.1016/s0735-1097(99)00097-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Goal of this study was to assess the long-term reproducibility of electrophysiologic drug testing in patients with ventricular tachyarrhythmias (VT/VF). BACKGROUND Programmed ventricular stimulation (PVS) is still widely used to guide antiarrhythmic therapy in patients with sustained ventricular tachycardia/fibrillation (VT/VF). Sotalol is considered as one of the most effective drugs for VT/VF. Because there is no proof of long-term reproducibility of a successful drug test with sotalol, we investigated the long-term reproducibility of drug testing with sotalol. METHODS Thirty patients with VT/VF (age: 57+/-11 years, 20 patients with coronary heart disease, 7 patients with no structural heart disease, 3 with others) and reproducible induction of VT/VF (28 patients VT, two patients VF) in a baseline PVS, were suppressible with sotalol (mean dosage 395+/-137 mg) in a subsequent PVS. After a mean follow-up of 13+/-10 months a PVS was again performed in patients, who had no evidence of progressive cardiac disease, who did not experience any arrhythmia recurrences or who were drug compliant. Irrespective of the inducibility after long-term therapy with sotalol, all patients were kept on the initial sotalol regimen. All 30 patients had a stable cardiac condition, were free of VT/VF recurrences and were drug compliant. RESULTS Despite the clinical efficacy of sotalol, in 12 patients (40%) VT/VF could again be induced after 13+/-10.2 months. Inducibility was independent of age, heart disease, ejection fraction and follow-up time. During a further follow-up of 22.1+/-10.9 months, five patients experienced nonfatal VT recurrences independently of the prior inducibility. CONCLUSIONS This study shows a lacking long-term reproducibility of an initial effective PVS with sotalol. Despite an uneventful clinical follow-up, late electrophysiologic testing showed a VT/VF inducibility in a high portion of patients. Hence, electrophysiologic testing performed late after the initial drug test may no longer be predictive of outcome.
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Affiliation(s)
- C Mewis
- Department of Cardiology, University Hospital Tübingen, Germany
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12
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Abstract
Sotalol, the most recently approved oral antiarrhythmic drug, has a unique pharmacologic profile. Its electrophysiology is explained by nonselective beta-blocking action as well as class III antiarrhythmic activity (including fast-activating cardiac membrane-delayed rectifier current blockade), which leads to increases in action potential duration and refractory period throughout the heart and in QT interval on the surface electrocardiogram. Its better hemodynamic tolerance than other beta-blockers may be a result of enhanced inotropy associated with class III activity. Sotalol's ability to suppress ventricular ectopy is similar to that of class I agents and better than that of standard beta-blockers. Unlike class I agents, its use in a postinfarction trial was not associated with increased mortality rate. Therapeutically, it has shown superior efficacy for prevention of recurrent ventricular tachycardia and ventricular fibrillation, which was the basis for its approval. In a randomized study, the Electrophysiologic Study Versus Electrocardiographic Monitoring (ESVEM) trial, sotalol was associated with an increased in-hospital efficacy prediction rate (by Holter monitor or electrophysiologic study), reduced long-term arrhythmic recurrence rate with superior tolerance, and lower mortality rate than class I ("standard") antiarrhythmic drugs. Sotalol was 1 of 2 drugs selected for comparison with implantable defibrillators in the recent National Institutes of Health Antiarrhythmics versus Implantable Defibrillator (AVID) study. Sotalol appears to be a preferred drug for use with implantable defibrillators; unlike some other agents (eg, amiodarone) it does not elevate and, indeed, may lower defibrillation threshold. Although unapproved for this use, sotalol is active against atrial arrhythmias. It has shown efficacy equivalent to propafenone and quinidine in preventing atrial fibrillation recurrence, but it is better tolerated than quinidine and provides excellent rate control during recurrence. Sotalol's major side effects are related to beta-blockade and the risk of torsades de pointes (acceptably small if appropriate precautions are taken). Unlike several other antiarrhythmics (eg, amiodarone), it has no pharmacokinetic drug-drug interactions, is not metabolized, and is entirely renally excreted. Initial dose is 80 mg twice daily, with gradual titration to 240 to 360 mg/day as needed. The daily dose must be reduced in renal failure. On the basis of favorable clinical trials and practice experience, sotalol has shown a steadily growing impact on the treatment of arrhythmias during its 5 years of market availability, a trend that is likely to continue.
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Affiliation(s)
- J L Anderson
- University of Utah and St. Vincent'sHospital, Northside Cardiology, Salt Lake City, USA
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Kühlkamp V, Mewis C, Mermi J, Bosch RF, Seipel L. Suppression of sustained ventricular tachyarrhythmias: a comparison of d,l-sotalol with no antiarrhythmic drug treatment. J Am Coll Cardiol 1999; 33:46-52. [PMID: 9935007 DOI: 10.1016/s0735-1097(98)00521-x] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This study evaluates the clinical efficacy of d,l-sotalol in patients with sustained ventricular tachyarrhythmias. BACKGROUND D,l-sotalol is an important antiarrhythmic agent to prevent recurrences of sustained ventricular tachyarrhythmias (VT/VF). However, evidence is lacking that an antiarrhythmic agent like d,l-sotalol can reduce the incidence of sustained ventricular tachyarrhythmias in comparison to no antiarrhythmic drug treatment. METHODS A prospective study was performed in 146 consecutive patients with inducible sustained ventricular tachycardia or ventricular fibrillation. In 53 patients, oral d,l-sotalol prevented induction of VT/VF during electrophysiological testing and patients were discharged on oral d,l-sotalol (sotalol group). In 93 patients, VT/VF remained inducible and a defibrillator (ICD) was implanted. After implantation of the device patients were randomly assigned to oral treatment with d,l-sotalol (ICD/sotalol group, n=46) or no antiarrhythmic medication (n=47, ICD-only group). RESULTS During follow-up, 25 patients (53.2%) in the ICD-only group had a VT/VF recurrence in comparison to 15 patients (28.3%) in the sotalol group and 15 patients (32.6%) in the ICD/sotalol group (p=0.0013). Therapy with d,l-sotalol, amiodarone or metoprolol was instituted in 12 patients (25.5%) of the ICD-only group due to frequent VT/VF recurrences or symptomatic supraventricular tachyarrhythmias. In nine patients, 17% of the sotalol group, an ICD was implanted after VT/VF recurrence, three patients (5.7%) received amiodarone. Total mortality was not different between the three groups. CONCLUSIONS D,l-sotalol significantly reduces the incidence of recurrences of sustained ventricular tachyarrhythmias in comparison to no antiarrhythmic drug treatment.
