[Comparative characteristics of various anti-arrhythmia agents used under clinical conditions]

Comparative clinical and experimental study of the efficacy of the currently used anti-arrhythmic agents was conducted on 610 patients (828 cases) with various disorders of the cardiac rhythm. The modern classification of these agents is given. The indications and contra-indications for the prescription of the drugs, the optimum doses, and the routes of administration are discussed. Differentiated therapy in various disorders of the cardiac rhythm is recommended.

Antiarrhythmic drug effect assessed from ventricular arrhythmia reduction in the ambulatory electrocardiogram and treadmill test: comparison of propranolol, procainamide and quinidine

A 5 week study was performed in 17 patients with frequent ventricular ectopic complexes. The study design comprised an initial control period, 1 week each of treatment with propranolol (240 mg daily), procainamide (3.0 g daily) and quinidine (1.8 g daily) and a final control period. Twenty-four hour ambulatory electrocardiograms and maximal exercise tests were performed each week. For the group, the total number and qualitative types of ventricular ectopic complexes were similar during the two control periods; however, there were large variations among individual patients. Each drug reduced the total number of ventricular ectopic impulses and the percent of patients with each qualitative type. There was agreement between the ambulatory electrocardiogram and treadmill test in three quarters of the drug evaluations. Although it is possible to determine antiarrhythmic drug effects for a group, spontaneous variability in the occurrence of ventricular arrhythmias makes it difficult to evaluate the effects in individual patients.

Pharmacokinetic approach to intravenous procainamide therapy

A pharmacokinetic approach was employed to design a dosing regimen for the i.v. use of procainamide (PA) which consisted of a loading infusion given over one hour followed by a maintenance infusion. Therapeutic serum concentrations of PA were achieved in less than 15 min, and toxic serum concentrations were avoided in 12 patients. A mean maximum serum concentration of PA of 5.78 mg/l was obtained with a loading infusion of 16.6 mg/min PA HCl. An average steady-state serum concentration of PA of 5.05 mg/l was obtained with a mean maintenance infusion of 222 mg/hour PA HCl. The total body clearance of PA in slow and fast acetylators averaged 31 and 43 l/h respectively. Use of PA in cardiac patients by i. v. infusion can be safe and effective therapy.

Effect of acetylator phenotype on the rate at which procainamide induces antinuclear antibodies and the lupus syndrome

To investigate the relation between acetvlator phenotype and the development of procainamide-induced lupus, we determined the rate of development of antinuclear antibodies in 20 patients of known acetylator phenotype receiving chronic procainamide therapy. The duration of therapy required to induce antibodies in 50 per cent of slow (11) and rapid (nine) acetylators was 2.9 and 7.3 months respectively. The median total dose that produced ant;bodies was 1.5 g per kilogram and 6.1 g per kilogram respectively. After one year antibodies had developed in 18 patients. Retrospective studies of patients in whom procainamide lupus had developed revealed that the duration of therapy required for induction in 14 slow and seven rapid acetylators was 12 +/- 5 and 48 +/- 22 months respectively (P less than 0.002). We conclude that acetylator phenotype influences the rate at which procainamide induces antinuclear antibodies and probably the lupus syndrome. Antibody production is probably related to the parent compound or a non-acetylated metabolite.

The quantitative disposition of procainamide and N-acetylprocainamide in the rat

The objectives of this study were to investigate: 1) the rat acetylator phenotype, 2) the systemic availability of oral procainamide (PA), 3) the kinetic disposition of PA and its N-acetyl metabolite (NAPA) and 4) the relationship between PA dose and steady-state blood PA and NAPA levels. The rat acetylator phenotype seems to be monomorphic in type. The systemic availability of PA was estimated to be 78%. The half-life (T 1/2) of PA elimination was 55 minutes and that of NAPA was 51 minutes. PA clearance was 64 ml/kg/min and NAPA clearance 22.4 ml/kg/min. The apparent distribution volume for PA was 4.92 liters/kg and for NAPA 1.64 liters/kg. Acetylation accounted for 38% of PA disposition, urinary excretion 34% and other metabolism 28%. Urinary excretion of NAPA accounted for 72% of administered drug. Steady-state blood PA levels showed a linear increase with dose whereas NAPA did not. The latter observation suggests saturation of PA acetylation at higher PA doses.

