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Abramochkin DV, Pustovit OB, Mironov NY, Filatova TS, Nesterova T. Characterization of hERG K + channel inhibition by the new class III antiarrhythmic drug cavutilide. Naunyn Schmiedebergs Arch Pharmacol 2024:10.1007/s00210-023-02940-5. [PMID: 38224347 DOI: 10.1007/s00210-023-02940-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/30/2023] [Indexed: 01/16/2024]
Abstract
Cavutilide (niferidil, refralon) is a new class III antiarrhythmic drug which effectively terminates persistent atrial fibrillation (AF; 84.6% of patients, mean AF duration 3 months) and demonstrates low risk of torsade de pointes (1.7%). ERG channels of rapid delayed rectifier current(IKr) are the primary target of cavutilide, but the particular reasons of higher effectiveness and lower proarrhythmic risk in comparison with other class III IKr blockers are unclear. The inhibition of hERG channels expressed in CHO-K1 cells by cavutilide was studied using whole-cell patch-clamp. The present study demonstrates high sensitivity of IhERG expressed in CHO-K1 cells to cavutilide (IC50 = 12.8 nM). Similarly to methanesulfonanilide class III agents, but unlike amiodarone and related drugs, cavutilide does not bind to hERG channels in their resting state. However, in contrast to dofetilide, cavutilide binds not only to opened, but also to inactivated channels. Moreover, at positive constantly set membrane potential (+ 60 mV) inhibition of IhERG by 100 nM cavutilide develops faster than at 0 mV and, especially, - 30 mV (τ of inhibition was 78.8, 103, and 153 ms, respectively). Thereby, cavutilide produces IhERG inhibition only when the cell is depolarized. During the same period of time, cavutilide produces greater block of IhERG when the cell is depolarized with 2 Hz frequency, if compared to 0.2 Hz. We suggest that, during the limited time after injection, cavutilide produces stronger inhibition of IKr in fibrillating atrium than in non-fibrillating ventricle. This leads to beneficial combination of antiarrhythmic effectiveness and low proarrhythmicity of cavutilide.
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Affiliation(s)
- Denis V Abramochkin
- Department of Human and Animal Physiology, Biological Faculty, Lomonosov Moscow State University, Leninskiye Gory, 1, 12, Moscow, Russia.
| | - Oksana B Pustovit
- Department of Human and Animal Physiology, Biological Faculty, Lomonosov Moscow State University, Leninskiye Gory, 1, 12, Moscow, Russia
| | | | - Tatiana S Filatova
- Department of Human and Animal Physiology, Biological Faculty, Lomonosov Moscow State University, Leninskiye Gory, 1, 12, Moscow, Russia
- Chazov National Medical Research Center for Cardiology, Moscow, Russia
- Department of Physiology, Pirogov Russian National Research Medical University, Ostrovityanova str., 1, Moscow, Russia
| | - Tatiana Nesterova
- Institute of Immunology and Physiology, Ural Branch of Russian Academy of Sciences, 620049, Ekaterinburg, Russia
- Institute of Natural Sciences and Mathematics, Ural Federal University, 620075, Ekaterinburg, Russia
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Ma Y, Guo L, Pang H, Yan Q, Li J, Hu M, Yi F. Failure of intravenous nifekalant cardioversion as an independent predictor for persistent atrial fibrillation recurrence after catheter ablation. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01713-7. [PMID: 38051431 DOI: 10.1007/s10840-023-01713-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/24/2023] [Indexed: 12/07/2023]
Abstract
AIMS Nifekalant is a class III antiarrhythmic drug that exerts antiarrhythmic effects by inhibiting rapid rectifying potassium channels and extending the effective refractory period of cardiomyocytes. It has a high success rate in converting atrial fibrillation (AF) to sinus rhythm. Whether the failure of intravenous nifekalant cardioversion is an independent predictor for persistent AF recurrence after catheter ablation has not been reported. METHODS A total of 92 patients with drug-refractory persistent AF were retrospectively enrolled. After all ablations, intravenous nifekalant was administrated. Patients were assigned to the success group (group 1) and failure group (group 2) based on nifekalant cardioversion results and followed for 12 months to note any episode of atrial arrhythmia recurrence. RESULTS Each group included 46 patients. After 12 months of follow-up, nine (19.6%) patients from group 1 and 23 (50.0%) patients from group 2 had a recurrence of atrial tachyarrhythmia (P = 0.002). AF duration and type 2 diabetes were strongly associated with failure of intravenous nifekalant cardioversion. Univariable Cox proportional hazard regression showed that failure of intravenous nifekalant cardioversion, AF duration, and type 2 diabetes were potential risk factors. Multivariable Cox proportional hazard regression showed that failure of nifekalant cardioversion was statistically associated with AF recurrence (adjusted RR = 2.257, 95% CI: 1.006-5.066, P = 0.048). Failure of intravenous nifekalant cardioversion could bring a positive effect on the prognostic differentiation when added into the multivariable model (0.767 ± 0.042 vs. 0.774 ± 0.045, P = 0.025). CONCLUSION Failure of nifekalant cardioversion is an independent predictor for persistent AF recurrence after catheter ablation.
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Affiliation(s)
- Yibo Ma
- Department of Cardiology, Xijing Hospital, Air Force Medical University, 169 Changle West Road, Xi'an, Shaanxi, 710032, China
| | - Lanyan Guo
- Department of Cardiology, Xijing Hospital, Air Force Medical University, 169 Changle West Road, Xi'an, Shaanxi, 710032, China
| | - Huani Pang
- Department of Cardiology, Xijing Hospital, Air Force Medical University, 169 Changle West Road, Xi'an, Shaanxi, 710032, China
| | - Qun Yan
- Department of Cardiology, Xijing Hospital, Air Force Medical University, 169 Changle West Road, Xi'an, Shaanxi, 710032, China
| | - Jie Li
- Department of Cardiology, Xijing Hospital, Air Force Medical University, 169 Changle West Road, Xi'an, Shaanxi, 710032, China
| | - Miaoyang Hu
- Department of Cardiology, Xijing Hospital, Air Force Medical University, 169 Changle West Road, Xi'an, Shaanxi, 710032, China
| | - Fu Yi
- Department of Cardiology, Xijing Hospital, Air Force Medical University, 169 Changle West Road, Xi'an, Shaanxi, 710032, China.
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Lenhoff H, Järnbert-Petersson H, Darpo B, Tornvall P, Frick M. Mortality and ventricular arrhythmias in patients on d,l-sotalol for rhythm control of atrial fibrillation: A nationwide cohort study. Heart Rhythm 2023; 20:1473-1480. [PMID: 37598987 DOI: 10.1016/j.hrthm.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/03/2023] [Accepted: 08/11/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Use of d,l-sotalol for rhythm control in patients with atrial fibrillation (AF) has raised safety concerns. Previous randomized studies are few and not designed for mortality outcome. OBJECTIVE The purpose of this study was to compare the incidences of mortality and ventricular arrhythmias in AF patients treated with d,l-sotalol for rhythm control vs matched control patients treated with cardioselective beta-blockers. METHODS This population-based cohort study included AF patients from the Swedish National Patient Registry (2006-2017) who underwent rhythm control after a second cardioversion. Incidence rates (IRs) and adjusted hazard ratios (aHRs) for mortality and a composite endpoint of cardiac arrest/death and ventricular arrhythmias were calculated for the overall cohort and a 1:1 propensity score matched cohort of d,l-sotalol vs beta-blocker treatment. RESULTS Among patient treated with d,l-sotalol (n = 4987) and beta-blocker (n = 27,078) (mean follow-up 458 days), all-cause mortality was lower in patients treated with d,l-sotalol: IR 1.21; 95% confidence interval 0.95-1.52 vs 2.42 (2.26-2.60) deaths per 100 patient-years; aHR 0.66 (0.52-0.83). The difference in mortality persisted in the propensity score matched comparison (n = 4953 in each group): aHR 0.63 (0.48-0.86). No differences were observed in the composite outcome: IR in propensity cohorts 2.13 (1.78-2.52) vs 2.07 (1.73-2.53) events per 100 years; aHR 1.01 (0.78-1.29). CONCLUSION There was no excess mortality with d,l-sotalol compared with cardioselective beta-blockers in patients undergoing rhythm control treatment for AF after a second cardioversion. Our results indicate that the risk associated with d,l-sotalol treatment for AF can be mitigated by careful patient selection and strict adherence to follow-up protocols.
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Affiliation(s)
- Hanna Lenhoff
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, South Hospital, Stockholm, Sweden.
| | - Hans Järnbert-Petersson
- Department of Clinical Science and Education, Karolinska Institutet, South Hospital, Stockholm, Sweden
| | | | - Per Tornvall
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, South Hospital, Stockholm, Sweden
| | - Mats Frick
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, South Hospital, Stockholm, Sweden
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Gruber M, Iglesias M, Khanna R, Zhang D, Karim S. Heart failure risk in patients with atrial fibrillation treated with catheter ablation vs antiarrhythmic drugs. Heart Rhythm O2 2023; 4:681-691. [PMID: 38034885 PMCID: PMC10685151 DOI: 10.1016/j.hroo.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023] Open
Abstract
Background Atrial fibrillation (AF) increases heart failure (HF) risk. Whereas the risk of HF-related hospitalization and mortality are known in the setting of AF, the impact of AF treatment on HF development is understudied. Objective The purpose of this study was to compare HF incidence among AF patients treated with antiarrhythmic drugs (AADs) vs catheter ablation (CA). Methods AF patients with 1 prior AAD usage were identified in 2014-2022 Optum Clinformatics database. Patients were classified into 2 cohorts: those receiving CA vs those receiving a different AAD prescription. The 2 cohorts were matched on sociodemographic and clinical covariates using propensity score matching technique. Cox regression model was used to compare incident HF risk in the 2 cohorts. Subgroup analyses were performed by race/ethnicity, sex, AF subtype, and CHA2DS2-VASc score. Results After matching, 9246 patients were identified in each cohort (AAD and CA). Patients receiving CA had a 57% lower risk of incident HF than those treated with AADs (hazard ratio [HR] 0.43; 95% confidence interval [CI] 0.40-0.46). Subgroup analysis by race/ethnicity depicted similar results, with non-Hispanic White (HR 0.43; 95% CI 0.40-0.46), non-Hispanic Black (HR 0.46; 95% CI 0.35-0.60), Hispanic (HR 0.53; 95% CI 0.40-0.70), and Asian (HR 0.46; 95% CI 0.24-0.92) patients treated with CA (vs AAD) having significantly lower risk of HF, respectively. The effect size of CA remained significant in subgroups defined by sex, AF subtypes, and CHA2DS2-VASc score. Conclusion AF patients receiving CA had ∼57% lower risk of developing HF than those receiving AAD. The lower risk of HF associated with CA vs AAD persisted across different race/ethnicity, sex, AF subtypes, and CHA2DS2-VASc score.
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Affiliation(s)
- Megan Gruber
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Maximiliano Iglesias
- Franchise Health Economics and Market Access, Johnson & Johnson, Irvine, California
| | - Rahul Khanna
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, New Jersey
| | - Dongyu Zhang
- Medical Device Epidemiology and Real-World Data Sciences, Johnson & Johnson, New Brunswick, New Jersey
| | - Saima Karim
- Case Western Reserve University School of Medicine, Cleveland, Ohio
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Wazni O, Moss J, Kuniss M, Andrade J, Chierchia GB, Mealing S, Mburu W, Sale A, Kaplon R, Ismyrloglou E, Bromilow T, Lane E, Lewis D, Reynolds MR. An economic evaluation of first-line cryoballoon ablation vs antiarrhythmic drug therapy for the treatment of paroxysmal atrial fibrillation from a U.S. Medicare perspective. Heart Rhythm O2 2023; 4:528-537. [PMID: 37744940 PMCID: PMC10513914 DOI: 10.1016/j.hroo.2023.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Background Three recent randomized controlled trials have demonstrated that, as an initial rhythm control strategy, first-line cryoballoon ablation (cryoablation) reduces atrial arrhythmia recurrence compared with antiarrhythmic drugs (AADs) in patients with symptomatic paroxysmal atrial fibrillation (PAF). Objective The study sought to evaluate the cost-effectiveness of first-line cryoablation compared with first-line AADs for treating symptomatic PAF from a U.S. Medicare payer perspective. Methods Individual patient-level data from 703 participants with PAF enrolled into the Cryo-FIRST (NCT01803438), STOP AF First (NCT03118518), and EARLY-AF (NCT02825979) trials were used to derive parameters for the cost-effectiveness model. The cost-effectiveness model used a hybrid decision tree and Markov structure. The decision tree had a 1-year time horizon and was used to inform the initial health state allocation in the first cycle of the Markov model. The Markov model used a 40-year time horizon (3-month cycle length). Health benefits were expressed in quality-adjusted life years (QALYs). Costs and benefits were discounted at 3% per year. Results Cryoablation was estimated to yield higher QALYs (+0.17) and higher costs (+$4274) per patient over a 40-year time horizon than AADs. Ultimately, this produced an average incremental cost-effectiveness ratio of $24,637 per QALY gained. Independent of initial treatment, individuals were expected to receive ∼1.2 ablations over a lifetime. There was a 45% relative reduction in time spent in atrial fibrillation health states for those initially treated with cryoablation compared with AADs. Conclusion Initial rhythm control with first-line cryoballoon ablation is highly cost-effective compared with first-line AADs from a U.S. Medicare payer perspective.