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Affiliation(s)
- V Kühlkamp
- Eberhard-Karls-University, Medical Department III, Tübingen, Germany.
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Abstract
BACKGROUND: The role of antiarrhythmic drug therapy continues to undergo major changes. The change is necessitated by the advent of invasive interventional procedures, such as catheter ablation of arrhythmias and the use of implantable devices for sensing and terminating life-threatening ventricular arrhythmias and symptomatically traublesome supraventricular arrhythmias. Many conventional and time-honored drugs, such as sodium channel blockers, have been found either to be ineffective or to have the potential to produce serious proarrhythmic reactions. Attention is therefore focused on compounds that prolong repolarization and reduce sympathetic stimulation. Two compounds, amiodarone and sotalol, have emerged as prototypes of drugs of the future. METHODS AND RESULTS: This review focuses on sotalol for controlling supraventricular and ventricular tachyarrhythmias. Sotalol is a major antiarrhythmic agent that combines potent class III action with nonselective beta-blocking properties. The drug's pharmacokinetics is simple. Its elimination half-life is 10-15 hours, the drug being excreted almost exclusively by the kidneys. Sotalol's pharmacokinetics allows development of optimal dosing for initiation of therapy relative to changes in creatinine clearance with further dose adjustment by monitoring the QT interval on the surface electrocardiogram. The compound exerts broad-spectrum antiarrhythmic actions in supraventricular and ventricular arrhythmias. It prevents inducible ventricular tachycardia (VT) and ventricular fibrillation (VF) in approximately 30% of patients with a higher figure for the suppression of spontaneously occurring arrhythmias documented on Holter recordings. CONCLUSIONS: The major role of sotalol is in the management of VT/VF often in conjunction with an implantable cardioverter/defibrillator, in which context it lowere the defibrillation threshold. Sotalol is superior to class I agents, especially in VT/VF and in survivors of cardiac arrest. Sotalol has emerged as a major antifibrillatory compound for the control of life-threatening ventricular arrhythmias as the main indication. Data have indicated its potential for the maintenance of stability of sinus rhythm in patients with atrial fibrillation and flutter after electrical conversion and in preventing their occurrence in a variety of clinical settings.
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Affiliation(s)
- BN Singh
- UCLA School of Medicine, Veterans Affairs Medical Center of West Los Angeles, Los Angeles, California, USA
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Seidl K, Hauer B, Schwick NG, Zahn R, Senges J. Comparison of metoprolol and sotalol in preventing ventricular tachyarrhythmias after the implantation of a cardioverter/defibrillator. Am J Cardiol 1998; 82:744-8. [PMID: 9761084 DOI: 10.1016/s0002-9149(98)00478-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The purpose of this prospective study was to evaluate, on an intention-to-treat basis, the efficacy of d,l-sotalol and metoprolol with regards to the recurrence of arrhythmic events after implantable cardioverter defibrillator (ICD) implantation. After ICD implantation, 70 patients were randomly assigned to treatment with either metoprolol (mean dosage 104+/-37 mg/day in 35 patients) or d,l-sotalol (mean dosage 242+/-109 mg/day in 35 patients). During follow up ventricular tachycardia (VT), fast VT, and ventricular fibrillation (VF) episodes were calculated. Metoprolol treatment led to a marked reduction in the recurrence of arrhythmic events. Actuarial rates for absence of VT recurrence at 1 and 2 years were significantly higher in the metoprolol group compared with the d,l-sotalol group (83% and 80% vs 57% and 51%, respectively, p=0.016). The actuarial rates for absence of fast VT or VF were 80% in the metoprolol group compared with 46% in the d,l-sotalol group (p=0.002). During a follow up of 26+/-16 months, there were 3 deaths in the metoprolol group compared with 6 deaths in the d,l-sotalol group. Actuarial rates of overall survival were not significantly different in the 2 groups (91% vs 83%, p=0.287). In this prospective, randomized, controlled study the recurrence rate of ventricular tachyarrhythmias in patients treated with metoprolol was lower than in patients treated by d,l-sotolol.
