Effect of disopyramide on systolic and early diastolic time intervals in patients with hypertrophic cardiomyopathy

Beneficial Effect of Cibenzoline on Left Ventricular Pressure Gradient With Sigmoid Septum

An 83-year-old woman with hypertension was admitted to hospital with episodes of dyspnea on effort after having breakfast. Physical examination revealed a systolic murmur at the left sternal border in the third to fourth intercostal space. Cross-sectional echocardiography showed a sigmoid-shaped interventricular septum markedly protruding into the left ventricle, concentric left ventricular hypertrophy, systolic anterior motion of the mitral valve, and a resultant left ventricular outflow tract obstruction with a pressure gradient of 121.8 mmHg. She began daily treatment with 60 mg metoprolol. However, the chest symptoms were not relieved and the left ventricular outflow tract obstruction was still visible on echocardiography. She was then given 200 mg daily of cibenzoline, in addition to 40 mg metoprolol, and the left ventricular pressure gradient significantly decreased and she was free of symptoms without any complications. This case shows that cibenzoline may be useful in the treatment of left ventricular outflow tract obstruction caused by sigmoid septum.

Antiarrhythmic drug, cibenzoline, can directly improve the left ventricular diastolic function in patients with hypertrophic cardiomyopathy

The effect of cibenzoline on left ventricular diastolic function was investigated in patients with hypertrophic cardiomyopathy (HCM). Before and 2 h after an oral administration of 200 mg of cibenzoline, echocardiographic, apexcardiographic and gated radionuclide angiographic studies were performed in 12 patients with hypertrophic obstructive cardiomyopathy (HOCM) and 7 with hypertrophic nonobstructive cardiomyopathy (HNCM). After administration of cibenzoline, the left ventricular pressure gradient decreased from 96+/-33 mmHg to 29+/-22 mmHg (<0.0001). Fractional shortening decreased from 53.3+/-7.5 to 45.4+/-6.2% (p=0.0008) in patients with HOCM and from 49.9+/-8.7 to 40.9+/-7.5% (p=0.0039) in patients with HNCM. On the other hand, E-wave velocity increased and A-wave velocity decreased in both groups. The time between the second heart sound and O point was shortened from 253+/-53 to 176+/-21 ms (p<0.0001) in patients with HOCM and from 245+/-54 to 185+/-44 ms (p=0.0050) in patients with HNCM. The time to peak filling rate was shortened from 248+/-79 to 190+/-40 ms (p=0.0072) in patients with HOCM and from 218+/-33 to 163+/-26 ms (p=0.0052) in patients with HNCM. These results indicate that in patients with HCM, cibenzoline suppresses left ventricular systolic function, but can markedly improve left ventricular diastolic dysfunction through its direct action.

Class Ia antiarrhythmic drug cibenzoline: a new approach to the medical treatment of hypertrophic obstructive cardiomyopathy

BACKGROUND

The class Ia antiarrhythmic drug disopyramide relieves the outflow tract obstruction of hypertrophic obstructive cardiomyopathy (HOCM). Disopyramide, however, has several adverse effects, such as dysuria and thirst, resulting from its anticholinergic activity. A new class Ia antiarrhythmic drug, cibenzoline, has little anticholinergic activity. The aim of this study is to elucidate whether cibenzoline attenuates left ventricular pressure gradient (LVPG) in patients with HOCM.

METHODS AND RESULTS

Ten patients with HOCM (mean age, 59+/-12 years) participated in this study. LVPG and left ventricular functions were measured before and 2 hours after administration of a single oral dose of 150 or 200 mg cibenzoline. LVPG decreased from 123+/-60 to 39+/-33 mm Hg (P=.0026). The E/A ratio in transmitral Doppler flow increased from 1.20+/-0.84 to 2.00+/-1.72 (P=.029). Isovolumic relaxation time increased from 73+/-16 to 101+/-23 ms (P=.0026). Left ventricular diastolic dimension remained unchanged, but left ventricular systolic dimension enlarged significantly, from 21.6+/-2.4 to 26.2+/-3.3 mm (P=.0004). Fractional shortening decreased from 47.6+/-6.1% to 34.6+/-8.8% (P=.0007). Left ventricular ejection time index decreased significantly, and preejection period index increased in all the patients. Decreased LVPG remained maintained even in the long-term treatment with cibenzoline. Conclusions These results indicate that cibenzoline can markedly attenuate LVPG in patients with HOCM. A decrease in myocardial contractility seems to be closely related to a marked decrease in LVPG.

Salutary effect of disopyramide on left ventricular diastolic function in hypertrophic obstructive cardiomyopathy

OBJECTIVES

The purpose of this study was to estimate the effect of disopyramide on left ventricular diastolic function in patients with hypertrophic obstructive cardiomyopathy.

BACKGROUND

Although disopyramide has been reported to lessen clinical symptoms in patients with hypertrophic obstructive cardiomyopathy, few data exist regarding its effect on diastolic function in these patients.