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Affiliation(s)
- Oussama Wazni
- Department of Cardiac Electrophysiology and Pacing, Cleveland Clinic, Cleveland, Ohio
| | - Joe Moss
- York Health Economics Consortium, York, United Kingdom
| | - Malte Kuniss
- Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Jason Andrade
- Division of Cardiology and Cardiac Electrophysiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gian Battista Chierchia
- Department of Cardiology at Heart Rhythm Management Center, Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | | | | | | | | | | | - Tom Bromilow
- York Health Economics Consortium, York, United Kingdom
| | - Emily Lane
- York Health Economics Consortium, York, United Kingdom
| | - Damian Lewis
- York Health Economics Consortium, York, United Kingdom
| | - Matthew R. Reynolds
- Baim Institute for Clinical Research, Boston, Massachusetts
- Lahey Hospital and Medical Center, Burlington, Massachusetts
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6
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Blomström-Lundqvist C, Naccarelli GV, McKindley DS, Bigot G, Wieloch M, Hohnloser SH. Effect of dronedarone vs. placebo on atrial fibrillation progression: a post hoc analysis from ATHENA trial. Europace 2023; 25:845-854. [PMID: 36758013 PMCID: PMC10062319 DOI: 10.1093/europace/euad023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/17/2023] [Indexed: 02/10/2023] Open
Abstract
AIMS This post hoc analysis of the ATHENA trial (NCT00174785) assessed the effect of dronedarone on the estimated burden of atrial fibrillation (AF)/atrial flutter (AFL) progression to presumed permanent AF/AFL, and regression to sinus rhythm (SR), compared with placebo. METHODS AND RESULTS The burden of AF/AFL was estimated by a modified Rosendaal method using available electrocardiograms (ECG). Cumulative incidence of permanent AF/AFL (defined as ≥6 months of AF/AFL until end of study) or permanent SR (defined as ≥6 months of SR until end of study) were calculated using Kaplan-Meier estimates. A log-rank test was used to assess statistical significance. Hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) were estimated using a Cox model, adjusted for treatment group. Of the 4439 patients included in this analysis, 2208 received dronedarone, and 2231 placebo. Baseline and clinical characteristics were well balanced between groups. Overall, 304 (13.8%) dronedarone-treated patients progressed to permanent AF/AFL compared with 455 (20.4%) treated with placebo (P < 0.0001). Compared with those receiving placebo, patients receiving dronedarone had a lower cumulative incidence of permanent AF/AFL (log-rank P < 0.001; HR: 0.65; 95% CI: 0.56-0.75), a higher cumulative incidence of permanent SR (log-rank P < 0.001; HR: 1.19; 95% CI: 1.09-1.29), and a lower estimated AF/AFL burden over time (P < 0.01 from Day 14 to Month 21). CONCLUSION These results suggest that dronedarone could be a useful antiarrhythmic drug for early rhythm control due to less AF/AFL progression and more regression to SR vs. placebo, potentially reflecting reverse remodeling. CLINICAL TRIAL REGISTRATION NCT00174785.
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Affiliation(s)
- Carina Blomström-Lundqvist
- Department of Medical Science, Uppsala University, Uppsala, 751 85, Sweden.,Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, SE-701 82, Sweden
| | - Gerald V Naccarelli
- Penn State University College of Medicine, Penn State Hershey Heart and Vascular Institute, 500 University Drive, Hershey, PA 17033, USA
| | | | - Gregory Bigot
- IVIDATA Life Sciences, 79 Rue Baudin, Paris, 92300 Levallois-Perret, France
| | - Mattias Wieloch
- Sanofi, Rue la Boetie 54-56, Paris 75008, France.,Department of Coagulation Disorders, Lund University, Jan Waldenströms gata 14, Lund 20502, Sweden
| | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J.W. Goethe University, Theodor-Stern-Kai 7, Frankfurt D 60590, Germany
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DeLurgio DB, Blauth C, Halkos ME, Crossen KJ, Talton D, Oza SR, Magnano AR, Mostovych MA, Billakanty S, Duff S, Stees C, Sperling J, Ahsan S, Yap J, Shults C, Pederson D, Garrison J, Tabereaux P, Gilligan DM, Bundy G, Costantini O, Espinal E, La Pietra A, Yang F, Greenberg Y, Jacobowitz I, Gill J. Hybrid epicardial-endocardial ablation for long-standing persistent atrial fibrillation: A subanalysis of the CONVERGE Trial. Heart Rhythm O2 2023; 4:111-118. [PMID: 36873309 PMCID: PMC9975017 DOI: 10.1016/j.hroo.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Favorable clinical outcomes are difficult to achieve in long-standing persistent atrial fibrillation (LSPAF) with catheter ablation (CA). The CONVERGE (Convergence of Epicardial and Endocardial Ablation for the Treatment of Symptomatic Persistent Atrial FIbrillation) trial evaluated the effectiveness of hybrid convergent (HC) ablation vs endocardial CA. Objective The study sought to evaluate the safety and effectiveness of HC vs CA in the LSPAF subgroup from the CONVERGE trial. Methods The CONVERGE trial was a prospective, multicenter, randomized trial that enrolled 153 patients at 27 sites. A post hoc analysis was performed on LSPAF patients. The primary effectiveness was freedom from atrial arrhythmias off new or increased dose of previously failed or intolerant antiarrhythmic drugs (AADs) through 12 months. The primary safety endpoint was major adverse event incidence through 30 days with HC. Key secondary effectiveness measures included (1) percent of patients achieving ≥90% AF burden reduction vs baseline and (2) AF freedom. Results Sixty-five patients (42.5% of total enrollment) had LSPAF; 38 in HC and 27 in CA. Primary effectiveness was 65.8% (95% confidence interval [CI] 50.7%-80.9%) with HC vs 37.0% (95% CI 5.1%-52.4%) with CA (P = .022). Through 18 months, these rates were 60.5% (95% CI 50.0%-76.1%) with HC vs 25.9% (95% CI 9.4%-42.5%) with CA (P = .006). Secondary effectiveness rates were higher than CA with HC at 12 and 18 months. Freedom from atrial arrhythmias off AADs was 52.6% (95% CI 36.8%-68.5%) and 47.4% (95% CI 31.5%-63.2%) with HC at 12 and 18 months vs 25.9% (95% CI 9.4%-42.5%) and 22.2% (95% CI 6.5%-37.9%) with CA, respectively (12 months: P = .031; 18 months: P = .038). Three (7.9%) major adverse events occurred within 30 days of HC. Conclusion Post hoc analysis demonstrated effectiveness and acceptable safety of HC compared with CA in LSPAF.
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Affiliation(s)
| | | | | | - Karl J Crossen
- Cardiology Associates Research, LLC, Tupelo, Mississippi
| | - David Talton
- Cardiology Associates Research, LLC, Tupelo, Mississippi
| | | | | | | | | | - Steven Duff
- Riverside Methodist Hospital, OhioHealth, Columbus, Ohio
| | | | - Jason Sperling
- HealthOne Cardiothoracic Surgery Associates, Aurora, Colorado
| | - Syed Ahsan
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - John Yap
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | | | - David Pederson
- STAR Clinical Trials/Methodist Cardiology Clinic San Antonio, San Antonio, Texas
| | - James Garrison
- STAR Clinical Trials/Methodist Cardiology Clinic San Antonio, San Antonio, Texas
| | | | | | - Graham Bundy
- Virginia Cardiovascular Specialists, Richmond, Virginia
| | | | | | | | - Felix Yang
- Maimonides Medical Center, Brooklyn, New York
| | | | | | - Jaswinder Gill
- Guy's and St. Thomas' Foundation Trust, London, United Kingdom
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8
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El Assaad I, Jurow K, Dasgupta S, Alexander ME, Beroukhim R, Del Nido P, Geva T, Walsh EP, Mah DY, O'Leary ET. Ventricular arrhythmias after fibroma resection: Are patients still at risk? Heart Rhythm 2023; 20:243-249. [PMID: 36228870 DOI: 10.1016/j.hrthm.2022.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 09/20/2022] [Accepted: 10/05/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Ventricular fibromas frequently present with life-threatening ventricular tachycardia (VT) or ventricular fibrillation (VF) in children. The long-term risk of sustained ventricular arrhythmias after surgical resection is unknown. OBJECTIVES The aims of this study were to quantify the VT/VF risk after surgical resection and to examine the results of early (during index surgical hospitalization) and late (≥3 months after surgery) postoperative ventricular stimulation (V-stim) studies. METHODS We performed a retrospective cohort study of all patients with ventricular fibromas who underwent surgical resection at our institution (2000-2020). The primary outcome was defined as recurrent VT/VF ≥3 months after index surgical resection. RESULTS Forty-six patients with a median age at surgery of 2 years (range 0.3-18.9 years) formed our study cohort. Indications for surgery included cardiac arrest in 11 (24%), sustained VT in 16 (35%), premature ventricular contractions/nonsustained VT in 10 (22%), and hemodynamic abnormalities in 9 (20%). Of the 11 patients who presented with cardiac arrest, 4 underwent pre-resection implantable cardioverter-defibrillator (ICD) implantation, all of which were explanted at the time of surgery. An early postoperative V-stim study was performed in 26 (57%) patients, and all were negative for inducible VT/VF. Of the 13 late postoperative V-stim studies, 3 were positive: 2 underwent ICD implantation and 1 was initiated on amiodarone and underwent loop recorder implantation. At the time of last follow-up (median 1.5 years; range 0.3-16.5 years), 45 (98%) were free of clinical VT/VF and no patient with an ICD has received an appropriate shock. CONCLUSION Surgical resection of ventricular fibromas significantly reduces the risk of life-threatening arrhythmias in children; however, a small number of patients remain vulnerable.
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Affiliation(s)
- Iqbal El Assaad
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Kelsey Jurow
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Soham Dasgupta
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Mark E Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Rebecca Beroukhim
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Pedro Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Edward P Walsh
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Edward T O'Leary
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.
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Bottino R, Carbone A, D'Andrea A, Liccardo B, Cimmino G, Imbalzano E, Russo V. Pharmacokinetic determinants for the right dose of antiarrhythmic drugs. Expert Opin Drug Metab Toxicol 2022; 18:165-176. [PMID: 35209796 DOI: 10.1080/17425255.2022.2046733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Antiarrhythmic drugs (AADs) show a narrow therapeutic range and marked intersubject variability in pharmacokinetics (PK), which may lead to inappropriate dosing and drug toxicity. AREAS COVERED The aim of the present review is to describe PK properties of AADs, discussing the main changes in different clinical scenarios, such as the elderly and patients with obese, chronic kidney, liver, and cardiac disease, in order to guide their right prescription in clinical practice. EXPERT OPINION There are few data about PK properties of AADs in a special population or challenging clinical setting. The use and dose of AADs is commonly based on physicians' clinical experience observing the clinical effects rather than being personalized on the individual patients PK profiles. More and updated studies are needed to validate a patient centered approach in the pharmacological treatment of arrhythmias based on patients' clinical features, including pharmacogenomics, and AAD pharmacokinetics.
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Affiliation(s)
- Roberta Bottino
- Division of Cardiology, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy
| | - Andreina Carbone
- Division of Cardiology, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy
| | - Antonello D'Andrea
- Division of Cardiology, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy.,Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Biagio Liccardo
- Division of Cardiology, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy.,Department of Cardiology, Umberto I° Hospital Nocera Inferiore, Italy
| | - Giovanni Cimmino
- Division of Cardiology, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Vincenzo Russo
- Division of Cardiology, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy
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Kimura M, Kobori A, Nitta J, Hirao K, Shizuta S, Kurita T, Okishige K, Kumagai K, Koyama J, Hiroshima K, Inaba O, Goya M, Yamauchi Y, Kueffer FJ, Becker D, Okumura K. Cryoballoon ablation for paroxysmal atrial fibrillation in Japan: 2-year safety and efficacy results from the Cryo AF Global Registry. J Interv Card Electrophysiol 2022; 64:695-703. [PMID: 35119586 PMCID: PMC9470593 DOI: 10.1007/s10840-022-01132-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 01/17/2022] [Indexed: 11/24/2022]
Abstract
Purpose Catheter ablation is a recommended rhythm control therapy after failed or intolerant antiarrhythmic drug (AAD) treatment for patients with atrial fibrillation (AF). This study evaluates clinical performance and safety of pulmonary vein isolation (PVI) using the cryoballoon (Arctic Front Advance) in Japan. Methods Cryo AF Global Registry is a prospective, multi-center registry. Patients with paroxysmal AF (PAF) were treated at 10 Japanese hospitals. Efficacy was evaluated by freedom from a ≥ 30-s recurrence of AF/atrial flutter (AFL)/atrial tachycardia (AT), AF-related symptoms, and quality of life using the EQ-5D-3L questionnaire. The safety endpoint was serious device- and procedure-related adverse events. Results The study included 352 patients with PAF (65 ± 10 years of age, 36% female, 36% without prior failure of AAD). Mean duration since first diagnosis of AF was 3.0 ± 5.5 years. Serious device- and procedure-related adverse event rate was 2.6% (95% CI: 1.2–4.8%). Freedom from AF/AFL/AT was 88.5% (95% CI: 84.7–91.4%) at 12 months and 86.7% (95% CI: 81.1–90.8%) at 24 months. The number of patients with ≥ 1 AF symptom was significantly decreased from 88% at enrollment to 22% (p < 0.01) at 12-month follow-up. General quality of life using EQ-5D did not improve significantly after 12 months in the summary score. However, in the visual analog scale score, there was improvement (5.8 ± 18.4; p < 0.01). Conclusions This study demonstrates that cryoablation used for PVI is a safe and effective treatment in real-world use for patients with PAF in Japan. Supplementary Information The online version contains supplementary material available at 10.1007/s10840-022-01132-0.
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Affiliation(s)
| | | | | | - Kenzo Hirao
- Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | | | | | | | | | | | | | | | - Masahiko Goya
- Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | | | | | | | - Ken Okumura
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
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11
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Curtis AB, Zeitler EP, Malik A, Bogard A, Bhattacharyya N, Stewart J, Hohnloser SH. Efficacy and safety of dronedarone across age and sex subgroups: a post hoc analysis of the ATHENA study among patients with non-permanent atrial fibrillation/flutter. Europace 2021; 24:1754-1762. [PMID: 34374766 PMCID: PMC9681127 DOI: 10.1093/europace/euab208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 07/19/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS Age and sex may impact the efficacy of antiarrhythmic drugs on cardiovascular outcomes and arrhythmia recurrences in patients with atrial fibrillation (AF). We report on a post hoc analysis of the ATHENA study (NCT00174785), which examined cardiovascular outcomes in patients with non-permanent AF treated with dronedarone vs. placebo. METHODS AND RESULTS Efficacy and safety of dronedarone were assessed in patients according to age and sex. Baseline characteristics were comparable across subgroups, except for cardiovascular comorbidities, which were more frequent with increasing age. Dronedarone significantly reduced the risk of cardiovascular hospitalization or death due to any cause among patients 65-74 [n = 1830; hazard ratio (HR) 0.71, 95% confidence interval (CI) 0.60-0.83; P < 0.0001] and ≥75 (n = 1925; HR 0.75, 95% CI 0.65-0.88; P = 0.0002) years old and among males (n = 2459; HR 0.74, 95% CI 0.64-0.84; P < 0.00001) and females (n = 2169; HR 0.77, 95% CI 0.67-0.89; P = 0.0002); outcomes were similar for time to AF/AFL recurrence. Among patients aged <65 years (n = 873), cardiovascular hospitalization or death due to any cause with dronedarone vs. placebo was associated with an HR of 0.89 (95% CI 0.71-1.11; P = 0.3). The incidence of all treatment-emergent adverse events (TEAEs) and TEAEs leading to treatment discontinuation was comparable among males and females, and increased with increasing age. CONCLUSIONS These results support the use of dronedarone for the improvement of clinical outcomes among patients aged ≥65 years and regardless of sex.