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Affiliation(s)
- K Seidl
- Department of Cardiology, Herzzentrum Ludwigshafen, Germany
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Chung MK, Schweikert RA, Wilkoff BL, Niebauer MJ, Pinski SL, Trohman RG, Kidwell GA, Jaeger FJ, Morant VA, Miller DP, Tchou PJ. Is hospital admission for initiation of antiarrhythmic therapy with sotalol for atrial arrhythmias required? Yield of in-hospital monitoring and prediction of risk for significant arrhythmia complications. J Am Coll Cardiol 1998; 32:169-76. [PMID: 9669266 DOI: 10.1016/s0735-1097(98)00189-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES We sought to determine the yield of in-hospital monitoring for detection of significant arrhythmia complications in patients starting sotalol therapy for atrial arrhythmias and to identify factors that might predict safe outpatient initiation. BACKGROUND The need for hospital admission during initiation of antiarrhythmic therapy has been questioned, particularly for sotalol, with which proarrhythmia may be dose related. METHODS The records of 120 patients admitted to the hospital for initiation of sotalol therapy were retrospectively reviewed to determine the incidence of significant arrhythmia complications, defined as new or increased ventricular arrhythmias, significant bradycardia or excessive corrected QT (QTc) interval prolongation. RESULTS Twenty-five patients (20.8%) experienced 35 complications, triggering therapy changes during the hospital period in 21 (17.5%). New or increased ventricular arrhythmias developed in 7 patients (5.8%) (torsade de pointes in 2), significant bradycardia in 20 (16.7%) (rate <40 beats/min in 13, pause >3.0 s in 4, third-degree atrioventricular block in 1, permanent pacemaker implantation in 3) and excessively prolonged QTc intervals in 8 (6.7%) (dosage reduced or discontinued in 6). Time to the earliest detection of complications was 2.1 +/- 2.5 (mean +/- SD) days after initiation of sotalol, with 22 of 25 patients meeting criteria for complications within 3 days of monitoring. Baseline electrocardiographic intervals or absence of heart disease failed to distinguish a low risk group. Multivariate analysis identified absence of a pacemaker as the only significant predictor of arrhythmia complications (p = 0.022). CONCLUSIONS Because clinically significant complications can be detected with in-hospital monitoring in one of five patients starting sotalol therapy, hospital admission is warranted for initiation of sotalol. Patients without pacemakers are at higher risk for these complications.
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Affiliation(s)
- M K Chung
- Department of Cardiology, The Cleveland Clinic Foundation, Ohio 44195, USA.
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17
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Abstract
Class III antiarrhythmic drugs have been under extensive clinical investigation as safer, more effective alternatives to class I drugs, which have recognized risks in selected populations. Class III drugs prolong the action potential duration of myocardial cells, resulting in a lengthening of the effective refractory period. This pharmacologic activity has antiarrhythmic properties, but it may induce a distinctive form of proarrhythmia known as torsades de pointes. Amiodarone and d,l-sotolol are class III drugs that have been available for many years. In addition to their ability to prolong refractoriness, these drugs have other pharmacodynamic properties. Recent antiarrhythmic drug discovery has focused on the identification and development of selective or so-called pure class III drugs that are devoid of additional actions. Investigators have hoped that these drugs would be as effective as sotalol and amiodarone but have fewer adverse effects. Accumulating data, however, indicate that complex compounds exhibiting antiadrenergic and other electrophysiologic properties may be superior to pure class III agents.
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Affiliation(s)
- D J MacNeil
- Bristol-Myers Squibb Pharmaceutical Research Institute, Princeton, New Jersey 08543-4000, USA
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Reiffel JA. Prolonging survival by reducing arrhythmic death: pharmacologic therapy of ventricular tachycardia and fibrillation. Am J Cardiol 1997; 80:45G-55G. [PMID: 9354411 DOI: 10.1016/s0002-9149(97)00713-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Antiarrhythmic drug therapy of sustained ventricular tachyarrhythmias is undertaken to reduce arrhythmic symptoms, recurrences, and mortality. Ideally, reduction of arrhythmic death will reduce total mortality as well, although this may not hold true in the presence of competing risk. Whether, in fact, antiarrhythmic therapy actually reduces arrhythmic death remains uncertain in the absence of any placebo-controlled trials. Nonetheless, the following conclusions can be drawn from the Electrophysiologic Study versus Electrocardiographic Monitoring (ESVEM) trial, the Cardiac Arrest Study Hamburg (CASH), and the Cardiac Arrest in Seattle: Conventional versus Amiodarone Drug Evaluation (CASCADE) study, as well as a beta blocker study by Steinbeck et al: (1) class I antiarrhythmics are less effective than amiodarone or sotalol for the prevention of recurrent sustained ventricular tachycardia/ventricular fibrillation; (2) sympathetic inhibition as a component of the antiarrhythmic regimen may strongly contribute to mortality reduction; and (3) the respective roles of antiarrhythmic drugs, implantable devices, and the concurrent use of both are in a state of flux, awaiting results of randomized controlled clinical trials.
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Affiliation(s)
- J A Reiffel
- Department of Medicine, Columbia University, College of Physicians and Surgeons, Columbia-Presbyterian Medical Center, New York, New York, USA
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19
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Link MS, Foote CB, Sloan SB, Homoud MK, Wang PJ, Estes NA. Torsade de pointes and prolonged QT interval from surreptitious use of sotalol: use of drug levels in diagnosis. Chest 1997; 112:556-7. [PMID: 9266902 DOI: 10.1378/chest.112.2.556] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Torsade de pointes is a well-established toxic effect of sotalol hydrochloride. In a patient presenting with torsade de pointes and a long QTc interval of unknown cause, a serum sotalol level was used to secure an otherwise difficult diagnosis.
