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Ruskin JN, Camm AJ, Dufton C, Woite-Silva AC, Tuininga Y, Badings E, De Jong JSSG, Oosterhof T, Aksoy I, Kuijper AFM, Van Gelder IC, van Dijk V, Nuyens D, Schellings D, Lee MY, Kowey PR, Crijns HJGM, Maupas J, Belardinelli L. Orally Inhaled Flecainide for Conversion of Atrial Fibrillation to Sinus Rhythm: INSTANT Phase 2 Trial. JACC Clin Electrophysiol 2024; 10:1021-1033. [PMID: 38613545 DOI: 10.1016/j.jacep.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 02/09/2024] [Accepted: 02/14/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND INSTANT (INhalation of flecainide to convert recent-onset SympTomatic Atrial fibrillatioN to sinus rhyThm) was a multicenter, open-label, single-arm study of flecainide acetate oral inhalation solution (FlecIH) for acute conversion of recent-onset (≤48 hours) symptomatic atrial fibrillation (AF) to sinus rhythm. OBJECTIVES This study investigated the efficacy and safety in 98 patients receiving a single dose of FlecIH delivered via oral inhalation. METHODS Patients self-administered FlecIH over 8 minutes in a supervised medical setting using a breath-actuated nebulizer and were continuously monitored for 90 minutes using a 12-lead Holter. RESULTS Mean age was 60.5 years, mean body mass index was 27.0 kg/m2, and 34.7% of the patients were women. All patients had ≥1 AF-related symptoms at baseline, and 87.8% had AF symptoms for ≤24 hours. The conversion rate was 42.6% (95% CI: 33.0%-52.6%) with a median time to conversion of 14.6 minutes. The conversion rate was 46.9% (95% CI: 36.4%-57.7%) in a subpopulation that excluded predose flecainide exposure for the current AF episode. Median time to discharge among patients who converted was 2.5 hours, and only 2 patients had experienced AF recurrence by day 5. In the conversion-no group, 44 (81.5%) patients underwent electrical cardioversion by day 5. The most common adverse events were related to oral inhalation of flecainide (eg, cough, oropharyngeal irritation/pain), which were mostly of mild intensity and limited duration. CONCLUSIONS The risk-benefit of orally inhaled FlecIH for acute cardioversion of recent-onset AF appears favorable. FlecIH could provide a safe, effective, and convenient first-line therapeutic option. (INhalation of Flecainide to Convert Recent Onset SympTomatic Atrial Fibrillation to siNus rhyThm [INSTANT]; NCT03539302).
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Affiliation(s)
| | - A John Camm
- St. George's University, London, United Kingdom
| | | | | | | | | | | | | | - Ismail Aksoy
- Admiraal de Ruyter Ziekenhuis, Goes, the Netherlands
| | | | - Isabelle C Van Gelder
- University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | | | | | | | - Peter R Kowey
- Lankenau Heart Institute, Wynnewood, Pennsylvania, USA
| | - Harry J G M Crijns
- Maastricht University Medical Center (MUMC), Maastricht, the Netherlands
| | - Jean Maupas
- InCarda Therapeutics, Newark, California, USA
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Islam N, Cichero E, Rahman S, Ranasinghe I. Novel Pulmonary Delivery of Drugs for the Management of Atrial Fibrillation. Am J Cardiovasc Drugs 2023; 23:1-7. [PMID: 36255655 PMCID: PMC9845156 DOI: 10.1007/s40256-022-00551-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2022] [Indexed: 01/21/2023]
Abstract
Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, affecting approximately 335 million patients worldwide. Comprehensive pharmacological treatment of AF includes medications for rate or rhythm control and anticoagulants to reduce the risk of thromboembolism; yet, these agents have significant limitations. Oral anti-arrhythmic agents have a slow onset of action, and rapid onset formulations require hospitalization for intravenous therapy. Orally administered drugs also require high doses to attain therapeutic levels, and thus dose-related severe adverse effects are often unavoidable. Given the therapeutic benefits of inhaled drug delivery, including rapid onset of action and very low doses to achieve therapeutic efficacy, this review will discuss the benefits of novel pulmonary delivery of drugs for the management of AF.