Determination of procainamide acetylator status

Variation in renal function can obscure the measurement of acetylator status for compounds such as procainamide in which appreciable active drug or acetyl metabolite is excreted in urine. Computer simulations and patient studies were used to compare two common metabolite/drug ratio methods and a proposed clearance technique for phenotyping acetylation rate. The calculation of apparent acetylation clearance from steady-state serum concentrations of procainamide and urinary excretion rates of N-acetyl-procainamide provides the most definitive discrimination between fast and slow acetylators.

Effects of procainamide and chloramphenicol on acute vasospasm

The basilar artery of the dog was exposed through the clivus and made spastic by puncture or by topical application of 5% barium chloride. Injections of procainamide or chloramphenicol into the vertebral artery or into a peripheral vein had no discernable effect on the acute vasospasm. Topical application of 0.1% to 10% concentrations of either of these drugs effected definite vasodilation, with the extent and rapidity of vasodilation increasing with increasing concentrations. Lesser concentrations were ineffective.

The assessment of an antiarrhythmic agent, sustained-release procainamide, with the aid of Holter monitoring

A sustained-release preparation of procainamide (PAD) was evaluated in a double-blind cross-over study. The preparation was found to reduce ventricular ectopic activity in all seven patients who completed the investigation in five patients the effectiveness reached the defined level of significance. A larger clinical trial to assess the long-term use of this preparation in terms of efficacy, safety and convenience is recommended.

Absorption kinetics of procainamide in humans

Plasma procainamide concentrations following the administration of 500 mg of procainamide hydrochloride via intravenous infusion, conventional capsules, and sustained-release tablets were compared in 11 healthy male volunteers. Two-compartment open modeling of the plasma levels from the intravenous infusion experiments yielded mean Kel, k12, and k21 values of 0.0162, 0.0542, and 0.0233 min-1, respectively. The bioavailability of the oral preparations (versus intravenous) averaged 83% for the capsule and 79% for the sustained-release tablet. Calculations using a previously reported method suggested that absorption was a first-order process with mean ka's of 0.0336 and 0.0039 min-1 for the capsule and sustained-release tablet, respectively. The sustained-release formulation exhibited delayed release and adequate bioavailability.

Procainamide-induced systemic lupus erythematosus with hypocomplementemia

Procainamide-induced systemic lupus erythematosus (SLE) is a well recognized clinical syndrome believed to be characterized by normocomplementemia. However, in 7 cases of drug-induced SLE recorded in the literature, hypocomplementemia was found. The present report concerns a well documented case of procainamide-induce SLE with hypocomplementemia. The patient improved and complement values returned to normal after procainamide therapy was discontinued and replaced by digitalis and steroid therapy.

Procaineamide blood levels after administration of a sustained-release preparation

Procaineamide is now available as a sustained-release preparation. This preparation was administered in an eight-hourly regime to 26 patients, and therapeutic blood levels were obtained for the duration of the 56-hour study period in 20 patients. No side effects were observed. Inadequate blood levels may be predicted from a single blood level eight hours after the first dose, which could allow for dosage adjustment.

Comparative evaluation of intravenous phenytoin, procainamide and practolol in the acute treatment of ventricular arrhythmias

Ten patients with a persistent ventricular arrhythmia, but no other sign of heart disease, were studied by means of an exercise test performed 4 times with a fixed work load, over 30--40 min. No drug was given in the first exercise test and in the others phenytoin, procainamide or practolol were chosen at random for i.v. administration. Blood samples for determination of plasma concentration were frequently collected. The ECG was recorded continuously during the exercise test and was analysed minute by minute. Despite plasma levels within the suggested therapeutic range, only procainamide showed a statistically significant antiarrhythmic effect in this group of patients.