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Affiliation(s)
- M S Link
- Cardiac Arrhythmia Service, Tufts/New England Medical Center, Boston, MA 02111, USA
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20
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Haverkamp W, Martinez-Rubio A, Hief C, Lammers A, Mühlenkamp S, Wichter T, Breithardt G, Borggrefe M. Efficacy and safety of d,l-sotalol in patients with ventricular tachycardia and in survivors of cardiac arrest. J Am Coll Cardiol 1997; 30:487-95. [PMID: 9247523 DOI: 10.1016/s0735-1097(97)00190-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to assess the antiarrhythmic efficacy and safety of d,l-sotalol in patients with ventricular tachycardia (VT) or ventricular fibrillation (VF) and in survivors of cardiac arrest and to identify the factors that are associated with arrhythmia suppression and therefore might be helpful in predicting drug efficacy. BACKGROUND Despite increasing use of the class III antiarrhythmic agent d,l-sotalol, data on its short- and long-term efficacy in a large patient cohort are lacking. Information on its long-term tolerability and safety is limited. METHODS A total of 396 patients with inducible sustained VT or VF (VT/VF) underwent programmed stimulation before and after receiving oral d,l-sotalol (240 to 640 mg/day). Patients in whom VT/VF was rendered either noninducible or more difficult to induce (more extrastimuli or faster drive cycle length needed for VT/VF induction) were discharged on a regimen of oral d,l-sotalol. RESULTS d,l-Sotalol suppressed VT/VF in 151 patients (38.1%) and rendered the arrhythmia more difficult to induce in 76 patients (19.2%). The extent of drug-induced prolongation of right ventricular refractoriness and a shorter VT cycle length at baseline were independent predictors of immediate drug efficacy. Torsade de pointes developed in seven patients (1.8%). Two hundred ten patients (53%) continued to receive d,l-sotalol and were followed up for 34 +/- 18 months (mean +/- SD). The actuarial rates for the absence of arrhythmic recurrence (either VT/VF or sudden death) at 1 and 3 years were 89% and 77%, respectively. Actuarial rates for overall survival at 1 and 3 years were 94% and 86%, respectively. VT/VF suppression by d,l-sotalol was an independent discriminant variable that separated patients with and without arrhythmia recurrence. However, noninducibility of VT/VF did not predict freedom from sudden death. CONCLUSION Oral d,l-sotalol is effective and safe in patients with VT/VF. However, sudden cardiac death develops in a significant proportion of patients, and programmed stimulation seems to be of limited value for its prediction.
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Affiliation(s)
- W Haverkamp
- Hospital of the Westfälische Wilhelms-University, Department of Cardiology and Angiology, Münster, Germany.
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21
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Reiffel JA, Hahn E, Hartz V, Reiter MJ. Sotalol for ventricular tachyarrhythmias: beta-blocking and class III contributions, and relative efficacy versus class I drugs after prior drug failure. ESVEM Investigators. Electrophysiologic Study Versus Electrocardiographic Monitoring. Am J Cardiol 1997; 79:1048-53. [PMID: 9114762 DOI: 10.1016/s0002-9149(97)00045-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In the Electrophysiologic Study Versus Electrocardiographic Monitoring (ESVEM) trial, d,l-sotalol was associated with a lower arrhythmia recurrence and mortality than class I antiarrhythmic drugs. To further evaluate the relative efficacy of d,I-sotalol compared with class I drugs, and to assess the relative importance of its class II (beta-blocking) and class III effects, 6-year arrhythmia recurrence and mortality in patients receiving sotalol were compared with those in patients receiving class I drugs, subdivided according to whether they also received coadministered beta blockers. Relative efficacy was also determined for sotalol and for class I drugs as stratified by the presence/absence of prior drug failure. Arrhythmia recurrence was lower for the 84 patients receiving sotalol than for patients given class I agents with (n = 28) (p = 0.008) or without (n = 184) (p = 0.001) alpha beta blocker. Mortality was lower for patients taking sotalol than for those given a class I drug without alpha beta blocker (p = 0.034), but similar (p = 0.835) if alpha beta blocker was also administered. In contrast to class I drugs, which had lower efficacy rates when prior drug trials had failed, sotalol maintained its efficacy despite prior drug failures preceding or during the ESVEM trial. Both class II and III actions in the ESVEM trial were important to the clinical superiority of sotalol in the treatment of ventricular tachyarrhythmias.
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Affiliation(s)
- J A Reiffel
- Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York, USA
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22
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Kühlkamp V, Mermi J, Mewis C, Seipel L. Efficacy and proarrhythmia with the use of d,l-sotalol for sustained ventricular tachyarrhythmias. J Cardiovasc Pharmacol 1997; 29:373-81. [PMID: 9125676 DOI: 10.1097/00005344-199703000-00011] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study prospectively evaluated the clinical efficacy, the incidence of torsades de pointes, and the presumable risk factors for torsades de pointes in patients treated with d,l-sotalol for sustained ventricular tachyarrhythmias. Eighty-one consecutive patients (54 with coronary artery disease, and 20 with dilated cardiomyopathy) with inducible sustained ventricular tachycardia or ventricular fibrillation received oral d,l-sotalol to prevent induction of the ventricular tachyarrhythmia. During oral loading with d,l-sotalol, continuous electrocardiographic (ECG) monitoring was performed. Those patients in whom d,l-sotalol prevented induction of ventricular tachycardia or ventricular fibrillation were discharged with the drug and followed up on an outpatient basis for 21 +/- 18 months. Induction of the ventricular tachyarrhythmia was prevented by oral d,l-sotalol in 35 (43%) patients; the ventricular tachyarrhythmia remained inducible in 40 (49%) patients; and two (2.5%) patients did not tolerate even 40 mg of d,l-sotalol once daily. Four (5%) patients had from torsades de pointes during the initial oral treatment with d,l-sotalol. Neither ECG [sinus-cycle length (SCL), QT or QTc interval, or U wave] nor clinical parameters identified patients at risk for torsades de pointes. However, the oral dose of d,l-sotalol was significantly lower in patients with torsades de pointes (200 +/- 46 vs. 328 +/- 53 mg/day; p = 0.0017). Risk factors associated with the development of torsades de pointes were the appearance of an U wave (p = 0.049), female gender (p = 0.015), and significant dose-corrected changes of SCL, QT interval, and QTc interval (p < 0.05). During follow-up, seven (20%) patients had a nonfatal ventricular tachycardia recurrence, and two (6%) patients died suddenly. One female patient with stable cardiac disease had recurrent torsades de pointes after 2 years of successful treatment with d,l-sotalol. Torsades de pointes occurred early during treatment even with low doses of oral d,l-sotalol. Pronounced changes in the surface ECG (cycle length, QT, and QTc) in relation to the dose of oral d,l-sotalol might identify a subgroup of patients with an increased risk for torsades de pointes. Other ECG parameters before the application of d,l-sotalol did not identify patients at increased risk for torsades de pointes. Recurrence rates of ventricular tachyarrhythmias are high despite complete suppression of the arrhythmia during programmed stimulation. Therefore programmed electrical stimulation in the case of d,l-sotalol seems to be of limited prognostic value.