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Affiliation(s)
- Nazrul Islam
- Pharmacy Discipline, Faculty of Health, Queensland University of Technology, Brisbane, QLD 4000 Australia
| | - Emma Cichero
- Faculty of Health, School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD 4000 Australia
| | - Shafiqur Rahman
- Department of Pharmaceutical Sciences, Avera Health and Science Center, South Dakota State University, 1055 Campanile Avenue, SAV 265, Brookings, SD 57007 USA
| | - Isuru Ranasinghe
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia ,Northside Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Emerging Antiarrhythmic Drugs for Atrial Fibrillation. Int J Mol Sci 2022; 23:ijms23084096. [PMID: 35456912 PMCID: PMC9029767 DOI: 10.3390/ijms23084096] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/28/2022] [Accepted: 04/01/2022] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF), the most common cardiac arrhythmia worldwide, is driven by complex mechanisms that differ between subgroups of patients. This complexity is apparent from the different forms in which AF presents itself (post-operative, paroxysmal and persistent), each with heterogeneous patterns and variable progression. Our current understanding of the mechanisms responsible for initiation, maintenance and progression of the different forms of AF has increased significantly in recent years. Nevertheless, antiarrhythmic drugs for the management of AF have not been developed based on the underlying arrhythmia mechanisms and none of the currently used drugs were specifically developed to target AF. With the increased knowledge on the mechanisms underlying different forms of AF, new opportunities for developing more effective and safer AF therapies are emerging. In this review, we provide an overview of potential novel antiarrhythmic approaches based on the underlying mechanisms of AF, focusing both on the development of novel antiarrhythmic agents and on the possibility of repurposing already marketed drugs. In addition, we discuss the opportunity of targeting some of the key players involved in the underlying AF mechanisms, such as ryanodine receptor type-2 (RyR2) channels and atrial-selective K+-currents (IK2P and ISK) for antiarrhythmic therapy. In addition, we highlight the opportunities for targeting components of inflammatory signaling (e.g., the NLRP3-inflammasome) and upstream mechanisms targeting fibroblast function to prevent structural remodeling and progression of AF. Finally, we critically appraise emerging antiarrhythmic drug principles and future directions for antiarrhythmic drug development, as well as their potential for improving AF management.
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Investigational Anti-Atrial Fibrillation Pharmacology and Mechanisms by Which Antiarrhythmics Terminate the Arrhythmia: Where Are We in 2020? J Cardiovasc Pharmacol 2021; 76:492-505. [PMID: 33165131 PMCID: PMC7641178 DOI: 10.1097/fjc.0000000000000892] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Antiarrhythmic drugs remain the mainstay therapy for patients with atrial fibrillation (AF). A major disadvantage of the currently available anti-AF agents is the risk of induction of ventricular proarrhythmias. Aiming to reduce this risk, several atrial-specific or -selective ion channel block approaches have been introduced for AF suppression, but only the atrial-selective inhibition of the sodium channel has been demonstrated to be valid in both experimental and clinical studies. Among the other pharmacological anti-AF approaches, “upstream therapy” has been prominent but largely disappointing, and pulmonary delivery of anti-AF drugs seems to be promising. Major contradictions exist in the literature about the electrophysiological mechanisms of AF (ie, reentry or focal?) and the mechanisms by which anti-AF drugs terminate AF, making the search for novel anti-AF approaches largely empirical. Drug-induced termination of AF may or may not be associated with prolongation of the atrial effective refractory period. Anti-AF drug research has been largely based on the “suppress reentry” ideology; however, results of the AF mapping studies increasingly indicate that nonreentrant mechanism(s) plays an important role in the maintenance of AF. Also, the analysis of anti-AF drug-induced electrophysiological alterations during AF, conducted in the current study, leans toward the focal source as the prime mechanism of AF maintenance. More effort should be placed on the investigation of pharmacological suppression of the focal mechanisms.