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Affiliation(s)
- Anne B Curtis
- Corresponding author. Tel: 716-859-4828, E-mail address:
| | - Emily P Zeitler
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, The Dartmouth Institute, Lebanon, NH, USA
| | - Aysha Malik
- Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo General Medical Center, 100 High Street, D2-76, Buffalo, NY 14203, USA
| | - Andrew Bogard
- US General Medicines Medical, Sanofi, Bridgewater, NJ, USA
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12
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Gharaviri A, Pezzuto S, Potse M, Conte G, Zeemering S, Sobota V, Verheule S, Krause R, Auricchio A, Schotten U. Synergistic antiarrhythmic effect of inward rectifier current inhibition and pulmonary vein isolation in a 3D computer model for atrial fibrillation. Europace 2021; 23:i161-i168. [PMID: 33751085 DOI: 10.1093/europace/euaa413] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022] Open
Abstract
AIMS Recent clinical studies showed that antiarrhythmic drug (AAD) treatment and pulmonary vein isolation (PVI) synergistically reduce atrial fibrillation (AF) recurrences after initially successful ablation. Among newly developed atrial-selective AADs, inhibitors of the G-protein-gated acetylcholine-activated inward rectifier current (IKACh) were shown to effectively suppress AF in an experimental model but have not yet been evaluated clinically. We tested in silico whether inhibition of inward rectifier current or its combination with PVI reduces AF inducibility. METHODS AND RESULTS We simulated the effect of inward rectifier current blockade (IK blockade), PVI, and their combination on AF inducibility in a detailed three-dimensional model of the human atria with different degrees of fibrosis. IK blockade was simulated with a 30% reduction of its conductivity. Atrial fibrillation was initiated using incremental pacing applied at 20 different locations, in both atria. IK blockade effectively prevented AF induction in simulations without fibrosis as did PVI in simulations without fibrosis and with moderate fibrosis. Both interventions lost their efficacy in severe fibrosis. The combination of IK blockade and PVI prevented AF in simulations without fibrosis, with moderate fibrosis, and even with severe fibrosis. The combined therapy strongly decreased the number of fibrillation waves, due to a synergistic reduction of wavefront generation rate while the wavefront lifespan remained unchanged. CONCLUSION Newly developed blockers of atrial-specific inward rectifier currents, such as IKAch, might prevent AF occurrences and when combined with PVI effectively supress AF recurrences in human.
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Affiliation(s)
- Ali Gharaviri
- Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland
| | - Simone Pezzuto
- Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland
| | - Mark Potse
- Carmen Team, Inria Bordeaux-Sud-Ouest, Talence, France.,Université de Bordeaux, IMB, UMR 5251, F-33400, Talence, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Foundation Bordeaux Université, Bordeaux, France
| | - Giulio Conte
- Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland.,Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, 6900 Lugano, Switzerland
| | - Stef Zeemering
- Department of Physiology, Maastricht University, Maastricht, The Netherlands
| | - Vladimír Sobota
- Department of Physiology, Maastricht University, Maastricht, The Netherlands
| | - Sander Verheule
- Department of Physiology, Maastricht University, Maastricht, The Netherlands
| | - Rolf Krause
- Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland
| | - Angelo Auricchio
- Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland.,Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, 6900 Lugano, Switzerland
| | - Ulrich Schotten
- Department of Physiology, Maastricht University, Maastricht, The Netherlands
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13
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Kuniss M, Pavlovic N, Velagic V, Hermida JS, Healey S, Arena G, Badenco N, Meyer C, Chen J, Iacopino S, Anselme F, Packer DL, Pitschner HF, Asmundis CD, Willems S, Di Piazza F, Becker D, Chierchia GB. Cryoballoon ablation vs. antiarrhythmic drugs: first-line therapy for patients with paroxysmal atrial fibrillation. Europace 2021; 23:1033-1041. [PMID: 33728429 PMCID: PMC8286851 DOI: 10.1093/europace/euab029] [Citation(s) in RCA: 104] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/25/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS Treatment guidelines for patients with atrial fibrillation (AF) suggest that patients should be managed with an antiarrhythmic drug (AAD) before undergoing catheter ablation (CA). This study evaluated whether pulmonary vein isolation employing cryoballoon CA is superior to AAD therapy for the prevention of atrial arrhythmia (AA) recurrence in rhythm control naive patients with paroxysmal AF (PAF). METHODS AND RESULTS A total of 218 treatment naive patients with symptomatic PAF were randomized (1 : 1) to cryoballoon CA (Arctic Front Advance, Medtronic) or AAD (Class I or III) and followed for 12 months. The primary endpoint was ≥1 episode of recurrent AA (AF, atrial flutter, or atrial tachycardia) >30 s after a prespecified 90-day blanking period. Secondary endpoints included the rate of serious adverse events (SAEs) and recurrence of symptomatic palpitations (evaluated via patient diaries). Freedom from AA was achieved in 82.2% of subjects in the cryoballoon arm and 67.6% of subjects in the AAD arm (HR = 0.48, P = 0.01). There were no group differences in the time-to-first (HR = 0.76, P = 0.28) or overall incidence [incidence rate ratio (IRR)=0.79, P = 0.28] of SAEs. The incidence rate of symptomatic palpitations was lower in the cryoballoon (7.61 days/year) compared with the AAD arm (18.96 days/year; IRR = 0.40, P < 0.001). CONCLUSIONS Cryoballoon CA was superior to AAD therapy, significantly reducing AA recurrence in treatment naive patients with PAF. Additionally, cryoballoon CA was associated with lower symptom recurrence and a similar rate of SAEs compared with AAD therapy.
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Affiliation(s)
- Malte Kuniss
- Kerckhoff Heart Center, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
| | - Nikola Pavlovic
- Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia
| | | | | | | | | | - Nicolas Badenco
- AP-HP Sorbonne Université, ICAN Institute, Hopital Pitié-Salpétrière, Paris, France
| | - Christian Meyer
- University Heart Center, Hamburg, Cardiac Neuro- and Electrophysiology Research Consortium, EVK Düsseldorf, Düsseldorf, Germany
| | - Jian Chen
- Haukeland University Hospital, University of Bergen, Bergen, Norway
| | | | | | | | | | - Carlo de Asmundis
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Postgraduate program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Brussels, Belgium
| | - Stephan Willems
- University Heart Center, Hamburg, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Fabio Di Piazza
- Medtronic, Core Clinical Solutions, Study and Scientific Solutions, Rome, Italy
| | | | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Postgraduate program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Brussels, Belgium
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14
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Okawa K, Hara S, Morimoto T, Tsushima R, Sudo Y, Sogo M, Ozaki M, Takahashi M, Doi M, Morita H, Ito H. Effect of preprocedural pharmacologic cardioversion on pulmonary vein isolation in patients with persistent atrial fibrillation. Heart Rhythm 2021; 18:1473-1479. [PMID: 33932587 DOI: 10.1016/j.hrthm.2021.04.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/07/2021] [Accepted: 04/24/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND The optimal strategy for catheter ablation of persistent atrial fibrillation (PeAF) remains unknown. A preprocedural additive treatment for patients undergoing pulmonary vein isolation (PVI) alone to optimize catheter ablation should be investigated. OBJECTIVE The purpose of this study was to determine whether pharmacologic cardioversion with a fixed low-dose antiarrhythmic drug (AAD) before ablation could stratify the long-term outcome of a PVI-alone strategy. METHODS We conducted a prospective cohort study of PeAF patients who underwent PVI using contact force-sensing catheters. No substrate modification was performed. Fixed low-dose bepridil was administered before ablation for cardioversion and patients were classified into 2 groups based on obtaining sinus rhythm (SR). The rate of recurrence of atrial fibrillation (AF) and/or atrial tachycardia (AT) within 36 months was compared between the 2 groups. RESULTS Among the 303 PeAF patients who received the AAD, 102 returned to SR (SR group), and the other 201 had persistence of AF (non-SR group). AF persistence duration at baseline and during bepridil administration was similar between the 2 groups. The SR group had a significantly lower 36-month AF/AT recurrence rate than the non-SR group (17 [22.2%] vs 55 [34.0%], log-rank P = .022). AT-type recurrence was observed in 16 patients (2 [3.3%] in the SR group vs 14 [8.9%] in the non-SR group; log-rank P = .051). Nonresponse to AAD was an independent predictor of AF/AT recurrence after adjusting for other risk factors (hazard ratio 1.34; 95% confidence interval 1.01-1.77; P = .040). CONCLUSION Preprocedural pharmacologic cardioversion could be a useful determinant for patients with treatable PeAF by PVI alone.
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Affiliation(s)
- Keisuke Okawa
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital, Kagawa, Japan.
| | - Shohei Hara
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Hyogo, Japan
| | - Ryu Tsushima
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Yuya Sudo
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Masahiro Sogo
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Masatomo Ozaki
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Masahiko Takahashi
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Masayuki Doi
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Hiroshi Morita
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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15
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Jiang D, Gamal El-Din T, Zheng N, Catterall WA. Expression and purification of the cardiac sodium channel Na V1.5 for cryo-EM structure determination. Methods Enzymol 2021; 653:89-101. [PMID: 34099183 DOI: 10.1016/bs.mie.2021.01.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Voltage-gated sodium channel NaV1.5 is responsible for initiating and propagating cardiac action potentials by selectively conducting Na+ into cardiomyocytes. Class-I antiarrhythmic drugs target NaV1.5 for treatment of arrhythmias. During the last few years, cryogenic electron microscopy (cryo-EM) has become a powerful technique to determine the structures of ion channels at atomic level. In order to reveal the structural features of NaV1.5 and the structural basis for its interaction with antiarrhythmic drugs by cryo-EM, NaV1.5 protein must be expressed at high levels and purified to homogeneity. In this chapter, we discuss the expression and purification of NaV1.5 in a mammalian expression system. We optimized the construct by deleting unstructured intracellular loops of rat NaV1.5 while retaining core functional regions. The resulting rNaV1.5C is fully functional and is blocked by Class-I antiarrhythmic drugs in a state-dependent manner. Protocols are presented for expressing and purifying sufficient sample of NaV1.5 for preparing cryo-EM grids. The resulting cryo-EM structure is briefly described.
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Affiliation(s)
- Daohua Jiang
- Department of Pharmacology, University of Washington, Seattle, WA, United States; Laboratory of Soft Matter Physics, Institute of Physics, Chinese Academy of Sciences, Beijing, China
| | - Tamer Gamal El-Din
- Department of Pharmacology, University of Washington, Seattle, WA, United States
| | - Ning Zheng
- Department of Pharmacology, University of Washington, Seattle, WA, United States; Howard Hughes Medical Institute, University of Washington, Seattle, WA, United States
| | - William A Catterall
- Department of Pharmacology, University of Washington, Seattle, WA, United States.
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16
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Sun LJ, Du X, Liu SW, He R, Zeng H, Sun C, Li L, Zhang Y, Ma CS, Gao W. [Current status of the clinical practice and analysis on the ratioanl prescription of antiarrhythmic drugs in Chinese patients with atrial fibrillation: Results from the Chinese Atrial Fibrillation Registry (CAFR) trial]. Zhonghua Xin Xue Guan Bing Za Zhi 2020; 48:740-747. [PMID: 32957756 DOI: 10.3760/cma.j.cn112148-20200103-00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To explore the practice patterns and the related factors of oral antiarrhythmic drug (AAD) treatment in Chinese patients with atrial fibrillation (AF), and to evaluate the compliance of AAD application to atrial fibrillation management guidelines. Methods: From August 2011 to August 2016, medical records from 18 014 patients with AF were analyzed based on data from the Chinese Atrial Fibrillation Registry trial. Patients were divided into AAD group (7 788 cases, 43.23%) and non-AAD group (10 226 cases, 56.77%) according to whether AAD was used at baseline or at the time of first use during follow-up. Amiodarone (4 129 cases, 53.02%) and propafenone (3 211 cases, 41.23%) were the mostly prescribed AAD and subgroup analysis was performed accordingly. Medical records were analyzed by random forest regression to evaluate the use of AAD and related factors in patients with AF, and the rationality of AAD was analyzed according to the guidelines for the management of atrial fibrillation. Result: A total of 18 014 patients were included in this study, of which 60.48% (10 895/18 014) were male patients, 22.65% (4 081/18 014) were elderly patients(≥75 years old), there were 7 788 patients (43.23%) in AAD group, and 10 226 patients(56.77%) in non-AAD group. Compared with the non-AAD group, the elderly patients (≥75 years old, 13.74%(1 070/7 788) vs. 29.44%(3 011/10 226)), persistent AF (28.95% (2 250/7 788) 45.80% (4 683/10 226)), heart failure(8.29% (646/7 788) vs. 21.95% (2 245/10 226)), stroke and (or) TIA(12.15% (946/7 788) vs. 19.95% (2 040/10 226)), renal dysfunction(16.36%(1 274/7 788) vs. 29.37% (3 003/10 226)), and high thromboembolism risk(60.17% (4 748/7 788) vs. 76.40% (7 813/10 226)) were less prevalent in the AAD subgroup (P<0.001). Multivariate analysis showed that patients in tertiary hospitals (OR=3.72, 95%CI 3.17-4.37) were more likely to use AAD, elderly patients (≥75 years old, OR=0.47, 95%CI 0.39-0.55), persistent atrial fibrillation (OR=0.66, 95%CI 0.60-0.72), and patients with heart failure (OR=0.54, 95%CI 0.47-0.63), stroke and (or) TIA (OR=0.77, 95%CI 0.68-0.87), renal dysfunction (OR=0.75, 95%CI 0.59-0.95) and high thromboembolism risk(OR=0.7, 95%CI 0.58-0.84) were more likely not to use AAD(P<0.05). In the AAD group, amiodarone and propafenone were the most commonly used AAD, accounting for 53.02% (4 129/7 788) and 41.23% (3 211/7 788), respectively. Multivariate analysis showed that patients with persistent atrial fibrillation (OR=4.57, 95%CI 3.94-5.29) and coronary heart disease (OR=4.14, 95%CI 3.03-5.64), heart failure (OR=2.07, 95%CI 1.48-2.89), non-ischemic cardiomyopathy (OR=4.84, 95%CI 2.41-9.73) were more likely to use amiodarone, and those with normal left ventricular ejection fraction (OR=0.31, 95%CI 0.15-0.65) and low thromboembolism risk (OR=0.78, 95%CI 0.63-0.97) were more likely to use propafenone (P<0.001). The overall incidence of AAD treatment, which was not indicated by the guidelines was 6.5% (480/7 340); 5.1% (212/4 129) in the amiodarone group and 8.3% (268/3 211) in the propafenone group, respectively. Compared with the rational AAD use group, the proportion of irrational drug use was higher in the elderly (≥75 years old) (20.4% (98/480) vs. 12.9% (887/6 860)), patients of high thromboembolism risk (77.1% (379/480) vs. 59.0% (4 047/6 860)), and in non-tertiary hospitals (7.1% (34/480) vs. 3.3% (299/6 860)), but lower in men(50.8% (244/480) vs. 64.5% (4 427/6 860)), P<0.001. Conclusions: The patients with paroxysmal atrial fibrillation, who were treated with AAD, were mostly patients with fewer complications, and the patients who were treated with amiodarone were mostly patients with persistent atrial fibrillation, patients were more likely to complicate with organic heart disease. The incidence of AAD that do not comply with the guidelines was low, and it was more common in non-tertiary hospitals and the elder patients with high thromboembolism risk.