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Affiliation(s)
- V Kühlkamp
- Medical Department III, University Hospital of Tubingen, Germany
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23
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Abstract
Sotalol is a unique compound with several potential antiarrhythmic mechanisms, including beta blockade (class II activity), action potential duration prolongation (class III activity), and possibly reduction of QT dispersion. In recent years, trials such as the Cardiac Arrhythmia Suppression Trial (CAST) and the Electrophysiologic Study versus Electrocardiographic Monitoring (ESVEM) trial reported disappointing results with the use of class I agents in the management of ventricular arrhythmias in patients with coronary artery disease. These results have led to increased interest in class III antiarrhythmic agents, including sotalol. Sotalol is effective in suppressing ventricular premature complexes as well as nonsustained and sustained ventricular tachyarrhythmias. The interaction between sotalol and implantable cardioverter-defibrillators (ICDs) is generally favorable. As is the case with other antiarrhythmic drugs, there is no placebo-controlled trial assessing the effect of sotalol on mortality. It is not known if sotalol is more effective than placebo, conventional beta blockade, amiodarone, or ICDs in reducing mortality from life-threatening ventricular arrhythmias. In addition, the optimal method of selecting patients for sotalol therapy has yet to be determined. The safety profile of sotalol has been well established in > 3,000 patients worldwide. Proarrhythmia occurs in approximately 4% of patients, and torsades de pointes occurs in approximately 2.5%. The majority of episodes of torsades de pointes occurs within 3 days of commencing sotalol therapy, and the risk of torsades de pointes increases sharply at dosages > 320 mg daily. It is recommended that initiation of sotalol therapy or dosage increases be performed in a monitored setting. Overall, only 1% of patients enrolled in clinical trials of sotalol discontinued therapy as a result of drug-related congestive heart failure. However, these trials have excluded patients with poor left ventricular systolic function and/or overt heart failure. The optimal management of these patients, who are at greatest risk of sudden cardiac death, and of patients with substrates other than coronary artery disease remains to be elucidated.
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Affiliation(s)
- P A O'Callaghan
- Cardiac Arrhythmia Services, Massachusetts General Hospital, Boston 02114, USA
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24
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Reiffel JA. Implications of the Electrophysiologic Study versus Electrocardiographic Monitoring trial for controlling ventricular tachycardia and fibrillation. Am J Cardiol 1996; 78:34-40. [PMID: 8780327 DOI: 10.1016/s0002-9149(96)00451-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The Electrophysiologic Study versus Electrocardiographic Monitoring (ESVEM) trial had 2 objectives. The first was to determine the accuracy of noninvasive versus invasive means of predicting the efficacy of drug treatment for ventricular tachycardia/ventricular fibrillation (VT/VF). A second objective was to determine the relative efficacies of 7 antiarrhythmic drugs used in the treatment of ventricular tachyarrhythmias. ESVEM was the first opportunity to compare prospectively the efficacy, safety, and tolerability of a variety of antiarrhythmic drugs in the same patient population. No significant difference was observed between suppression of spontaneous ventricular arrhythmias on Holter monitoring and suppression of inducible ventricular arrhythmias by electrophysiologic study (EPS) in terms of the ability to predict the success of drug therapy. There was also no difference in predictive accuracy if patients in the electrophysiologic limb showed suppression by Holter monitoring in addition to suppression by EPS. Sotalol was more effective than the other 6 antiarrhythmic drugs, all class I agents, in preventing death and recurrence of arrhythmia. Efficacy compared with placebo, however, was not evaluated. In the EPS limb, sotalol was also statistically more likely to achieve an efficacy prediction than any of the sodium channel blocking drugs. Amiodarone was not used in ESVEM. It has been suggested that these conclusions, which differ from those of other, less controlled, invasive and noninvasive studies, might be because of the particular efficacy criteria used in the ESVEM protocol. Retrospective analyses of the ESVEM data were performed using more rigid efficacy criteria than were used in the original ESVEM analysis: a greater degree of ectopy suppression was required for Holter monitoring, and more stringent efficacy definitions were required in the stimulation protocol of the EPS limb. Results from the retrospective analyses and other studies support the initial ESVEM conclusions. In patients with both spontaneous and inducible sustained ventricular tachyarrhythmias as well as frequent spontaneous premature ventricular contractions, therapy with sotalol (guided by either Holter monitoring or EPS) is a reasonable initial strategy because of its superior initial long-term efficacy and better acute and long-term tolerability compared with sodium channel blocking drugs.