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Yang PC, Giles WR, Belardinelli L, Clancy CE. Mechanisms of flecainide induced negative inotropy: An in silico study. J Mol Cell Cardiol 2021; 158:26-37. [PMID: 34004185 PMCID: PMC8772296 DOI: 10.1016/j.yjmcc.2021.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 11/27/2022]
Abstract
It is imperative to develop better approaches to predict how antiarrhythmic drugs with multiple interactions and targets may alter the overall electrical and/or mechanical function of the heart. Safety Pharmacology studies have provided new insights into the multi-target effects of many different classes of drugs and have been aided by the addition of robust new in vitro and in silico technology. The primary focus of Safety Pharmacology studies has been to determine the risk profile of drugs and drug candidates by assessing their effects on repolarization of the cardiac action potential. However, for decades experimental and clinical studies have described substantial and potentially detrimental effects of Na+ channel blockers in addition to their well-known conduction slowing effects. One such side effect, associated with administration of some Na+ channel blocking drugs is negative inotropy. This reduces the pumping function of the heart, thereby resulting in hypotension. Flecainide is a well-known example of a Na+ channel blocking drug, that exhibits strong rate-dependent block of INa and may cause negative cardiac inotropy. While the phenomenon of Na+ channel suppression and resulting negative inotropy is well described, the mechanism(s) underlying this effect are not. Here, we set out to use a modeling and simulation approach to reveal plausible mechanisms that could explain the negative inotropic effect of flecainide. We utilized the Grandi-Bers model [1] of the cardiac ventricular myocyte because of its robust descriptions of ion homeostasis in order to characterize and resolve the relative effects of QRS widening, flecainide off-target effects and changes in intracellular Ca2+ and Na+ homeostasis. The results of our investigations and predictions reconcile multiple data sets and illustrate how multiple mechanisms may play a contributing role in the flecainide induced negative cardiac inotropic effect.
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Affiliation(s)
- Pei-Chi Yang
- Department of Physiology and Membrane Biology, School of Medicine, University of California, Davis, United States of America
| | - Wayne R Giles
- Department of Physiology & Pharmacology, University of Calgary, Canada
| | | | - Colleen E Clancy
- Department of Physiology and Membrane Biology, School of Medicine, University of California, Davis, United States of America.
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Rabêlo Evangelista AB, Monteiro FR, Nearing BD, Belardinelli L, Verrier RL. Flecainide-induced QRS complex widening correlates with negative inotropy. Heart Rhythm 2021; 18:1416-1422. [PMID: 33848647 DOI: 10.1016/j.hrthm.2021.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/30/2021] [Accepted: 04/05/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The negative inotropic effect of Class IC antiarrhythmic drugs limits their use for acute cardioversion of atrial fibrillation (AF). OBJECTIVE The purpose of this study was to examine, in an intact porcine model, the effects of pulmonary and intravenous (IV) administration of flecainide on left ventricular (LV) contractility and QRS complex width at doses that are effective in converting new-onset AF to sinus rhythm. METHODS Flecainide (1.5 mg/kg bolus) was delivered by intratracheal administration and compared to 2.0 mg/kg 10-minute IV administration (European Society of Cardiology guideline) and to 0.5 and 1.0 mg/kg 2-minute IV doses in 40 closed-chest, anesthetized Yorkshire pigs. Catheters were fluoroscopically positioned in the LV to monitor QRS complex width and contractility and at the bifurcation of the main bronchi to deliver intratracheal flecainide. RESULTS Peak flecainide plasma concentrations (Cmax) were similar, but the 30-minute area under the curve (AUC) of plasma levels was 1.4- to 2.8-fold greater for 2.0 mg/kg 10-minute IV infusion than for the lower, more rapidly delivered intratracheal and IV doses. AUC for LV contractility (ie, negative inotropic burden) was 2.2- to 3.6-fold greater for 2.0 mg/kg 10-minute IV dose than for the lower, more rapidly delivered doses. QRS complex widening by flecainide was highly correlated with the decrease in LV contractility (r2 = 0.890, P <.0001, for all IV doses; r2 = 0.812, P = .01, for intratracheal flecainide). CONCLUSION QRS complex widening in response to flecainide is strongly correlated with decrease in LV contractility. Rapid pulmonary or IV flecainide delivery reduces the negative inotropic burden while quickly achieving Cmax levels associated with conversion of AF.
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Affiliation(s)
- Ana B Rabêlo Evangelista
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Felipe R Monteiro
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Bruce D Nearing
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | | | - Richard L Verrier
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts.