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Affiliation(s)
- L J Sun
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education. Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing 100191, China
| | - X Du
- Department of Cardiology, Beijing Anzhen Hospital of the Capital University of Medical Sciences, Beijing 100029, China
| | - S W Liu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education. Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing 100191, China
| | - R He
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education. Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing 100191, China
| | - H Zeng
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education. Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing 100191, China
| | - C Sun
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education. Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing 100191, China
| | - L Li
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education. Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing 100191, China
| | - Y Zhang
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education. Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing 100191, China
| | - C S Ma
- Department of Cardiology, Beijing Anzhen Hospital of the Capital University of Medical Sciences, Beijing 100029, China
| | - W Gao
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education. Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing 100191, China
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17
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Caves RE, Carpenter A, Choisy SC, Clennell B, Cheng H, McNiff C, Mann B, Milnes JT, Hancox JC, James AF. Inhibition of voltage-gated Na + currents by eleclazine in rat atrial and ventricular myocytes. Heart Rhythm O2 2020; 1:206-214. [PMID: 32864638 PMCID: PMC7442036 DOI: 10.1016/j.hroo.2020.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Atrial-ventricular differences in voltage-gated Na+ currents might be exploited for atrial-selective antiarrhythmic drug action for the suppression of atrial fibrillation without risk of ventricular tachyarrhythmia. Eleclazine (GS-6615) is a putative antiarrhythmic drug with properties similar to the prototypical atrial-selective Na+ channel blocker ranolazine that has been shown to be safe and well tolerated in patients. Objective The present study investigated atrial-ventricular differences in the biophysical properties and inhibition by eleclazine of voltage-gated Na+ currents. Methods The fast and late components of whole-cell voltage-gated Na+ currents (respectively, INa and INaL) were recorded at room temperature (∼22°C) from rat isolated atrial and ventricular myocytes. Results Atrial INa activated at command potentials ∼5.5 mV more negative and inactivated at conditioning potentials ∼7 mV more negative than ventricular INa. There was no difference between atrial and ventricular myocytes in the eleclazine inhibition of INaL activated by 3 nM ATX-II (IC50s ∼200 nM). Eleclazine (10 μM) inhibited INa in atrial and ventricular myocytes in a use-dependent manner consistent with preferential activated state block. Eleclazine produced voltage-dependent instantaneous inhibition in atrial and ventricular myocytes; it caused a negative shift in voltage of half-maximal inactivation and slowed the recovery of INa from inactivation in both cell types. Conclusions Differences exist between rat atrial and ventricular myocytes in the biophysical properties of INa. The more negative voltage dependence of INa activation/inactivation in atrial myocytes underlies differences between the 2 cell types in the voltage dependence of instantaneous inhibition by eleclazine. Eleclazine warrants further investigation as an atrial-selective antiarrhythmic drug.
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Affiliation(s)
- Rachel E Caves
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, United Kingdom
| | - Alexander Carpenter
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, United Kingdom
| | - Stéphanie C Choisy
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, United Kingdom
| | - Ben Clennell
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, United Kingdom
| | - Hongwei Cheng
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, United Kingdom
| | - Cameron McNiff
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, United Kingdom
| | - Brendan Mann
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, United Kingdom
| | | | - Jules C Hancox
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, United Kingdom
| | - Andrew F James
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, United Kingdom
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18
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Haanschoten DM, Vernooy K, Beukema RJ, Szili-Torok T, Ter Bekke RMA, Khan M, de Jong JSSG, Otten AM, Adiyaman A, Smit JJJ, Delnoy PPHM, Ramdat Misier AR, Elvan A. Elimination of Benign Ventricular Premature Beats or Ventricular Tachycardia with Catheter Ablation versus Two Different Optimal Antiarrhythmic Drug Treatment Regimens (Sotalol or Verapamil/Flecainide). Cardiology 2020; 145:795-801. [PMID: 32841937 DOI: 10.1159/000509661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/23/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Symptomatic idiopathic ventricular arrhythmias (VA), including premature beats (VPB) and nonsustained ventricular tachycardia (VT) are commonly encountered arrhythmias. Although these VA are usually benign, their treatment can be a challenge to primary and secondary health care providers. Mainstay treatment is comprised of antiarrhythmic drugs (AAD) and, in case of drug intolerance or failure, patients are referred for catheter ablation to tertiary health care centers. These patients require extensive medical attention and drug regimens usually have disappointing results. A direct comparison between the efficacy of the most potent AAD and primary catheter ablation in these patients is lacking. The ECTOPIA trial will evaluate the efficacy of 2 pharmacological strategies and 1 interventional approach to: suppress the VA burden, improve the quality of life (QoL), and safety. HYPOTHESIS We hypothesize that flecainide/verapamil combination and catheter ablation are both superior to sotalol in suppressing VA in patients with symptomatic idiopathic VA. STUDY DESIGN The Elimination of Ventricular Premature Beats with Catheter Ablation versus Optimal Antiarrhythmic Drug Treatment (ECTOPIA) trial is a randomized, multicenter, prospective clinical trial to compare the efficacy of catheter ablation versus optimal AAD treatment with sotalol or flecainide/verapamil. One hundred eighty patients with frequent symptomatic VA in the absence of structural heart disease or underlying cardiac ischemia who are eligible for catheter ablation with an identifiable monomorphic VA origin with a burden ≥5% on 24-h ambulatory rhythm monitoring will be included. Patients will be randomized in a 1:1:1 fashion. The primary endpoint is defined as >80% reduction of the VA burden on 24-h ambulatory Holter monitoring. After reaching the primary endpoint, patients randomized to one of the 2 AAD arms will undergo a cross-over to the other AAD treatment arm to explore differences in drug efficacy and QoL in individual patients. Due to the use of different AAD (with and without β-blocking characteristics) we will be able to explore the influence of alterations in sympathetic tone on VA burden reduction in different subgroups. Finally, this study will assess the safety of treatment with 2 different AAD and ablation of VA.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Arif Elvan
- Isala Heart Center, Zwolle, The Netherlands,
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19
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Abstract
PURPOSE OF REVIEW Atrial fibrillation (AF) predisposes to embolic strokes and reduced quality of life. Ablation (catheter-based or surgically performed) can be employed to promote the maintenance of sinus rhythm in a carefully selected subset of patients with AF. The goal of this review is to discuss the indications and techniques for AF ablation, as well as post-procedural outcomes. RECENT FINDINGS Atrial fibrillation ablation improves quality of life in patients with atrial fibrillation although no clear reduction in stroke or overall mortality has been shown. Familiarity with the indications for AF ablation is important for all cardiologists, as is having a sound understanding of the efficacy of the procedure and potential complications. Furthermore, acquiring a grasp of the different modalities of AF ablation (including percutaneous endocardial techniques and surgical ablation approaches) will help to facilitate effective and appropriate referrals.
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Affiliation(s)
- Neel J Patel
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Joan A Maradey
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Prashant D Bhave
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
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20
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Konieczny KM, Dorian P. Clinically Important Drug-Drug Interactions Between Antiarrhythmic Drugs and Anticoagulants. J Innov Card Rhythm Manag 2019; 10:3552-3559. [PMID: 32494414 PMCID: PMC7252850 DOI: 10.19102/icrm.2019.100304] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 06/22/2018] [Indexed: 12/02/2022] Open
Abstract
Until the last decade, vitamin K antagonists (VKAs) were the only agents available for oral anticoagulation. Although effective and accessible, their use was complicated by a narrow therapeutic window, the need for regular monitoring of the international normalized ratio, and an associated susceptibility to interactions with both food and numerous medications. Furthermore, the onset of action was delayed, often requiring bridging with intravenous agents. In more recent years, we have enjoyed the development of nonvitamin-K-dependent, direct oral anticoagulants (DOACs), which either directly inhibit the activity of factor IIa (eg, dabigatran) or factor Xa (eg, rivaroxaban, apixaban, edoxaban). These medications boast a more rapid onset of action, predictable pharmacokinetics, wider therapeutic window, and equal or superior safety profiles. Although these medications appear to have fewer drug–drug interactions than VKAs, their interactions remain of clinical importance, particularly in one of the largest populations requiring anticoagulation: patients with atrial fibrillation. These patients are rarely on single medications, with the majority of them requiring some form of rate or rhythm control due to their arrhythmia. Unfortunately, data on interactions between DOACs and antiarrhythmic medications, despite their common coadministration, remain limited. Here, we summarize the interactions between antiarrhythmics and VKAs and review existing knowledge regarding their interactions with DOACs.
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Affiliation(s)
- Kaja M Konieczny
- Division of Cardiology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Paul Dorian
- Division of Cardiology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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21
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Bińkowski BJ, Makowski M, Kubiński P, Lubiński A. Effect of Antazoline on Electrophysiological Properties of Atrial Muscle and Conduction System of the Heart. Cardiovasc Drugs Ther 2018; 32:169-73. [PMID: 29623481 DOI: 10.1007/s10557-018-6787-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Purpose Antazoline is a first-generation antihistaminic agent with additional anticholinergic properties and antiarrhythmic potential. Recent data shows its high effectiveness in sinus rhythm restoration among patients with paroxysmal atrial fibrillation. The effect of antazoline on electrophysiological parameters of the heart in vivo has not yet been examined. The aim of this study was to evaluate changes in electrophysiological parameters of the heart muscle and conduction system as a response to increasing doses of antazoline. Methods After successful ablation of supraventricular arrhythmias, the electrophysiological parameters: sinus rhythm cycle length (SRCL), AH, HV, QRS, QT, QTc intervals, Wenckebach point (WP), sinus node recovery period (SNRT), intra- (hRA-CSos) and interatrial conduction time (hRA-CSd), right and left atrium refractory period (RA-; LA-ERP), and atrioventricular node refractory period (AVN-ERP) were assessed initially and after 100, 200, and 300 mg of antazoline given intravenously. Results Fifteen patients (8 males, 19–72 years old) undergoing EPS and RF ablation were enrolled. After 100 mg bolus, a significant reduction in SRCL was noticed. After antazoline administration, significant prolongation of HV, QRS, QTc, hRA-CSos, hRA-CSd intervals, RA– and LA-ERP and reduction of SRCL were observed. After a total dose of 300 mg, QT interval prolonged significantly. Increasing the dose of antazoline had no impact on AH, Wenckebach point, AVN-ERP, and SNRT. Conclusion Antazoline has an effect on electrophysiological parameters of the atrial muscle and has rapid onset of action. No negative effect on sinus node function and atrioventricular conduction in a unique property among antiarrhythmic drugs.
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22
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Staudacher I, Illg C, Chai S, Deschenes I, Seehausen S, Gramlich D, Müller ME, Wieder T, Rahm AK, Mayer C, Schweizer PA, Katus HA, Thomas D. Cardiovascular pharmacology of K 2P17.1 (TASK-4, TALK-2) two-pore-domain K + channels. Naunyn Schmiedebergs Arch Pharmacol 2018; 391:1119-31. [PMID: 30008082 DOI: 10.1007/s00210-018-1535-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 07/06/2018] [Indexed: 10/28/2022]
Abstract
K2P17.1 (TASK-4, TALK-2) potassium channels are expressed in the heart and represent potential targets for pharmacological management of atrial and ventricular arrhythmias. Reduced K2P17.1 expression was found in atria and ventricles of heart failure (HF) patients. Modulation of K2P17.1 currents by antiarrhythmic compounds has not been comprehensively studied to date. The objective of this study was to investigate acute effects of clinically relevant antiarrhythmic drugs on human K2P17.1 channels to provide a more complete picture of K2P17.1 electropharmacology. Whole-cell patch clamp and two-electrode voltage clamp electrophysiology was employed to study human K2P17.1 channel pharmacology. K2P17.1 channels expressed in Xenopus laevis oocytes were screened for sensitivity to antiarrhythmic drugs, revealing significant activation by propafenone (+ 296%; 100 μM), quinidine (+ 58%; 100 μM), mexiletine (+ 21%; 100 μM), propranolol (+ 139%; 100 μM), and metoprolol (+ 17%; 100 μM) within 60 min. In addition, the currents were inhibited by amiodarone (- 13%; 100 μM), sotalol (- 10%; 100 μM), verapamil (- 21%; 100 μM), and ranolazine (- 8%; 100 μM). K2P17.1 channels were not significantly affected by ajmaline and carvedilol. Concentration-dependent K2P17.1 activation by propafenone was characterized in more detail. The onset of activation was fast, and current-voltage relationships were not modulated by propafenone. K2P17.1 activation was confirmed in mammalian Chinese hamster ovary cells, revealing 7.8-fold current increase by 100 μM propafenone. Human K2P17.1 channels were sensitive to multiple antiarrhythmic drugs. Differential pharmacological regulation of repolarizing K2P17.1 background K+ channels may be employed for personalized antiarrhythmic therapy.