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Affiliation(s)
- J A Reiffel
- Department of Clinical Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
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25
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Böcker D, Haverkamp W, Block M, Borggrefe M, Hammel D, Breithardt G. Comparison of d,l-sotalol and implantable defibrillators for treatment of sustained ventricular tachycardia or fibrillation in patients with coronary artery disease. Circulation 1996; 94:151-7. [PMID: 8674173 DOI: 10.1161/01.cir.94.2.151] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Implantable cardioverter-defibrillators (ICDs) and d,l-sotalol are widely used to treat ventricular tachyarrhythmia and ventricular fibrillation (VT/VF). The purpose of this study was to compare the long-term efficacy of d,l-sotalol and ICDs in patients with coronary artery disease. METHODS AND RESULTS In a case-control study, 50 patients treated with oral d,l-sotalol were matched to 50 patients treated with ICDs. Both groups were matched for sex (82 men), age (58 +/- 10 years), ejection fraction (40 +/- 12%), extent of coronary artery disease, presenting arrhythmia, and year that treatment began. In all patients in the sotalol group, VT/VF was inducible in the drug-free electrophysiological study. Induction of sustained VT/VF was suppressed by d,l-sotalol (438 +/- 95 mg/d). In the ICD group, either VT/VF was not inducible (n = 5) or inducible sustained VT/VF was refractory to antiarrhythmic drug treatment (n = 45). Sotalol treatment led to a marked reduction in arrhythmic events. Whereas 83% of the patients in the sotalol group were free of sudden death and nonfatal VT at 3 years, only 33% of the ICD patients did not receive appropriate ICD therapies (P < .005). Actuarial rates for absence of sudden death at 3 years were 85% in the sotalol group and 100% in the ICD group (P < .005). Actuarial rates for overall survival at 3 years were 75% in the sotalol group and 85% in the ICD group (P = .02). CONCLUSIONS In this case-control study, ICD therapy was more effective tha electrophysiologically guided antiar-rhythmic treatment with d,l-sotalol in prevention of sudden death and reduction of total morality in patients with coronary artery disease. Prospective studies are needed to confirm these results.
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Affiliation(s)
- D Böcker
- Westfälische Wilhelms-University, Department of Cardiology, Münster, Germany
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26
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Garan H. A perspective on the ESVEM trial current knowledge: sotalol should not be the first-line agent in the management of ventricular arrhythmias. Prog Cardiovasc Dis 1996; 38:455-6. [PMID: 8638026 DOI: 10.1016/s0033-0620(96)80009-0] [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: 02/01/2023]
Abstract
The Electrophysiologic Study Versus Electrocardiographic Monitoring (ESVEM) trial has recently shown the superiority of sotalol over class-1 agents in lowering the rate of recurrence of ventricular tachyarrhythmias. However, this study was not placebo-controlled, and amiodarone was not included as one of the antiarrhythmic drugs in the trial. Randomized comparative trials between sotalol and amiodarone are available, but the results are inconclusive mainly because of small sample sizes. Because of the specific pharmacokinetics of amiodarone, sotalol has become the first-line agent in the management of ventricular arrhythmias. Because this policy is based on expediency rather than follow-up data, the long-term efficacy, morbidity, and safety of sotalol should be compared with those of amiodarone as well as of nonpharmacological treatment modes for ventricular tachyarrhythmias, such as implantable cardioverter defibrillator therapy in prospective trials. Until these issues are resolved, it is incorrect to say that sotalol should be the first-line agent in the management of ventricular arrhythmias.
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Affiliation(s)
- H Garan
- Cardiac Unit, Massachusetts General Hospital, Boston, MA 02114, USA
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27
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Singh BN. Rise and Fall of Guided Antiarrhythmic Therapy for Ventricular Tachycardia and Fibrillation. J Cardiovasc Pharmacol Ther 1996; 1:89-94. [PMID: 10684404 DOI: 10.1177/107424849600100201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- BN Singh
- Veterans Affairs Medical Center of West Los Angeles, Los Angeles, California, USA
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28
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Reiffel JA. Data-driven Decisions: The Importance of Clinical Trials in Arrhythmia Management. J Cardiovasc Pharmacol Ther 1996; 1:79-88. [PMID: 10684403 DOI: 10.1177/107424849600100112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
As a result of clinical trials, the measurement of arrhythmias has evolved over the past three decades. In the late 1960s, customary teaching was that ventricular premature depolarizations were dangerous and antiarrhythmic therapy, in hopes of reducing fatal consequences, became common place; however, following clinical trials such as CAST, IMPACT, and SWORD, we learned that, at least in postinfarct patients, arrhythmia suppression may lead to increased rather than reduced mortality. Such trials have led to a marked reduction in therapy of indiscriminate ventricular ectopy and have led to ongoing testing of specific subgroups identified as having particularly higher adverse prognostic risk. With the advent of cardiac monitoring and the confirmation that ventricular tachyarrhythmias are the most common cause for sudden death, their therapy, too, has evolved and matured, again aided by clinical trials. The ESVEM study prospectively examined the role of monitor-guided versus electrophysiologically guided drug therapy of ventricular tachyarrhythmias and confirmed that both approaches may have a role in reducing arrhythmic deaths-though the specific benefits of each technique remain somewhat unsettled. Both the ESVEM and CASCADE studies suggested that the most effective drugs for ventricular tachyarrhythmias are the class II/III drugs, sotalol and amiodarone, both appearing more effective than our older class I agents. These should now be viewed as the first-line drugs for these arrhythmias. The relative benefits of these two agents with respect to each other and to implantable cardioverter defibrillators, however, remains to be determined by further clinical trials, such as AVID and CIDS. The therapy of atrial tachyarrhythmias has similarly evolved with the aid of clinical observations. While rate control is required in all patients with atrial fibrillation, we have come to realize that the applications of antiarrhythmic drugs for the purpose of maintaining sinus rhythm must be used only selectively rather than uniformly. Both a meta-analysis by Coplen and colleagues and a report by the SPAF investigators suggested that with atrial arrhythmias, too, antiarrhythmic drug therapy may result in enhanced rather than reduced mortality in some circumstances. Additional clinical trials are needed to further elucidate the role of antiarrhythmic therapy of atrial fibrillation.