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Abstract
Pharmacologic management of atrial fibrillation (AF) is a pressing problem. This arrhythmia afflicts >5 million individuals in the United States and prevalence is estimated to rise to 12 million by 2050. Although the pill-in-the-pocket regimen for self-administered AF cardioversion introduced over a decade ago has proven useful, significant drawbacks exist. Among these are the relatively long latency of effects in the range of hours along with potential for hypotension and other adverse effects. This experience prompted development of a new strategy for increasing plasma concentrations of antiarrhythmic drugs rapidly and for a limited time, namely, pulmonary delivery. In preclinical studies in Yorkshire pigs, intratracheal administration of flecainide was shown to cause a rapid, reproducible increase in plasma drug levels. Moreover, pulmonary delivery of flecainide converted AF to normal sinus rhythm by prolonging atrial depolarization, which slows intra-atrial conduction and seems to be directly correlated with efficacy in converting AF. The rapid rise in plasma flecainide levels optimizes its anti-AF effects while minimizing adverse influences on ventricular depolarization and contractility. A more concentrated and soluble formulation of flecainide using a novel cyclodextrin complex excipient reduced net drug delivery for AF conversion when compared to the acetate formulation. Inhalation of the beta-adrenergic blocking agent metoprolol slows ventricular rate and can also terminate AF. In human subjects, oral inhalation of flecainide acetate with a hand-held, breath-actuated nebulizer results in signature prolongation of the QRS complex without serious adverse events. Thus, pulmonary delivery is a promising advance in pharmacologic approach to management of AF.
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Wong CK, Tse HF. New methodological approaches to atrial fibrillation drug discovery. Expert Opin Drug Discov 2020; 16:319-329. [PMID: 33016154 DOI: 10.1080/17460441.2021.1826432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice and rhythm control using pharmacological agents is required in selected patients. Nonetheless, current medication is only modestly efficacious and associated with significant cardiovascular and systemic side effects. More efficacious and safe drugs are required to restore and maintain sinus rhythm in patients with AF. AREAS COVERED In this review, several potential drug targets are discussed including trans-membrane ion channels, intracellular calcium signaling, gap junction signaling, atrial inflammation and fibrosis, and the autonomic nervous system. New tools and methodologies for AF drug development are also reviewed including gene therapy, genome-guided therapy, stem cell technologies, tissue engineering, and optogenetics. EXPERT OPINION In recent decades, there has been an increased understanding of the underlying pathogenesis of AF. As a result, there is a gradual paradigm shift from focusing only on trans-membrane ion channel inhibition to developing therapeutic agents that target other underlying arrhythmogenic mechanisms. Gene therapy and genome-guided therapy are emerging as novel treatments for AF with some success in proof-of-concept studies. Recent advances in stem cell technology, tissue engineering, and optogenetics may allow more effective in-vitro drug screening than conventional methodologies.
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Affiliation(s)
- Chun-Ka Wong
- Cardiology Division, Department of Medicine, The University of Hong Kong, Hong Kong, SAR China
| | - Hung-Fat Tse
- Cardiology Division, Department of Medicine, The University of Hong Kong, Hong Kong, SAR China
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Pulmonary Delivery of Metoprolol Reduces Ventricular Rate During Atrial Fibrillation and Accelerates Conversion to Sinus Rhythm. J Cardiovasc Pharmacol 2020; 75:135-140. [DOI: 10.1097/fjc.0000000000000780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tessarolo Silva F, Pedreira GC, Medeiros SA, Bortolotto AL, Araujo Silva B, Hurrey M, Madhavapeddi P, Schuler C, Belardinelli L, Verrier RL. Multimodal mechanisms and enhanced efficiency of atrial fibrillation cardioversion by pulmonary delivery of a novel flecainide formulation. J Cardiovasc Electrophysiol 2019; 31:205-213. [DOI: 10.1111/jce.14289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/01/2019] [Accepted: 11/18/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Fernanda Tessarolo Silva
- Division of Cardiovascular Medicine, Harvard‐Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical CenterHarvard Medical School Boston Massachusetts
- Faculdade de Medicina da Universidade de Sao Paulo Sao Paulo Brazil
| | - Giovanna C. Pedreira
- Division of Cardiovascular Medicine, Harvard‐Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical CenterHarvard Medical School Boston Massachusetts
- Faculdade de Medicina da Universidade de Sao Paulo Sao Paulo Brazil
| | - Sofia A. Medeiros