Comparative effects of lidocaine and procainamide on acutely impaired hemodynamics

Controversy exists regarding the relative safety of intravenously administered lidocaine and procainamide to patients with acutely impaired hemodynamics. Accordingly, their effects were studied in 15 such patients, 14 with acute myocardial infarction and one with cardiomyopathy and severe congestive heart failure. All had elevated levels of pulmonary capillary wedge pressure (greater than 15 mm Hg) and/or low cardiac index (less than 2.5 liters/min/m2). Patients were given lidocaine, a 100 mg bolus followed by a 3 mg/min infusion and, after at least a 30 minute recovery period, procainamide, a 100 mg bolus over 2 minutes followed by a 20 mg/min infusion for 20 to 25 minutes. Hemodynamic measurements were compared early and late in the infusion of each drug. Small, clinically insignificant differences were observed in the hemodynamic responses to the drugs, and no clinically significant deterioration occurred with either. Conventional therapeutic doses of intravenous procainamide can be administered by this regimen, to patients with acute myocardial infarction complicated by cardiac failure or low cardiac output, without producing deleterious hemodynamic effects.

Maintenance therapy with a new retard tablet preparation of procainamide

The procainamide plasma concentration was followed during maintenance therapy with a new procainamide retard tablet preparation in 23 hospitalized patients suffering from acute or chronic coronary heart disease with complicating ventricular arrhythmias. After initial individually adjusted treatment with Pronestyl every third hour, either orally or intramuscularly, for at least eight dose intervals, the retard tablets were given at 6 hour intervals for 2 to 12 days, or more. In 19 patients with no major fluctuations in their circulatory or renal state, adequate and relatively stable plasma procainamide concentration was obtained upon a constant dose of the retard preparation. On an average, the difference from minimum to maximum concentration was 55 per cent within the 6 hour dose intervals. In four patients with unstable circulation and/or renal function, procainamide therapy had to be disrupted in two because of severe side effects and toxic concentrations, and the dose was adjusted in the remaining two. It is concluded that the formulation of procainamide tablet preparations has simplified procainamide therapy within and outside hospital and improved our possibilities to perform short-and long-term studies on the risk/ benefit ratio of procainamide treatment in patients with severe ventricular arrhythmias.

The effect of food on procainamide absorption

The effect of food on the absorption characteristics of procainamide was assessed after oral administration of the drug to eight male patients in the fasting and postprandial states. Serum concentration-time curves showed no significant difference in peak serum levels of procainamide, in the time the peak value was reached, or in the area under the serum concentration-time curves, indicating the total amount of procainamide present in the serum. The bioavailability of procainamide appears not to be significantly altered by taking an oral dose with food.

Treatment of recurrent symptomatic ventricular tachycardia

Eleven consecutive patients with recurrent ventricular arrhythmias were treated by an aggressive protocol and followed up prospectively. Arrhythmias, symptoms, and cardiac lesions were defined. Antiarrhythmic drugs were given on schedule, with blood levels determining dose; success or failure was defined by elimination or recurrence of symptomatic arrhythmias. When drug therapy failed, left ventricular aneurysmectomy was done when appropriate. Recurrent ventricular tachycardia was most frequently responsible for symptoms; coronary artery disease was the most frequent underlying disease. Symptomatic arrhythmias were eliminated in 8 of 11 patients (5 with drugs and 3 with aneurysmectomies), with a 16.5-month symptom-free average follow-up. An average of 2.9 therapeutic trials per patient was needed to control symptomatic arrhythmias. The average time from entry into the study until the start of ultimately effective therapy was 18 days. Therapy that eliminated symptoms did not eliminate all premature ventricular contractions, and occasionally even brief asymptomatic episodes of ventricular tachycardia persisted. Recurrent symptomatic ventricular arrhythmias can be controlled in many patients by rigorous application of current therapies.