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Affiliation(s)
- JA Reiffel
- Division of Cardiology, Columbia University, New York, New York, USA
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29
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Biblo LA, Carlson MD, Waldo AL. Insights into the Electrophysiology Study Versus Electrocardiographic Monitoring Trial: its programmed stimulation protocol may introduce bias when assessing long-term antiarrhythmic drug therapy. J Am Coll Cardiol 1995; 25:1601-4. [PMID: 7759711 DOI: 10.1016/0735-1097(95)00087-k] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES We hypothesized that if the Electrophysiology Study Versus Electrocardiographic Monitoring (ESVEM) trial programmed stimulation protocol misclassified some drug trials as effective, then the misclassification rate would be proportionally greater for drugs other than sotalol. BACKGROUND In the ESVEM trial, patients treated with sotalol had fewer arrhythmic recurrences than those treated with other antiarrhythmic drugs despite similar efficacy predictions during electrophysiologic testing. METHODS We retrospectively compared the standard programmed stimulation protocol used at Case Western Reserve University, which used three extrastimuli during all follow-up studies, with the ESVEM protocol in 176 antiarrhythmic drug trials: sotalol (n = 54), procainamide (n = 73) and quinidine/mexiletine (n = 49). RESULTS Predictions of efficacy were higher in the sotalol trials (14 of 54 standard, 20 of 54 ESVEM) than in procainamide trials (7 of 73 standard, 14 of 73 ESVEM) or quinidine/mexiletine trials (1 of 49 standard, 7 of 49 ESVEM). Thus, the two protocols classified 19 of 176 trials differently: not effective by the standard protocol but effective by the ESVEM trial. Discordant predictions of drug efficacy constituted a smaller proportion of ESVEM protocol efficacy predictions for sotalol (6 [30%] of 20) than for the other drugs (13 [62%] of 21, p < or = 0.05). CONCLUSIONS In the present study, the ESVEM programmed stimulation protocol predicted efficacy more often than the standard protocol. Discordant predictions represented a smaller portion of efficacy predictions for sotalol than for the other drugs. Thus, in the ESVEM trial, the superior long-term follow-up observed in patients assigned to sotalol may have been an artifact of the stimulation protocol utilized by the ESVEM investigators.
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Affiliation(s)
- L A Biblo
- Department of Medicine, Case Western Reserve University/University Hospitals of Cleveland, Ohio, USA
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30
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Abstract
Sotalol is a water-soluble, nonselective, beta-adrenergic blocker that was recently approved in oral form in the United States for the treatment of ventricular arrhythmias that are judged to be life-threatening. As a beta-blocker, sotalol is unique in having additional class-III antiarrhythmic activity. It is still not resolved whether sotalol is more effective than other beta-blockers in managing arrhythmias, but there are suggestions that it might possess greater antiarrhythmic and life-protecting activities than other types of antiarrhythmic drugs. The drug is well tolerated, but, because of its electrophysiologic activity, there is a small risk of proarrhythmia, specifically the development of polymorphic ventricular tachycardia and torsade de pointes.
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Affiliation(s)
- E Cavusoglu
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
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Claudel JP, Touboul P. Sotalol: from "just another beta blocker" to "the prototype of class III antidysrhythmic compound". Pacing Clin Electrophysiol 1995; 18:451-67. [PMID: 7770366 DOI: 10.1111/j.1540-8159.1995.tb02545.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Sotalol is a beta-blocking drug devoid of membrane stabilizing properties, as well as intrinsic sympathomimetic actions, or cardioselectivity. In addition, sotalol prolongs atrial and ventricular repolarization (Class III antiarrhythmic activity). It appears to have less myocardial depressant effect than other beta-blocking agents. Given orally, bioavailability of the drug reaches 100%. Sotalol's plasma half-life is 15 hours (range 7-18) and is dependent only on renal function. In clinical practice, it has been found effective in the suppression of nearly all supraventricular and ventricular dysrhythmias except those related to prolonged ventricular repolarization. Most common adverse effects are dyspnea, bradycardia, and fatigue, which results in drug termination in 16% of the cases. Torsades de pointes usually associated with bradycardia and drug induced QTc prolongation has been reported in 1.9%-3.5% of the patients receiving sotalol. This complication may be reduced by limiting the dose (< 640 mg/day) especially in patients with impaired renal function. In addition hypokalemia must be avoided. To sum up, the combination of Class II and Class III effects may carry additional benefits. However, further studies are required to test such hypotheses.