METHODS

Thirteen patients with hypertrophic cardiomyopathy (six with and seven without left ventricular outflow obstruction) were examined. Before and after intravenous disopyramide, hemodynamic and angiographic studies were performed.

RESULTS

In patients with outflow obstruction, pressure gradient at the outflow tract decreased from a mean +/- SD of 100 +/- 45 to 26 +/- 33 mm Hg (p < 0.01). Although systolic function was similarly impaired in both groups, the time constant of left ventricular pressure decay (tau) shortened from 56 +/- 10 to 44 +/- 8 ms (p < 0.01) and the constant of left ventricular chamber stiffness (kc) decreased from 0.049 +/- 0.017 to 0.038 +/- 0.014 m2/ml (p < 0.01) only in patients with outflow obstruction. Shortening in tau correlated best with decrease in left ventricular systolic pressure (r = 0.84, p < 0.01). In contrast, tau was prolonged from 52 +/- 10 to 64 +/- 11 ms (p < 0.01) and kc was unchanged in patients without outflow obstruction.

CONCLUSIONS

The primary effects of disopyramide on the hypertrophied left ventricle were negative inotropic and negative lusitropic. However, left ventricular diastolic properties in patients with outflow obstruction were improved with a decrease in outflow pressure gradient. Relief of clinical symptoms in hypertrophic obstructive cardiomyopathy with disopyramide might be due in part to improvement of diastolic function, which appears secondary to the reduction in ventricular afterload.

Acute dose-response effects of intravenous disopyramide in hypertrophic obstructive cardiomyopathy

To evaluate the acute hemodynamic effects of intravenous disopyramide in hypertrophic obstructive cardiomyopathy (HOCM), 25 patients (12 men, 13 women) with an average age of 40 years (range 18 to 70 years) were evaluated while undergoing cardiac catheterization-angiography. Biplane left ventricular angiography was performed with standard intracardiac-systemic hemodynamics, including resting and provoked (after ventricular premature beat) left ventricular outflow tract gradients, by using simultaneous LV and aortic pressures as disopyramide was being administered (total dose 100 mg, bolus 10 mg every 3 minutes). Average baseline thermodilution cardiac output equalled 4.5 +/- 1.2 L/min, with all 25 subjects demonstrating systolic anterior motion of the mitral apparatus (mild, 3 [12%]; moderate, 8 [32%]; severe, 14 [64%]). Although heart rate originally slowed during disopyramide administration, average heart rate increased during the final stages (before, 78 +/- 15 vs after, 82 +/- 13 beats/min; p < 0.05). Systemic aortic pressures increased during intravenous disopyramide (before, 107 +/- 21/71 +/- 19 mm Hg vs after, 120 +/- 28/81 +/- 13 mm Hg; p < 0.05), with a decline in LV end-diastolic pressure (before, 19 +/- 7 vs after, 16 +/- 6 mm Hg; p < 0.01). Maximum LV systolic pressures decreased (before, 193 +/- 32 vs after, 146 +/- 29 mm Hg; p < 0.01), with a substantial reduction in resting LV outflow tract gradients (before, 86 +/- 34 vs after, 27 +/- 20 mm Hg; p < 0.001) in conjunction with less inducible obstruction (before, 124 +/- 33 vs after, 64 +/- 33 mm Hg; p < 0.001). Only minor electrocardiographic changes were seen during disopyramide infusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of disopyramide on left ventricular diastolic function in patients with hypertrophic cardiomyopathy: comparison with diltiazem

Left ventricular diastolic function before and after the administration of disopyramide (100 mg) or diltiazem (30 mg) was assessed in 10 patients with nonobstructive type hypertrophic cardiomyopathy. Left ventricular diastolic function was assessed by Doppler echocardiography. The peak early (E) and late (A) diastolic flow velocities and E/A ratio (E/A) were measured. Three hours after the administration of disopyramide, blood pressure did not significantly change, but heart rate was decreased significantly (p less than 0.01). Disopyramide increased the E velocity and E/A ratio from 43.8 +/- 15.0 cm/sec to 51.3 +/- 16.1 cm/sec and from 0.71 +/- 0.20 to 1.00 +/- 0.24 (each p less than 0.01), respectively, and decreased the A velocity from 63.9 +/- 18.5 cm/sec to 52.1 +/- 14.9 cm/sec (p less than 0.01). Diltiazem increased the E velocity and E/A ratio from 42.8 +/- 12.5 cm/sec to 46.4 +/- 13.4 cm/sec (p less than 0.05) and from 0.74 +/- 0.21 to 0.96 +/- 0.28 (p less than 0.01), respectively, and decreased the A velocity from 60.6 +/- 16.4 cm/sec to 50.2 +/- 15.6 cm/sec (p less than 0.01). These results indicate that disopyramide improved left ventricular diastolic filling in hypertrophic cardiomyopathy, and its effect was similar to that of diltiazem.