Electrophysiologic effects of procainamide in subtherapeutic to therapeutic doses on human atrioventricular conduction system

The effects of single intravenous infusions of 50 to 400 mg of procainamide on the functional properties of the atrioventricular (A-V) conduction system were studied in 36 patients and correlated with plasma concentrations. A 50 mg dose of procainamide resulted in a plasma concentration of less than 1.0 mug/ml and produced no electrophysiologic changes. Doses of 100, 200, 300 and 400 mg resulted in progresively increasing plasma concentrations (1.2, 1.8, 3.5 and 4.2 mug/ml, respectively). The effects of procainamide on the sinus rate were variable and not dose-related. The effects of doses of up to 300 mg on A-V nodal conduction were variable and not dose-related. Only in a dose of 400 mg did procainamide prolong A-V nodal conduction in six of seven patients. Whereas 100 mg had no effect on His-Purkinje system conduction, doses of 200, 300 and 400 mg prolonged His-Purkinje system conduction time by 6, 8 and 9 msec, respectively. Dose-related increases in atrial refractoriness started with a dose of 200 mg and became statistically significant with doses of 300 and 400 mg. The effects of procainamide on A-V nodal functional refractoriness were variable and not dose-related, but in doses of 100 to 400 mg, procainamide produced significant and progressively dose-related increases in His-Purkinje system refractoriness. Suppression of some types of ventricular arrhythmia by small doses of this drug may be explained by changes in refractoriness of the His-Purkinje system produced by doses of procainamide as small as 100 mg.

Comparison of the acetylation of procainamide and sulfadimidine in man

The acetylation of procainamide and sulfadimidine has been measured simultaneously in plasma and urine in 20 healthy human volunteers by a specific G.L.C. method, after single and multiple oral dral doses of procainamide retard tablets. A distinct bimodality (9 rapid and 11 slow acetylators) was apparent from the concentrations of procainamide and N-acetylprocainamide both in urine and plasma, which was in complete agreement with data about sulfadimidine acetylation. The influence of acetylator phenotype on the relative concentrations of procainamide and N-acetylprocainamide in plasma as cn 5 additional healthy subjects after a single oral dose of procainamide. The present results show that acetylator phenotype can now be determined using procainamide as the test substance, and for this purpose multiple doses offer hardly any advantage over a single dose of the drug. However, because the separation between rapid and slow acetylators is less pronounced for procainamide than for sulfadimidine, precise criteria must be established for the conditions of the test, and the influence of diseases, such as renal insufficiency, should be taken into consideration.

Electrophysiological studies in left bundle branch block as a result of procainamide therapy

A patient of coronary heart disease with depressed intraventricular conduction who developed left bundle branch block upon administration of procainamide instead of the usual nonspecific widening of qrs is presented. The possible mechanism of genesis of this very rare side effect of procainamide is discussed and the review of the literature revealed this patient to be the first documented, electrophysiologically studied case with this side effect of procainamide.

Sustained release procainamide in patients with myocardial infarction

Sustained release procainamide tablets were administered to 34 patients 48 hours after the onset of an acute myocardial infarct. Therapeutic blood levels of procainamide in the range of 4 to 8 mug/ml were consistently achieved using an 8-hourly maintenance dose of 1.5g after an initial loading dose of 2g. In contrast conventional procainamide capsules administered to 21 comparable patients repeatedly failed to produce plasma concentrations in the therapeutic range, despite the administration of a maintenance dose of 375 mg 3 hourly, after a loading dose of 1g. It is suggested that when the oral administration of procainamide is indicated for the management of ventricular arrhythmias after myocardial infarction, a sustained release preparation should be used.

Effects of long-term treatment with procaine amide. A prospective study with special regard to ANF and SLE in fast and slow acetylators

During 1970-75 a total of 42 patients have been subjected to long-term treatment with procaine amide (PrA) because of different cardiac arrhythmias and have been observed up to over 5 years. Among these patients 35 (83%) developed a significantly increased titer of ANF and of these, 12 patients (29%) developed a "classical" drug-induced SLE syndrome. In the SLE group all but 2 improved rapidly after cessation of PrA, and the ANF titer decreased continuously but slowly in both groups. Acetylation test with sulphamidine and/or isoniazid in 11 patients among the SLE cases showed 8 slow and 3 fast acetylators. Among 12 patients who also had received PrA for a long time, but had not shown any signs of an SLE syndrome, there were 10 fast and 2 slow acetylators.