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23
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Hesselkilde EZ, Carstensen H, Haugaard MM, Carlson J, Pehrson S, Jespersen T, Buhl R, Platonov PG. Effect of flecainide on atrial fibrillatory rate in a large animal model with induced atrial fibrillation. BMC Cardiovasc Disord 2017; 17:289. [PMID: 29221440 PMCID: PMC5723027 DOI: 10.1186/s12872-017-0720-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 11/24/2017] [Indexed: 11/25/2022] Open
Abstract
Background Atrial fibrillatory cycle length has been considered one of the indices of atrial electrical remodelling during atrial fibrillation (AF), which can be assessed from surface ECG by computer-assisted calculation of atrial fibrillatory rate (AFR). Horses have been suggested as a bona fide model for AF studies since horses too, develop lone AF, however data on AF characteristics in horses are extremely sparse and non-invasive characterization of AF complexity using surface ECG processing has not been reported. Aim The aim was to study characteristics of induced AF and its modification by flecainide. Methods The study group consisted on 3 horses with spontaneous persistent AF and 13 with pace-induced AF. Seven horses were treated with saline (control) and eight with flecainide (2 mg/kg). ECGs were analysed using spatiotemporal cancellation of QRST complexes and calculation of AFR from the residual atrial signal. Results At AF onset, AFR was 295 ± 52 fibrillations per minute (fpm) in the horses with induced AF treated with flecainide, 269 ± 36 fpm in the control group (ns), and 364 ± 26 fpm in the horses with spontaneous persistent AF (P < 0.05 compared to the control group). Flecainide caused a decrease in AFR in all animals and restored sinus rhythm in the animals with induced AF. In the control animals, AFR increased from 269 ± 36 fpm to a plateau of 313 ± 14 fpm before decreasing to 288 ± 28 fpm during the last 10% of the AF episodes preceding spontaneous conversion (P < 0.05). Conclusion AFR in horses with induced AF resembles AFR in humans with paroxysmal AF. Flecainide caused a rapid decrease in AFR in all horses, further supporting the method to be a non-invasive technique to study the effect of antiarrhythmic compounds.
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Affiliation(s)
- Eva Z Hesselkilde
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Højbakkegaard Allé 5, 2630, Taastrup, Denmark
| | - Helena Carstensen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Højbakkegaard Allé 5, 2630, Taastrup, Denmark
| | - Maria M Haugaard
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Højbakkegaard Allé 5, 2630, Taastrup, Denmark
| | - Jonas Carlson
- Department of Cardiology, Lund University, 21185, Lund, Sweden
| | - Steen Pehrson
- Department of Cardiology, The Heart Centre, University of Copenhagen, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Thomas Jespersen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200, Copenhagen, Denmark
| | - Rikke Buhl
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Højbakkegaard Allé 5, 2630, Taastrup, Denmark.
| | - Pyotr G Platonov
- Arrhythmia Clinic, Skåne University Hospital and Department of Cardiology, Clinical Sciences, Lund University, 21185, Lund, Sweden
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24
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Abramochkin DV, Kuzmin VS, Rosenshtraukh LV. A New Class III Antiarrhythmic Drug Niferidil Prolongs Action Potentials in Guinea Pig Atrial Myocardium via Inhibition of Rapid Delayed Rectifier. Cardiovasc Drugs Ther 2017; 31:525-533. [PMID: 29181609 DOI: 10.1007/s10557-017-6762-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE A new class III antiarrhythmic drug niferidil (RG-2) has been introduced as a highly effective therapy for cases of persistent atrial fibrillation, but ionic mechanisms of its action are poorly understood. In the present study, the effects of niferidil on action potential (AP) waveform and potassium currents responsible for AP repolarization were investigated in guinea pig atrial myocardium. METHODS APs were recorded with sharp glass microelectrodes in multicellular atrial preparations. Whole-cell patch-clamp technique was used to measure K+ currents in isolated myocytes. RESULTS In multicellular atrial preparations, 10-8 M niferidil effectively prolonged APs by 15.2 ± 2.8% at 90% repolarization level. However, even the highest tested concentrations, 10-6 M and 10-5 M failed to prolong APs more than 32.5% of control duration. The estimated concentration of niferedil for half-maximal AP prolongation was 1.13 × 10-8 M. Among the potassium currents responsible for AP repolarization phase, I K1 was found to be almost insensitive to niferidil. However, another inward rectifier, I KACh, was effectively suppressed by micromolar concentrations of niferidil with IC50 = 9.2 × 10-6 M. I KATP was much less sensitive to the drug with IC50 = 2.26 × 10-4 M. The slow component of delayed rectifier, I Ks, also demonstrated low sensitivity to niferidil-the highest used concentration, 10-4 M, decreased peak I Ks density to 46.2 ± 5.5% of control. Unlike I Ks, the rapid component of delayed rectifier, I Kr, appeared to be extremely sensitive to niferidil. The IC50 was 1.26 × 10-9 M. I Kr measured in ventricular myocytes was found to be less sensitive to niferidil with IC50 = 3.82 × 10-8 M. CONCLUSIONS Niferidil prolongs APs in guinea pig atrial myocardium via inhibition of I Kr.
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Affiliation(s)
- Denis V Abramochkin
- Lomonosov Moscow State University, Moscow, Russia. .,Pirogov Russian National Research Medical University, Moscow, Russia. .,Department of Human and Animal Physiology, Moscow State University, Leninskije Gory, 1, 12, Moscow, Russia.
| | - Vladislav S Kuzmin
- Lomonosov Moscow State University, Moscow, Russia.,Pirogov Russian National Research Medical University, Moscow, Russia.,Institute of Experimental Cardiology, Moscow, Russia
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25
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Caves RE, Cheng H, Choisy SC, Gadeberg HC, Bryant SM, Hancox JC, James AF. Atrial-ventricular differences in rabbit cardiac voltage-gated Na + currents: Basis for atrial-selective block by ranolazine. Heart Rhythm 2017; 14:1657-64. [PMID: 28610990 DOI: 10.1016/j.hrthm.2017.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Indexed: 01/15/2023]
Abstract
Background Class 1 antiarrhythmic drugs are highly effective in restoring and maintaining sinus rhythm in atrial fibrillation patients but carry a risk of ventricular tachyarrhythmia. The antianginal agent ranolazine is a prototypic atrial-selective voltage-gated Na+ channel blocker but the mechanisms underlying its atrial-selective action remain unclear. Objective The present study examined the mechanisms underlying the atrial-selective action of ranolazine. Methods Whole-cell voltage-gated Na+ currents (INa) were recorded at room temperature (∼22°C) from rabbit isolated left atrial and right ventricular myocytes. Results INa conductance density was ∼1.8-fold greater in atrial than in ventricular cells. Atrial INa was activated at command potentials ∼7 mV more negative and inactivated at conditioning potentials ∼11 mV more negative than ventricular INa. The onset of inactivation of INa was faster in atrial cells than in ventricular myocytes. Ranolazine (30 μM) inhibited INa in atrial and ventricular myocytes in a use-dependent manner consistent with preferential activated/inactivated state block. Ranolazine caused a significantly greater negative shift in voltage of half-maximal inactivation in atrial cells than in ventricular cells, the recovery from inactivation of INa was slowed by ranolazine to a greater extent in atrial myocytes than in ventricular cells, and ranolazine produced an instantaneous block that showed marked voltage dependence in atrial cells. Conclusion Differences exist between rabbit atrial and ventricular myocytes in the biophysical properties of INa. The more negative voltage dependence of INa activation and inactivation, together with trapping of the drug in the inactivated channel, underlies an atrial-selective action of ranolazine.
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26
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Simó-Vicens R, Sauter DRP, Grunnet M, Diness JG, Bentzen BH. Effect of antiarrhythmic drugs on small conductance calcium - activated potassium channels. Eur J Pharmacol 2017; 803:118-123. [PMID: 28322838 DOI: 10.1016/j.ejphar.2017.03.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/16/2017] [Accepted: 03/17/2017] [Indexed: 10/19/2022]
Abstract
Atrial fibrillation (AF) is the most common type of arrhythmia. Current pharmacological treatment for AF is moderately effective and/or increases the risk of serious ventricular adverse effects. To avoid ventricular adverse effects, a new target has been considered, the small conductance calcium-activated K+ channels (KCa2.X, SK channels). In the heart, KCa2.X channels are functionally more important in atria compared to ventricles, and pharmacological inhibition of the channel confers atrial selective prolongation of the cardiac action potential and converts AF to sinus rhythm in animal models of AF. Whether antiarrhythmic drugs (AADs) recommended for treating AF target KCa2.X channels is unknown. To this end, we tested a large number of AADs on the human KCa2.2 and KCa2.3 channels to assess their effect on this new target using automated whole-cell patch clamp. Of the AADs recommended for treatment of AF only dofetilide and propafenone inhibited hKCa2.X channels, with no subtype selectivity. The calculated IC50 were 90±10µmol/l vs 60±10µmol/l for dofetilide and 42±4µmol/l vs 80±20µmol/l for propafenone (hKCa2.3 vs hKCa2.2). Whether this inhibition has clinical importance for their antiarrhythmic effect is unlikely, as the calculated IC50 values are very high compared to the effective free therapeutic plasma concentration of the drugs when used for AF treatment, 40,000-fold for dofetilide and 140-fold higher for propafenone.
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Affiliation(s)
- Rafel Simó-Vicens
- Biomedical Institute, University of Copenhagen, Blegdamsvej 3B, DK-2200 Copenhagen, Denmark; Acesion Pharma, Ole Maaløes Vej 3, DK-2200 Copenhagen, Denmark
| | - Daniel R P Sauter
- Biomedical Institute, University of Copenhagen, Blegdamsvej 3B, DK-2200 Copenhagen, Denmark; Acesion Pharma, Ole Maaløes Vej 3, DK-2200 Copenhagen, Denmark
| | - Morten Grunnet
- Acesion Pharma, Ole Maaløes Vej 3, DK-2200 Copenhagen, Denmark
| | - Jonas G Diness
- Acesion Pharma, Ole Maaløes Vej 3, DK-2200 Copenhagen, Denmark
| | - Bo H Bentzen
- Biomedical Institute, University of Copenhagen, Blegdamsvej 3B, DK-2200 Copenhagen, Denmark; Acesion Pharma, Ole Maaløes Vej 3, DK-2200 Copenhagen, Denmark.
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27
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Abstract
Ectopic atrial tachycardia (EAT) is a relatively common type of supraventricular tachycardia in the pediatric population, and it can be resistant to antiarrhythmic drugs and lead to tachycardia-induced cardiomyopathy (TIC) if not properly managed. The purpose of this study was to determine the predictors of the response to pharmacological therapy in children with EAT. From January 2009 to April 2014, 115 children were admitted to our hospital with a diagnosis of EAT and placed on antiarrhythmic drugs. We examined the clinical history, response to therapy, and follow-up of the children. The incidence of TIC secondary to EAT was 22.6% (n = 26) in children. Incessant EAT accounted for 44.3% of all patients. Control of EAT with antiarrhythmic therapy was achieved in 73.9% (n = 85) of the children. The combination of sotalol and propafenone performed well in controlling EAT in children [complete control in 35 (49.3%) of 71]. The mean time of conversion to sinus rhythm was 24 days, and the mean duration of therapy was 11 months in children with resolution. Multivariate predictors of the control of EAT were age at presentation (OR 0.289, P = 0.038) and tachycardia type (OR 0.276, P = 0.006). TIC occurs in 22.6% of children with EAT. Incessant EAT is more frequently complicated by TIC. Independent factors associated with a good response to pharmacological therapy include a younger age at presentation and non-incessant tachycardia in children with EAT.
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Affiliation(s)
- Haiyan Ge
- Department of Pediatric Cardiology, Heart Center, The First Hospital of Tsinghua University, Medical Center, Tsinghua University, Beijing, China.,Beijing Huaxin Hospital, Beijing, 100016, China
| | - Xiaomei Li
- Department of Pediatric Cardiology, Heart Center, The First Hospital of Tsinghua University, Medical Center, Tsinghua University, Beijing, China. .,Beijing Huaxin Hospital, Beijing, 100016, China.
| | - Haiju Liu
- Department of Pediatric Cardiology, Heart Center, The First Hospital of Tsinghua University, Medical Center, Tsinghua University, Beijing, China.,Beijing Huaxin Hospital, Beijing, 100016, China
| | - He Jiang
- Department of Pediatric Cardiology, Heart Center, The First Hospital of Tsinghua University, Medical Center, Tsinghua University, Beijing, China.,Beijing Huaxin Hospital, Beijing, 100016, China
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28
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Karlis G, Iacovidou N, Lelovas P, Niforopoulou P, Papalois A, Siafaka I, Mentzelopoulos S, Xanthos T. Nifekalant Versus Amiodarone in the Treatment of Cardiac Arrest: an Experimental Study in a Swine Model of Prolonged Ventricular Fibrillation. Cardiovasc Drugs Ther 2016; 29:425-31. [PMID: 26145169 DOI: 10.1007/s10557-015-6604-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of the experiment was to compare the effects of nifekalant and amiodarone on the return of spontaneous circulation (ROSC), survival, as well as on the hemodynamic parameters in a swine model of prolonged ventricular fibrillation (VF). METHODS After 8 min of untreated VF, bolus doses of epinephrine (adrenaline) and either nifekalant, or amiodarone, or saline (n = 10 per group), were administered after randomization. Cardiopulmonary resuscitation (CPR) was commenced immediately after drug administration and defibrillation was attempted 2 min later. CPR was resumed for another 2 min after each defibrillation attempt and the same dose of adrenaline was given every 4th minute during CPR. RESULTS Forty-eight hour survival was significantly higher with nifekalant compared to amiodarone (p < 0.001) and saline (p = 0.02), (9/10 vs. 0/10 vs. 3/10, respectively). Systolic aortic pressure, diastolic aortic pressure and coronary perfusion pressure were significantly higher with nifekalant during CPR and immediate post-resuscitation period (p < 0.05). The animals in the amiodarone group had a slower heart rate at the 1st and 45th min post-ROSC (p < 0.001 and p = 0.006, respectively). The number of electric shocks required for terminating VF, time to ROSC and adrenaline dose were significantly higher with amiodarone compared to nifekalant (p < 0.001). CONCLUSIONS Nifekalant showed a more favorable hemodynamic profile and improved survival compared to amiodarone and saline in this swine model.