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Affiliation(s)
- J P Claudel
- Service de Soins Intensifs Cardiologiques (U-51), Hôpital Cardiovasculaire Louis Pradel, Lyon, France
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Singh BN, Kehoe R, Woosley RL, Scheinman M, Quart B. Multicenter trial of sotalol compared with procainamide in the suppression of inducible ventricular tachycardia: a double-blind, randomized parallel evaluation. Sotalol Multicenter Study Group. Am Heart J 1995; 129:87-97. [PMID: 7817931 DOI: 10.1016/0002-8703(95)90048-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Sotalol is the prototype class III agent that combines beta-blocking properties with the propensity to prolong the effective refractory period by lengthening the action potential duration. Its precise effect on the prevention of ventricular tachycardia-ventricular fibrillation (VTVF) compared to class I agents has not been evaluated in a blinded study. In a double-blind parallel-design multicenter study, the electrophysiologic and antiarrhythmic effects of intravenous and oral sotalol (n = 55) and procainamide (n = 55) were therefore compared in patients with VTVF inducible by programmed electric stimulation. Sotalol produced a greater effect on lengthening the ventricular effective refractory period (VERP). It prevented the inducibility of VTVF in 30% versus 20% for procainamide, but this was not significantly different. In an alternate therapy group (n = 41) of similar patients previously refractory to or intolerant of procainamide, intravenous sotalol prevented inducibility in 32%. The pooled overall sotalol efficacy rate was 31%. There was a significant relation between the increase in the VERP and the prevention of inducibility of VTVF (n = 56; p < 0.02). VERP of > or = 300 msec was critical for the prevention of VTVF inducibility. Thirteen sotalol and 6 procainamide responders from the randomized group and 30 from the nonrandomized groups completed 1 year of oral sotalol therapy follow-up. Life-table analysis of these patient in each group showed a trend in favor of sotalol; however, statistical analysis was not possible because of the small numbers of patients. Both sotalol and procainamide were well tolerated. In the randomized group there was one case of sudden death during treatment with sotalol and two cases of nonfatal torsades de pointes in the procainamide group and two in the sotalol group; in the nonrandomized alternate therapy group, there were 6 cases of nonfatal torsades de pointes. The data support the emerging role of sotalol in the control of symptomatic ventricular tachycardia and fibrillation.
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Affiliation(s)
- B N Singh
- Department of Cardiology, Veterans Affairs Medical Center of West Los Angeles, CA 90073
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Abstract
To study the effects of class III agents on QT/QTc dispersion in patients with heart disease and cardiac arrhythmias, QT dispersion and QRS and RR intervals were compared in patients before and after treatment with amiodarone (n = 26), sematilide (n = 26), and sotalol (n = 26). QT, QRS, and RR intervals, and QTc values were calculated for each complex, and their mean values were calculated for each lead. QT and QTc dispersions were defined as differences between the minimal and maximal QT or QTc values in each of the 12 leads studied. Amiodarone, sematilide, and sotalol all significantly prolonged the QT interval and the QTc value. Significant reductions in QT and QTc dispersions were only found in the amiodarone group (QT dispersions: 79 +/- 13 vs 49 +/- 14 ms; p < 0.001; QTc dispersions: 0.08 +/- 0.02 vs 0.05 +/- 0.01 s1/2; p < 0.001). The mean RR interval was significantly increased in patients after treatment with amiodarone (p < 0.001) and sotalol (p < 0.001), but not in patients receiving sematilide treatment (p > 0.2). The baseline QT and QTc dispersions were significantly greater in patients with than without myocardial infarction before treatment (p < 0.001). The mean baseline values for QT/QTc dispersions were not significantly different among all 3 groups. However, only amiodarone significantly reduced the QT dispersion (from 76 +/- 10 to 46 +/- 11 ms; p < 0.001) and QTc dispersion (from 0.09 +/- 0.02 to 0.05 +/- 0.01 s1/2; p < 0.001) in patients with myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- G Cui
- Department of Medicine, Veterans Affairs Medical Center of West Los Angeles
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Abstract
Two trial designs have been used in evaluating sotalol in patients with sustained tachyarrhythmias: open-label dose escalation and randomized comparison with reference agents. At least 7 open-label studies (n = 16-65) have been reported from single centers in patients in whom trials of numerous other antiarrhythmic agents were unsuccessful. At the doses used, usually 320-640 mg/day, plasma concentrations were in the range associated with both beta blockade and class III antiarrhythmic activity (2-3 micrograms/mL). These concentrations produced electrophysiologic changes that were consistent across studies: 10-16% increase in right ventricular effective refractory period (ERP), 4-8% increase in corrected QT interval (QTc), and 17-30% increase in sinus cycle length (corresponding to a 15-23% decrease in heart rate). In these open-label trials, sotalol suppressed inducible ventricular tachyarrhythmias in 20-72% of patients; the higher degrees of efficacy were reported when induction protocols were confined to double extrastimuli. Side effects leading to discontinuation of sotalol in patients with sustained ventricular tachycardia or fibrillation include fatigue (4.0%), marked bradycardia (3.0%), torsades de pointes (3.0%), and heart failure or pulmonary edema (1.0%). A multicenter randomized trial compared intravenous sotalol with intravenous procainamide in a double-blind prospective fashion. Sotalol suppressed ventricular tachyarrhythmias inducible with triple extrastimuli in 15 (30%) of 50 patients, whereas procainamide was effective in 10 (20%) of 50. In this and other series, responsiveness to sotalol was prospectively identified by a particularly fast tachycardia at baseline (e.g., cycle length of < 270 msec), but not by the extent of changes in global indices of repolarization (QTc, ERP).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D M Roden
- Department of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-6602
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