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Affiliation(s)
- George Karlis
- 2nd Department of Internal Medicine, Sismanoglio General Hospital, Athens, Greece. .,Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece.
| | - Nicoletta Iacovidou
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece.,2nd Department of Obstetrics and Gynecology, Neonatal Division, Aretaieio Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Pavlos Lelovas
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | | | | | - Ioanna Siafaka
- 1st Anesthesiology Clinic, Pain Relief and Palliative Care Unit, Aretaieio Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Spyros Mentzelopoulos
- 1st Department of Intensive Care Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Theodoros Xanthos
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece.,MSc "Cardiopulmonary Resuscitation", National and Kapodistrian University of Athens, Medical School, Athens, Greece.,Midwestern University of Chicago, Chicago, IL, USA
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29
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Lugenbiel P, Schweizer PA, Katus HA, Thomas D. Antiarrhythmic gene therapy - will biologics replace catheters, drugs and devices? Eur J Pharmacol 2016; 791:264-273. [PMID: 27593579 DOI: 10.1016/j.ejphar.2016.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/08/2016] [Accepted: 09/01/2016] [Indexed: 01/08/2023]
Abstract
The clinical management of heart rhythm disorders still constitutes a major challenge. The development of alternatives to current approaches is of significant interest in order to establish more effective therapies that increase quality of life and reduce symptoms and hospitalizations. Over the past two decades the mechanistic understanding of pathophysiological pathways underlying cardiac arrhythmias has advanced profoundly, opening up novel avenues for mechanism-based therapeutic approaches. In particular, gene therapy offers greater selectivity than small molecule-based or interventional treatment. The gene of interest is packaged into viral or non-viral carriers and delivered to the target area via direct injection or using catheter-based techniques, providing the advantage of site-restricted action in contrast to systemic application of drugs. This work summarizes the current knowledge on mechanistic background, application strategies, and preclinical outcome of antiarrhythmic gene therapy for atrial fibrillation, ventricular tachycardia, and modulation of sinus node function.
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Affiliation(s)
- Patrick Lugenbiel
- Department of Cardiology, Medical University Hospital, Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany
| | - Patrick A Schweizer
- Department of Cardiology, Medical University Hospital, Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany; Heidelberg Research Center for Molecular Medicine (HRCMM), Im Neuenheimer Feld 350, D-69120 Heidelberg, Germany
| | - Hugo A Katus
- Department of Cardiology, Medical University Hospital, Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany
| | - Dierk Thomas
- Department of Cardiology, Medical University Hospital, Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany.
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Abstract
Dronedarone is the newest antiarrhythmic drug approved for the maintenance of sinus rhythm in patients with nonpermanent atrial fibrillation (AF). It is a multi-channel blocker with diverse electrophysiologic properties. Dronedarone decreases the incidence of AF recurrence and the ventricular rate during recurrence. Dronedarone decreases rates of cardiovascular hospitalizations in patients with paroxysmal and persistent AF. Dronedarone increases mortality in patients with permanent AF and those with moderate-severe heart failure, and should thus be avoided in these populations. Dronedarone is less effective than amiodarone but also has less toxicity. Direct comparison with other antiarrhythmic drugs is not available.
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Affiliation(s)
- Rafik Tadros
- Department of Medicine, Université de Montréal and Montreal Heart Institute, 5000 Rue Belanger, Montreal, Québec H1T 1C8, Canada
| | - Stanley Nattel
- Department of Medicine, Université de Montréal and Montreal Heart Institute, 5000 Rue Belanger, Montreal, Québec H1T 1C8, Canada
| | - Jason G Andrade
- Department of Medicine, Université de Montréal and Montreal Heart Institute, 5000 Rue Belanger, Montreal, Québec H1T 1C8, Canada; Heart Rhythm Services, Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada.
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Zheng YR, Chen ZY, Ye LF, Wang LH. Long-term stroke rates after catheter ablation or antiarrhythmic drug therapy for atrial fibrillation: a meta-analysis of randomized trials. J Geriatr Cardiol 2015; 12:507-14. [PMID: 26512242 DOI: 10.11909/j.issn.1671-5411.2015.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is an independent risk factor for ischemic stroke and is associated with increased risk of death. Randomized studies suggest improved quality of life for patients with AF after successful catheter ablation compared to antiarrhythmic drug therapy. The value of ablation in long-term risk of ischemic stroke, however, has not been assessed. We conducted a meta-analysis to determine whether AF ablation reduces the long-term risk of stroke compared to antiarrhythmic drug therapy in randomized controlled trials. METHODS & RESULTS PubMed and the Cochrane Central Register were searched for randomized trials from January 1990 to December 2014 comparing AF catheter ablation to drug therapy. The results are reported as risk differences (RDs) and 95% CI. Thirteen trials were analyzed with 1097 patients treated by catheter ablation and 855 patients received antiarrhythmic drug therapy. Overall, seven patients (0.64%) in the catheter ablation group had ischemic stroke or transient ischemic attacks vs. two patients (0.23%) in the drug therapy group. No difference was shown in the rate of stroke or transient ischemic attack between ablation and drug therapy (RD: 0.003, 95% CI: -0.006 to 0.012, P = 0.470), and no evidence of heterogeneity was observed (I (2) = 0, P = 0.981). No potential publication bias was found. There was also no difference in mortality between the two groups (RD: -0.004, 95% CI: -0.014 to 0.006, P = 0.472). CONCLUSIONS This meta-analysis of randomized controlled trials showed similar rates of ischemic stroke or transient ischemic attack and death in AF patients undergoing catheter ablation compared to drug therapy. A larger prospective randomized trial to confirm this finding is warranted.
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Kaitani K, Inoue K, Kobori A, Nakazawa Y, Ozawa T, Kurotobi T, Morishima I, Miura F, Watanabe T, Masuda M, Naito M, Fujimoto H, Nishida T, Furukawa Y, Shirayama T, Tanaka M, Okajima K, Yao T, Egami Y, Satomi K, Noda T, Miyamoto K, Haruna T, Kawaji T, Yoshizawa T, Toyota T, Yahata M, Nakai K, Sugiyama H, Higashi Y, Ito M, Horie M, Kusano KF, Shimizu W, Kamakura S, Morimoto T, Kimura T, Shizuta S. Efficacy of Antiarrhythmic Drugs Short-Term Use After Catheter Ablation for Atrial Fibrillation (EAST-AF) trial. Eur Heart J 2015; 37:610-8. [PMID: 26417061 DOI: 10.1093/eurheartj/ehv501] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 08/29/2015] [Indexed: 01/07/2023] Open
Abstract
AIMS Substantial portion of early arrhythmia recurrence after catheter ablation for atrial fibrillation (AF) is considered to be due to irritability in left atrium (LA) from the ablation procedure. We sought to evaluate whether 90-day use of antiarrhythmic drug (AAD) following AF ablation could reduce the incidence of early arrhythmia recurrence and thereby promote reverse remodelling of LA, leading to improved long-term clinical outcomes. METHODS AND RESULTS A total of 2038 patients who had undergone radiofrequency catheter ablation for paroxysmal, persistent, or long-lasting AF were randomly assigned to either 90-day use of Vaughan Williams class I or III AAD (1016 patients) or control (1022 patients) group. The primary endpoint was recurrent atrial tachyarrhythmias lasting for >30 s or those requiring repeat ablation, hospital admission, or usage of class I or III AAD at 1 year, following the treatment period of 90 days post ablation. Patients assigned to AAD were associated with significantly higher event-free rate from recurrent atrial tachyarrhythmias when compared with the control group during the treatment period of 90 days [59.0 and 52.1%, respectively; adjusted hazard ratio (HR) 0.84; 95% confidence interval (CI) 0.73-0.96; P = 0.01]. However, there was no significant difference in the 1-year event-free rates from the primary endpoint between the groups (69.5 and 67.8%, respectively; adjusted HR 0.93; 95% CI 0.79-1.09; P = 0.38). CONCLUSION Short-term use of AAD for 90 days following AF ablation reduced the incidence of recurrent atrial tachyarrhythmias during the treatment period, but it did not lead to improved clinical outcomes at the later phase.
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Affiliation(s)
| | - Koichi Inoue
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Atsushi Kobori
- Division of Cardiology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yuko Nakazawa
- Heart Rhythm Center, Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Tomoya Ozawa
- Heart Rhythm Center, Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Japan
| | | | - Itsuro Morishima
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Fumiharu Miura
- Department of Cardiology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | | | - Masaharu Masuda
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Masaki Naito
- Department of Cardiovascular Medicine, Nara Prefecture Western Medical Center, Nara, Japan
| | - Hajime Fujimoto
- Department of Cardiovascular Medicine, Nara Prefecture Western Medical Center, Nara, Japan
| | - Taku Nishida
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - Yoshio Furukawa
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Takeshi Shirayama
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Mariko Tanaka
- Department of Cardiology, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Katsunori Okajima
- Department of Cardiology, Himeji Cardiovascular Center, Himeji, Japan
| | - Takenori Yao
- Department of Cardiovascular Medicine, Okamura Memorial Hospital, Shizuoka, Japan
| | - Yasuyuki Egami
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Kazuhiro Satomi
- Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takashi Noda
- Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Koji Miyamoto
- Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tetsuya Haruna
- Cardiovascular Center, Tazuke Medical Research Institute Kitano Hospital, Osaka, Japan
| | - Tetsuma Kawaji
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Takashi Yoshizawa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Toshiaki Toyota
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Mitsuhiko Yahata
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Kentaro Nakai
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Hiroaki Sugiyama
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Yukei Higashi
- Department of Cardiovascular Medicine, Okamura Memorial Hospital, Shizuoka, Japan
| | - Makoto Ito
- Heart Rhythm Center, Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Minoru Horie
- Heart Rhythm Center, Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Kengo F Kusano
- Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Wataru Shimizu
- Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Shiro Kamakura
- Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Hyogo, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Satoshi Shizuta
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
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Raatikainen MJP, Hakalahti A, Uusimaa P, Nielsen JC, Johannessen A, Hindricks G, Walfridsson H, Pehrson S, Englund A, Hartikainen J, Kongstad O, Mortensen LS, Hansen PS. Radiofrequency catheter ablation maintains its efficacy better than antiarrhythmic medication in patients with paroxysmal atrial fibrillation: On-treatment analysis of the randomized controlled MANTRA-PAF trial. Int J Cardiol 2015; 198:108-14. [PMID: 26163901 DOI: 10.1016/j.ijcard.2015.06.160] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 06/03/2015] [Accepted: 06/28/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND The Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation (MANTRA-PAF) is a randomized trial comparing radiofrequency catheter ablation (RFA) to antiarrhythmic drugs (AADs) as first-line treatment of paroxysmal atrial fibrillation (PAF). In order to eliminate the clouding effect of crossover we performed an on-treatment analysis of the data. METHODS AND RESULTS Patients (n=294) were divided into three groups: those receiving only the assigned therapy (RFA and AAD groups) and those receiving both therapies (crossover group). The primary end points were AF burden in 7-day Holter recordings at 3, 6, 12, 18, and 24 months and cumulative AF burden in all recordings. At 24 months, AF burden was significantly lower in the RFA (n=110) than in the AAD (n=92) and the crossover (n=84) groups (90th percentile 1% vs. 10% vs. 16%, P=0.007), and more patients were free from any AF (89% vs. 73% vs. 74%, P=0.006). In the RFA, AAD and the crossover groups 63%, 59% and 21% (P<0.001) of the patients had no AF episodes in any Holter recording, respectively. Quality of life improved significantly in all groups. There were no differences in serious adverse events between the RFA, AAD and crossover groups (19% vs. 8% vs. 23%) (P=0.10). CONCLUSIONS In the treatment of antiarrhythmic therapy naïve patients with PAF long-term efficacy of RFA was superior to AAD therapy. Thus, it is reasonable to offer RFA as first-line treatment for highly symptomatic patients who accept the risks of the procedure and are aware of frequent need for reablation(s).
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Affiliation(s)
- M J Pekka Raatikainen
- Central Finland Health Care District, Jyväskylä, Finland and University of Eastern Finland, Kuopio, Finland.
| | | | | | | | | | | | - Håkan Walfridsson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | | | | | | | | | - Leif Spange Mortensen
- UNI-C, Danish Information Technology Centre for Education and Research, Aarhus, Denmark
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Abstract
Small-conductance Ca2+ -activated K+ (SK, KCa2) channels are unique in that they are gated solely by changes in intracellular Ca2+ and, hence, function to integrate intracellular Ca2+ and membrane potentials on a beat-to-beat basis. Recent studies have provided evidence for the existence and functional significance of SK channels in the heart. Indeed, our knowledge of cardiac SK channels has been greatly expanded over the past decade. Interests in cardiac SK channels are further driven by recent studies suggesting the critical roles of SK channels in human atrial fibrillation, the SK channel as a possible novel therapeutic target in atrial arrhythmias, and upregulation of SK channels in heart failure in animal models and in human heart failure. However, there remain critical gaps in our knowledge. Specifically, blockade of SK channels in cardiac arrhythmias has been shown to be both antiarrhythmic and proarrhythmic. This contemporary review provides an overview of the literature on the role of cardiac SK channels in cardiac arrhythmias and serves as a discussion platform for the current clinical perspectives. At the translational level, development of SK channel blockers as a new therapeutic strategy in the treatment of atrial fibrillation and the possible proarrhythmic effects merit further considerations and investigations.
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Affiliation(s)
- Xiao-Dong Zhang
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, California.
| | - Deborah K Lieu
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, California
| | - Nipavan Chiamvimonvat
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, California; Department of Veterans Affairs, Northern California Health Care System, Mather, California.
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Hakalahti A, Biancari F, Nielsen JC, Raatikainen MJP. Radiofrequency ablation vs. antiarrhythmic drug therapy as first line treatment of symptomatic atrial fibrillation: systematic review and meta-analysis. Europace 2015; 17:370-8. [PMID: 25643988 DOI: 10.1093/europace/euu376] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
AIMS New evidence about first-line radiofrequency catheter ablation (RFA) in symptomatic atrial fibrillation (AF) has emerged. In a single study the comparative treatment effect is potentially diminished by the high rate of cross-over to the alternative therapy. Therefore, we conducted a systematic review and meta-analysis of the available data to further evaluate the efficacy and safety of RFA vs. antiarrhythmic drugs (AADs). METHODS AND RESULTS Five databases were searched for randomized controlled trials comparing RFA and AAD therapy as first-line treatment of AF in August 2014. Three studies with 491 patients with recurrent symptomatic AF were included. The patients were relatively young and the majority of them had paroxysmal AF (98.7%) and no major comorbidity. Radiofrequency catheter ablation was associated with significantly higher freedom from AF recurrence compared with AAD therapy [risk ratio (RR) 0.63, 95% confidence interval (CI) 0.44-0.92, P = 0.02]. The difference in the rate of symptomatic AF recurrences was not statistically significant (RR 0.57, 95% CI 0.30-1.08, P = 0.09). There was one procedure-related death and seven tamponades with RFA, whereas symptomatic bradycardia was more frequent with AAD therapy. CONCLUSION Radiofrequency catheter ablation seems to be more effective than medical therapy as first-line treatment of paroxysmal AF in relatively young and otherwise healthy patients, but may also cause more severe adverse effects. These findings support the use of RFA as first-line therapy in selected patients, who understand the benefits and risks of the procedure.
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Affiliation(s)
- Antti Hakalahti
- Division of Cardiology, Oulu University Hospital, P.O. Box 5000, Oulu 90014, Finland
| | - Fausto Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | | | - M J Pekka Raatikainen
- Heart Center Co., Tampere University Hospital, Tampere, Finland Central Finland Central Hospital, Jyväskylä, Finland
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De Ferrari GM, Maier LS, Mont L, Schwartz PJ, Simonis G, Leschke M, Gronda E, Boriani G, Darius H, Guillamón Torán L, Savelieva I, Dusi V, Marchionni N, Quintana Rendón M, Schumacher K, Tonini G, Melani L, Giannelli S, Alberto Maggi C, Camm AJ. Ranolazine in the treatment of atrial fibrillation: Results of the dose-ranging RAFFAELLO (Ranolazine in Atrial Fibrillation Following An ELectricaL CardiOversion) study. Heart Rhythm 2015; 12:872-8. [PMID: 25602175 DOI: 10.1016/j.hrthm.2015.01.021] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Currently available antiarrhythmic agents for the treatment of atrial fibrillation (AF) have important limitations, leaving an unmet need for safe and effective therapy. Ranolazine is an approved antianginal agent with a favorable safety profile and electrophysiologic properties suggesting a potential role in the treatment of AF. OBJECTIVE The purpose of this study was to assess the safety and efficacy of ranolazine in the prevention of AF recurrence after successful electrical cardioversion and to ascertain the most appropriate dose of this agent. METHODS This prospective, multicenter, randomized, double-blind, placebo-control parallel group phase II dose-ranging trial randomized patients with persistent AF (7 days to 6 months) 2 hours after successful electrical cardioversion to placebo, or ranolazine 375 mg, 500 mg, or 750 mg bid. Patients were monitored daily by transtelephonic ECG. The primary end-point was the time to first AF recurrence. RESULTS Of 241 patients randomized, 238 took at least 1 drug dose. Ranolazine proved to be safe and tolerable. No dose of the drug significantly prolonged time to AF recurrence. AF recurred in 56.4%, 56.9%, 41.7%, and 39.7% of patients in the placebo, ranolazine 375 mg, ranolazine 500 mg, and ranolazine 750 mg groups, respectively. The reduction in overall AF recurrence in the combined 500-mg and 750-mg groups was of borderline significance compared to the placebo group (P = .053) and significant compared to 375-mg group (P = .035). CONCLUSION No dose of ranolazine significantly prolonged time to AF recurrence. However, the 500-mg and 750 mg-groups combined reduced AF recurrences, suggesting a possible role for this agent in the treatment of AF.
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Affiliation(s)
- Gaetano M De Ferrari
- Department of Cardiology and Cardiovascular Clinical Research Center, Fondazione IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia, Pavia, Italy.
| | - Lars S Maier
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Lluís Mont
- Department of Cardiology, Thorax Institute Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Peter J Schwartz
- Center for Cardiac Arrhythmias of Genetic Origin-IRCCS Istituto Auxologico Italiano, Milan, Italy
| | | | - Matthias Leschke
- Klinikum Esslingen GmbH, Abteilung Kardiologie, Esslingen, Germany
| | | | - Giuseppe Boriani
- Ospedale S. Orsola-Malpighi, Dipartimento di Cardiologia, Bologna, Italy
| | | | | | | | - Veronica Dusi
- Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia and University of Pavia, Italy
| | - Niccolò Marchionni
- Division of Geriatric Cardiology and Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Miguel Quintana Rendón
- The Karolinska Institute at Hospital de Torrevieja, Servicio de Cardiología, Alicante, Spain
| | - Kai Schumacher
- Menarini Research & Business Service GmbH, Berlin, Germany
| | | | - Lorenzo Melani
- Menarini Industrie Farmaceutiche Riunite s.r.l, Florence, Italy
| | | | | | - A John Camm
- St. George's University, London, United Kingdom
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Kotake Y, Kurita T, Akaiwa Y, Yasuoka R, Motoki K, Kobuke K, Iwanaga Y, Miyazaki S. Intravenous amiodarone homogeneously prolongs ventricular repolarization in patients with life-threatening ventricular tachyarrhythmia. J Cardiol 2015; 66:161-7. [PMID: 25468767 DOI: 10.1016/j.jjcc.2014.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 10/14/2014] [Accepted: 10/16/2014] [Indexed: 01/14/2023]
Abstract
BACKGROUND The most critical adverse effects of class III drugs are marked QT prolongation and torsade de pointes. Even though intravenous amiodarone (iv-Amio) is a representative class III drug, it peculiarly inhibits both clinical ventricular tachycardia/fibrillation (VT/VF) and proarrhythmic effects. To test the hypothesis that iv-Amio homogeneously prolongs repolarization, we evaluated electrocardiographic changes before and during short-term amiodarone therapy, focusing closely on the ventricular dispersion of repolarization. METHODS Twenty-seven consecutive patients treated with iv-Amio for VT/VF as a first-line antiarrhythmic therapy were enrolled in this study. Twelve-lead electrocardiography was recorded before and during amiodarone therapy to evaluate the following electrocardiographic intervals: R-R, QRS, QT, QRS to T-peak (QTp), and T-peak to T-end (Tp-e; as an index of dispersion of repolarization). Repolarization indices were corrected to the heart rate by Bazett's method (QTc, c-QTp, c-Tp-e). RESULTS Amiodarone suppressed VT/VF in 19/27 (70%) patients without conferring any proarrhythmic effect. The QTc, c-QTp, and R-R interval were significantly prolonged during amiodarone (476±45ms vs 511±45ms, p<0.05; 338±40ms vs 364±35ms, p<0.05; 762±272ms vs 870±189ms, p<0.05; respectively), whereas the c-Tp-e and QRS durations did not change significantly (139±33ms vs 145±41ms, p=0.25; 96±20ms vs 97±21ms, p=0.33; respectively). CONCLUSIONS Iv-Amio homogeneously prolongs repolarization and properly inhibits original VT/VF recurrence without inducing torsade de pointes.
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Seyler C, Schweizer PA, Zitron E, Katus HA, Thomas D. Vernakalant activates human cardiac K(2P)17.1 background K(+) channels. Biochem Biophys Res Commun 2014; 451:415-20. [PMID: 25108155 DOI: 10.1016/j.bbrc.2014.07.133] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 07/30/2014] [Indexed: 01/12/2023]
Abstract
Atrial fibrillation (AF) contributes significantly to cardiovascular morbidity and mortality. The growing epidemic is associated with cardiac repolarization abnormalities and requires the development of more effective antiarrhythmic strategies. Two-pore-domain K(+) channels stabilize the resting membrane potential and repolarize action potentials. Recently discovered K2P17.1 channels are expressed in human atrium and represent potential targets for AF therapy. However, cardiac electropharmacology of K2P17.1 channels remains to be investigated. This study was designed to elucidate human K2P17.1 regulation by antiarrhythmic drugs. Two-electrode voltage clamp and whole-cell patch clamp electrophysiology was used to record K2P currents from Xenopus oocytes and Chinese hamster ovary (CHO) cells. The class III antiarrhythmic compound vernakalant activated K2P17.1 currents in oocytes an in mammalian cells (EC50,CHO=40 μM) in frequency-dependent manner. K2P17.1 channel activation by vernakalant was specific among K2P channel family members. By contrast, vernakalant reduced K2P4.1 and K2P10.1 currents, in line with K2P2.1 blockade reported earlier. K2P17.1 open rectification characteristics and current-voltage relationships were not affected by vernakalant. The class I drug flecainide did not significantly modulate K2P currents. In conclusion, vernakalant activates K2P17.1 background potassium channels. Pharmacologic K2P channel activation by cardiovascular drugs has not been reported previously and may be employed for personalized rhythm control in patients with AF-associated reduction of K(+) channel function.
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Affiliation(s)
- Claudia Seyler
- Department of Cardiology, Medical University Hospital, Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany
| | - Patrick A Schweizer
- Department of Cardiology, Medical University Hospital, Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany
| | - Edgar Zitron
- Department of Cardiology, Medical University Hospital, Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany
| | - Hugo A Katus
- Department of Cardiology, Medical University Hospital, Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany
| | - Dierk Thomas
- Department of Cardiology, Medical University Hospital, Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany.
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Klieber S, Arabeyre-Fabre C, Moliner P, Marti E, Mandray M, Ngo R, Ollier C, Brun P, Fabre G. Identification of metabolic pathways and enzyme systems involved in the in vitro human hepatic metabolism of dronedarone, a potent new oral antiarrhythmic drug. Pharmacol Res Perspect 2014; 2:e00044. [PMID: 25505590 PMCID: PMC4186413 DOI: 10.1002/prp2.44] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 02/18/2014] [Accepted: 03/04/2014] [Indexed: 11/10/2022] Open
Abstract
The in vitro metabolism of dronedarone and its major metabolites has been studied in human liver microsomes and cryopreserved hepatocytes in primary culture through the use of specific or total cytochrome P450 (CYP) and monoamine oxidase (MAO) inhibitors. The identification of the main metabolites and enzymes participating in their metabolism was also elucidated by using rhCYP, rhMAO, flavin monooxygenases (rhFMO) and UDP-glucuronosyltransferases (rhUGT) and liquid chromatography/tandem mass spectrometry (LC/MS-MS) analysis. Dronedarone was extensively metabolized in human hepatocytes with a metabolic clearance being almost completely inhibited (98 ± 2%) by 1-aminobenzotriazole. Ketoconazole also inhibited dronedarone metabolism by 89 ± 7%, demonstrating the crucial role of CYP3A in its metabolism. CYP3A isoforms mostly contributed to N-debutylation while hydroxylation on the butyl-benzofuran moiety was catalyzed by CYP2D6. However, hydroxylation on the dibutylamine moiety did not appear to be CYP-dependent. N-debutyl-dronedarone was less rapidly metabolized than dronedarone, the major metabolic pathway being catalyzed by MAO-A to form propanoic acid-dronedarone and phenol-dronedarone. Propanoic acid-dronedarone was metabolized at a similar rate to that of N-debutyl-dronedarone and was predominantly hydroxylated by CYP2C8 and CYP1A1. Phenol-dronedarone was extensively glucuronidated while C-dealkyl-dronedarone was metabolized at a slow rate. The evaluation of the systemic clearance of each metabolic process together with the identification of both the major metabolites and predominant enzyme systems and isoforms involved in the formation and subsequent metabolism of these metabolites has enhanced the overall understanding of metabolism of dronedarone in humans.
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Affiliation(s)
- Sylvie Klieber
- SANOFI-AVENTIS Recherche & Development Disposition, Safety and Animal Research Scientific Core Platform, Drug Disposition Domain 371 Rue du Professeur Joseph Blayac, 34184 Montpellier, Cedex 4, France
| | - Catherine Arabeyre-Fabre
- SANOFI-AVENTIS Recherche & Development Disposition, Safety and Animal Research Scientific Core Platform, Drug Disposition Domain 371 Rue du Professeur Joseph Blayac, 34184 Montpellier, Cedex 4, France
| | - Patricia Moliner
- SANOFI-AVENTIS Recherche & Development Disposition, Safety and Animal Research Scientific Core Platform, Drug Disposition Domain 371 Rue du Professeur Joseph Blayac, 34184 Montpellier, Cedex 4, France
| | - Eric Marti
- SANOFI-AVENTIS Recherche & Development Disposition, Safety and Animal Research Scientific Core Platform, Drug Disposition Domain 371 Rue du Professeur Joseph Blayac, 34184 Montpellier, Cedex 4, France
| | - Martine Mandray
- SANOFI-AVENTIS Recherche & Development Disposition, Safety and Animal Research Scientific Core Platform, Drug Disposition Domain 371 Rue du Professeur Joseph Blayac, 34184 Montpellier, Cedex 4, France
| | - Robert Ngo
- SANOFI-AVENTIS Recherche & Development Disposition, Safety and Animal Research Scientific Core Platform, Drug Disposition Domain 371 Rue du Professeur Joseph Blayac, 34184 Montpellier, Cedex 4, France
| | - Céline Ollier
- SANOFI-AVENTIS Recherche & Development Disposition, Safety and Animal Research Scientific Core Platform, Drug Disposition Domain 371 Rue du Professeur Joseph Blayac, 34184 Montpellier, Cedex 4, France
| | - Priscilla Brun
- SANOFI-AVENTIS Recherche & Development Disposition, Safety and Animal Research Scientific Core Platform, Drug Disposition Domain 371 Rue du Professeur Joseph Blayac, 34184 Montpellier, Cedex 4, France
| | - Gérard Fabre
- SANOFI-AVENTIS Recherche & Development Disposition, Safety and Animal Research Scientific Core Platform, Drug Disposition Domain 371 Rue du Professeur Joseph Blayac, 34184 Montpellier, Cedex 4, France
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Steinberg BA, Broderick SH, Lopes RD, Shaw LK, Thomas KL, DeWald TA, Daubert JP, Peterson ED, Granger CB, Piccini JP. Use of antiarrhythmic drug therapy and clinical outcomes in older patients with concomitant atrial fibrillation and coronary artery disease. Europace 2014; 16:1284-90. [PMID: 24755440 DOI: 10.1093/europace/euu077] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
AIMS Atrial fibrillation (AF) and coronary artery disease (CAD) are common in older patients. We aimed to describe the use of antiarrhythmic drug (AAD) therapy and clinical outcomes in these patients. METHODS AND RESULTS We analysed AAD therapy and outcomes in 1738 older patients (age ≥65) with AF and CAD in the Duke Databank for cardiovascular disease. The primary outcomes were mortality and rehospitalization at 1 and 5 years. Overall, 35% of patients received an AAD at baseline, 43% were female and 85% were white. Prior myocardial infarction (MI, 31%) and heart failure (41%) were common. Amiodarone was the most common AAD (21%), followed by pure Class III agents (sotalol 6.3%, dofetilide 2.2%). Persistence of AAD was low (35% at 1 year). After adjustment, baseline AAD use was not associated with 1-year mortality [adjusted hazard ratio (HR) 1.23, 95% confidence interval (CI) 0.94-1.60] or cardiovascular mortality (adjusted HR 1.27, 95% CI 0.90-1.80). However, AAD use was associated with increased all-cause rehospitalization (adjusted HR 1.20, 95% CI 1.03-1.39) and cardiovascular rehospitalization (adjusted HR 1.20, 95% CI 1.01-1.43) at 1 year. This association did not persist at 5 years; however, these patients were at very high risk of death (55% for those >75 and on AAD) and all-cause rehospitalization (87% for those >75 and on AAD) at 5 years. CONCLUSIONS In older patients with AF and CAD, antiarrhythmic therapy was associated with increased rehospitalization at 1 year. Overall, these patients are at high risk of longer-term hospitalization and death. Safer, better-tolerated, and more effective therapies for symptom control in this high-risk population are warranted.
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Affiliation(s)
- Benjamin A Steinberg
- Duke Center for Atrial Fibrillation, Durham, NC, USA Department of Medicine, Duke University Medical Center, Durham, NC, USA Duke Clinical Research Institute, Duke University Medical Center, PO Box 17969, Durham, NC 27715, USA
| | - Samuel H Broderick
- Duke Clinical Research Institute, Duke University Medical Center, PO Box 17969, Durham, NC 27715, USA
| | - Renato D Lopes
- Department of Medicine, Duke University Medical Center, Durham, NC, USA Duke Clinical Research Institute, Duke University Medical Center, PO Box 17969, Durham, NC 27715, USA
| | - Linda K Shaw
- Duke Clinical Research Institute, Duke University Medical Center, PO Box 17969, Durham, NC 27715, USA
| | - Kevin L Thomas
- Duke Center for Atrial Fibrillation, Durham, NC, USA Department of Medicine, Duke University Medical Center, Durham, NC, USA Duke Clinical Research Institute, Duke University Medical Center, PO Box 17969, Durham, NC 27715, USA
| | - Tracy A DeWald
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - James P Daubert
- Duke Center for Atrial Fibrillation, Durham, NC, USA Department of Medicine, Duke University Medical Center, Durham, NC, USA Duke Clinical Research Institute, Duke University Medical Center, PO Box 17969, Durham, NC 27715, USA
| | - Eric D Peterson
- Department of Medicine, Duke University Medical Center, Durham, NC, USA Duke Clinical Research Institute, Duke University Medical Center, PO Box 17969, Durham, NC 27715, USA
| | - Christopher B Granger
- Department of Medicine, Duke University Medical Center, Durham, NC, USA Duke Clinical Research Institute, Duke University Medical Center, PO Box 17969, Durham, NC 27715, USA
| | - Jonathan P Piccini
- Duke Center for Atrial Fibrillation, Durham, NC, USA Department of Medicine, Duke University Medical Center, Durham, NC, USA Duke Clinical Research Institute, Duke University Medical Center, PO Box 17969, Durham, NC 27715, USA
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Hayashi M, Miyauchi Y, Iwasaki YK, Yodogawa K, Tsuboi I, Uetake S, Hayashi H, Takahashi K, Shimizu W. Three-month lower-dose flecainide after catheter ablation of atrial fibrillation. Europace 2014. [PMID: 24706088 DOI: 10.1093/europace/euu041.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Atrial tachyarrhythmias (AT) commonly recur within the first 3 months after radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF), and the influence of antiarrhythmic drugs (AADs) on the recurrences has not been fully elucidated. We sought to evaluate the efficacy of a 3-month lower-dose flecainide regime on early and late recurrences of ATs. METHODS AND RESULTS We randomly assigned 126 patients, who underwent RFCA for AF, to the flecainide group (150 or 100 mg/day according to their body weight) or to the control group receiving no AADs. The primary endpoint was any AT lasting for ≥30 s during the first 3 months and the secondary endpoint was a composite of ATs lasting for ≥24 h or requiring cardioversion or hospitalization during the same period. All AADs were stopped after the first 3 months and the late arrhythmia recurrences were also evaluated. The primary endpoint rates were 37 and 41% in the flecainide (143 ± 19 mg/day) and control groups, respectively (log-rank P = 0.76), and those of the secondary endpoint were 10 and 14%, respectively (log-rank P = 0.45). The estimated rates of maintaining sinus rhythm at 12 months after the first 3 months were 78 and 72%, in the flecainide and control groups, respectively (log-rank P = 0.68), and the rates were 51 and 90% in those with and without the primary endpoint, respectively (log-rank P < 0.001). CONCLUSION The 3-month lower-dose flecainide therapy after AF ablation did not reduce the early and late arrhythmia recurrences. The clinically significant ATs were also not prevented.
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Affiliation(s)
- Meiso Hayashi
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Yasushi Miyauchi
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Yu-ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Ippei Tsuboi
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Shunsuke Uetake
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Hiroshi Hayashi
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Kenta Takahashi
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
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Seyler C, Li J, Schweizer PA, Katus HA, Thomas D. Inhibition of cardiac two-pore-domain K+ (K2P) channels by the antiarrhythmic drug vernakalant--comparison with flecainide. Eur J Pharmacol 2013; 724:51-7. [PMID: 24374008 DOI: 10.1016/j.ejphar.2013.12.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 12/16/2013] [Accepted: 12/18/2013] [Indexed: 01/25/2023]
Abstract
The mixed ion channel blocker, vernakalant (RSD1235), is effective in rapid conversion of atrial fibrillation (AF) to sinus rhythm (SR). Suppression of cardiac two-pore-domain potassium (K2P) channels causes action potential prolongation and has recently been proposed as a novel antiarrhythmic strategy. The objective of this study was to investigate acute effects of vernakalant on human K2P2.1 (TREK-1) and K2P3.1 (TASK-1) channels to provide a more complete picture of its antiarrhythmic mechanism of action. The class IC antiarrhythmic drug flecainide was studied as a comparator agent. Two-electrode voltage clamp and whole-cell patch clamp electrophysiology was used to record K2P currents from Xenopus oocytes and Chinese hamster ovary (CHO) cells. Vernakalant inhibited cardiac K2P2.1 channels expressed in Xenopus oocytes and in CHO cells. The IC50 value obtained from mammalian cells (13.3 µM) was close to the range of vernakalant levels reported in patients (2-8 µM), indicating potential clinical significance of K2P2.1 blockade. Open rectification characteristics and current-voltage relationships of K2P2.1 currents were not affected by vernakalant. Vernakalant did not significantly reduce K2P3.1 currents. Finally, the class I antiarrhythmic drug flecainide had no effect on K2P2.1 or K2P3.1 channels. In conclusion, the recently developed antiarrhythmic drug vernakalant targets human K2P2.1 K(+) background channels. This previously unrecognized inhibitory property adds to the multichannel blocking profile of vernakalant and extends the mechanistic basis for its anti-fibrillatory effect.
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Affiliation(s)
- Claudia Seyler
- Department of Cardiology, Medical University Hospital, Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany
| | - Jin Li
- Department of Cardiology, Medical University Hospital, Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany
| | - Patrick A Schweizer
- Department of Cardiology, Medical University Hospital, Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany
| | - Hugo A Katus
- Department of Cardiology, Medical University Hospital, Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany
| | - Dierk Thomas
- Department of Cardiology, Medical University Hospital, Heidelberg, Im Neuenheimer Feld 410, D-69120 Heidelberg, Germany.
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Tsai SF, Houmsse M, Dakhil B, Augostini R, Hummel JD, Kalbfleisch SJ, Liu Z, Love C, Rhodes T, Tyler J, Weiss R, Hamam I, Winner M, Daoud EG. QTc compared to JTc for monitoring drug-induced repolarization changes in the setting of ventricular pacing. Heart Rhythm 2013; 11:485-91. [PMID: 24252288 DOI: 10.1016/j.hrthm.2013.11.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND QT prolongation is a risk factor for proarrhythmia when beginning antiarrhythmic drug therapy (AAD). However, there are no data regarding monitoring repolarization changes during a ventricular paced (VP) rhythm. OBJECTIVE The purpose of this study was to compare serial changes in corrected QT and JT intervals, during native conduction (NC) and VP rhythms when initiating Class III AADs. METHODS Twenty-two patients (73% men; mean age 65 ± 11 years) with an implantable device and with <10% VP were monitored during AAD initiation (16 sotalol, 6 dofetilide). QTc and JTc were measured from ECGs obtained during NC and VP at baseline (pre-AAD) and then after each AAD dose. RESULTS During AAD loading, mean QTc increased significantly during NC (431 ± 28 ms to 463 ± 33 ms, P = .002) but not with VP (520 ± 48 ms to 538 ± 45 ms, P = .07). Mean percent increase in peak QTc during NC was significantly greater than during VP (12% vs 7%, P = .003). In contrast, peak JTc during AAD loading was not significantly different between NC and VP (P = .67). CONCLUSION When initiating AAD, the change in QTc during VP does not correlate with the change in QTc during NC; thus, the VP QTc is inadequate for monitoring repolarization changes. However, VP JTc correlates well with JTc during NC. When initiating Class III AADs in patients with VP rhythms, the JTc, and not the QTc, interval is the useful marker for assessing repolarization.
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Affiliation(s)
- Shane F Tsai
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Mahmoud Houmsse
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Barrah Dakhil
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Ralph Augostini
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - John D Hummel
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Steven J Kalbfleisch
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Zhengou Liu
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Charles Love
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Troy Rhodes
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Jaret Tyler
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Raul Weiss
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Ismail Hamam
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Marshall Winner
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Emile G Daoud
- Section of Electrophysiology, Division of Cardiology, Ross Heart Hospital, Wexner Medical Center at The Ohio State University, Columbus, Ohio.
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Zhong L, Lee YH, Huang XM, Asirvatham SJ, Shen WK, Friedman PA, Hodge DO, Slusser JP, Song ZY, Packer DL, Cha YM. Relative efficacy of catheter ablation vs antiarrhythmic drugs in treating premature ventricular contractions: a single-center retrospective study. Heart Rhythm 2013; 11:187-93. [PMID: 24157533 DOI: 10.1016/j.hrthm.2013.10.033] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND It is unknown whether radiofrequency ablation (RFA) or antiarrhythmic therapy is superior when treating patients with symptomatic premature ventricular contractions (PVCs). OBJECTIVE To determine the relative efficacy of RFA and antiarrhythmic drugs (AADs) on PVC burden reduction and increasing left ventricular systolic function. METHODS Patients with frequent PVCs (>1000/24 h) were treated either by RFA or with AADs from January 2005 through December 2010. Data from 24-hour Holter monitoring and echocardiography before and 6-12 months after treatment were compared between the 2 groups. RESULTS Of 510 patients identified, 215 (40%) underwent RFA and 295 (60%) received AADs. The reduction in PVC frequency was greater by RFA than with AADs (-21,799/24 h vs -8,376/24 h; P < .001). The left ventricular ejection fraction (LVEF) was increased significantly after RFA (53%-56%; P < .001) but not after AAD (52%- 52%; P = .6) therapy. Of 121 (24%) patients with reduced LVEF, 39 (32%) had LVEF normalization to 50% or greater. LVEF was restored in 25 of 53 (47%) patients in the RFA group compared with 14 of 68 (21%) patients in the AAD group (P = .003). PVC coupling interval less than 450 ms, less impaired left ventricular function, and RFA were independent predictors of LVEF normalization performed by using multivariate analysis. CONCLUSION RFA appears to be more effective than AADs in PVC reduction and LVEF normalization.
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Affiliation(s)
- Li Zhong
- Department of Cardiology, Southwest Hospital, Third Military Medical University, Chongqing, People's Republic of China; Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Ying-Hsiang Lee
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; Cardiovascular Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Xin-Miao Huang
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Diseases, Changhai Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | | | - Win-Kuang Shen
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - David O Hodge
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester
| | - Joshua P Slusser
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester
| | - Zhi-Yuan Song
- Department of Cardiology, Southwest Hospital, Third Military Medical University, Chongqing, People's Republic of China.
| | - Douglas L Packer
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Yong-Mei Cha
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
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Mont L, Bisbal F, Hernández-Madrid A, Pérez-Castellano N, Viñolas X, Arenal A, Arribas F, Fernández-Lozano I, Bodegas A, Cobos A, Matía R, Pérez-Villacastín J, Guerra JM, Ávila P, López-Gil M, Castro V, Arana JI, Brugada J. Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study). Eur Heart J 2013; 35:501-7. [PMID: 24135832 PMCID: PMC3930872 DOI: 10.1093/eurheartj/eht457] [Citation(s) in RCA: 238] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Catheter ablation (CA) is a highly effective therapy for the treatment of paroxysmal atrial fibrillation (AF) when compared with antiarrhythmic drug therapy (ADT). No randomized studies have compared the two strategies in persistent AF. The present randomized trial aimed to compare the effectiveness of CA vs. ADT in treating persistent AF. Methods and results Patients with persistent AF were randomly assigned to CA or ADT (excluding patients with long-standing persistent AF). Primary endpoint at 12-month follow-up was defined as any episode of AF or atrial flutter lasting >24 h that occurred after a 3-month blanking period. Secondary endpoints were any atrial tachyarrhythmia lasting >30 s, hospitalization, and electrical cardioversion. In total, 146 patients were included (aged 55 ± 9 years, 77% male). The ADT group received class Ic (43.8%) or class III drugs (56.3%). In an intention-to-treat analysis, 69 of 98 patients (70.4%) in the CA group and 21 of 48 patients (43.7%) in the ADT group were free of the primary endpoint (P = 0.002), implying an absolute risk difference of 26.6% (95% CI 10.0–43.3) in favour of CA. The proportion of patients free of any recurrence (>30 s) was higher in the CA group than in the ADT group (60.2 vs. 29.2%; P < 0.001) and cardioversion was less frequent (34.7 vs. 50%, respectively; P = 0.018). Conclusion Catheter ablation is superior to medical therapy for the maintenance of sinus rhythm in patients with persistent AF at 12-month follow-up. Clinical Trial Registration Information NCT00863213 (http://clinicaltrials.gov/ct2/show/NCT00863213).
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Affiliation(s)
- Lluís Mont
- Unitat de Fibril·lació Auricular (UFA), Arrhythmia Section - Hospital Clínic, Universitat de Barcelona and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), C/ Villarroel, 170, Barcelona, Catalonia 08036, Spain
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Abstract
Ventricular arrhythmias may be benign, requiring only evaluation for associated risks and then reassurance, or associated with a risk of sudden death or significant morbidity. Therapies for these arrhythmias have evolved considerably over the past 20 years. For some, a definitive, curative therapy is available in the form of catheter ablation. Others are best managed with an implantable cardioverter-defibrillator that provides effective arrhythmia termination and protection from sudden death, with antiarrhythmic drugs or ablation to control recurrent arrhythmias. Although progress has been substantial, many challenges remain.
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