- Division of Cardiovascular Medicine, Harvard‐Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical CenterHarvard Medical School Boston Massachusetts
- Faculdade de Medicina da Universidade de Sao Paulo Sao Paulo Brazil
| | - Alexandre L. Bortolotto
- Division of Cardiovascular Medicine, Harvard‐Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical CenterHarvard Medical School Boston Massachusetts
- Faculdade de Medicina da Universidade de Sao Paulo Sao Paulo Brazil
| | - Bruna Araujo Silva
- Division of Cardiovascular Medicine, Harvard‐Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical CenterHarvard Medical School Boston Massachusetts
- Faculdade de Medicina da Universidade de Sao Paulo Sao Paulo Brazil
| | | | | | | | | | - Richard L. Verrier
- Division of Cardiovascular Medicine, Harvard‐Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical CenterHarvard Medical School Boston Massachusetts
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Marum AA, Silva BA, Bortolotto AL, Silva AC, de Antonio VZ, Belardinelli L, Verrier RL. Optimizing flecainide plasma concentration profile for atrial fibrillation conversion while minimizing adverse ventricular effects by rapid, low-dose intratracheal or intravenous administration. Int J Cardiol 2019; 274:170-174. [PMID: 30217428 DOI: 10.1016/j.ijcard.2018.09.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/21/2018] [Accepted: 09/07/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND We investigated whether rapid administration of a low dose of flecainide, either intratracheally or intravenously (IV), could accelerate conversion of atrial fibrillation (AF) while reducing adverse ventricular effects. METHODS Flecainide was delivered via intratracheal administration at 1.5 mg/kg bolus and compared to IV infusion at 1.0 mg/kg over 2 min (lower-dose, rapid) and 2.0 mg/kg over 10 min (ESC guideline) in closed-chest, anesthetized Yorkshire pigs. Catheters were fluoroscopically positioned in right atrium to measure atrial depolarization (Pa) duration and left ventricle (LV) to measure QRS complex duration and contractility (LV dP/dt) during atrial pacing at 140 beats/min. Flecainide was delivered intratracheally via a catheter positioned at the bifurcation of the main bronchi. AF was induced by intrapericardial administration of acetylcholine followed by burst pacing. RESULTS Flecainide reduced AF duration similarly by intratracheal and IV delivery. Peak plasma levels were comparable but Tmax differed and coincided with peaks in Pa prolongation. The area under the curve indicating sustained plasma levels was greater for higher-dose, slow IV flecainide than for either intratracheal instillation (by 32%) or lower-dose, rapid IV infusion (by 88%). As a result, higher-dose, slow IV flecainide caused 58% (p < 0.03) and 48% (p < 0.006) greater increases in QRS complex duration and 61% and 96% (both, p < 0.02) greater reductions in contractility compared to intratracheal and lower-dose, rapid IV flecainide, respectively. CONCLUSION Lower-dose, rapid flecainide, delivered either intratracheally or IV, optimizes the plasma concentration profile for effective conversion of AF while minimizing adverse effects on QRS complex duration and LV contractility.
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Affiliation(s)
- Alexandre A Marum
- Beth Israel Deaconess Medical Center, Boston, MA, United States of America; Department of Environmental Sciences, Harvard School of Public Health, Boston, MA, United States of America; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Bruna A Silva
- Beth Israel Deaconess Medical Center, Boston, MA, United States of America; Department of Environmental Sciences, Harvard School of Public Health, Boston, MA, United States of America; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Alexandre L Bortolotto
- Beth Israel Deaconess Medical Center, Boston, MA, United States of America; Department of Environmental Sciences, Harvard School of Public Health, Boston, MA, United States of America; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Anderson C Silva
- Beth Israel Deaconess Medical Center, Boston, MA, United States of America; Department of Environmental Sciences, Harvard School of Public Health, Boston, MA, United States of America; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Victor Z de Antonio
- Beth Israel Deaconess Medical Center, Boston, MA, United States of America; Department of Environmental Sciences, Harvard School of Public Health, Boston, MA, United States of America; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Richard L Verrier
- Beth Israel Deaconess Medical Center, Boston, MA, United States of America; Department of Environmental Sciences, Harvard School of Public Health, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
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de Antonio VZ, Silva AC, Stocco FG, Silva BA, Marum AA, Bortolotto AL, Belardinelli L, Verrier RL. Pulmonary delivery of flecainide causes a rate‐dependent predominant effect on atrial compared with ventricular depolarization duration revealed by intracardiac recordings in an intact porcine model. J Cardiovasc Electrophysiol 2018; 29:1563-1569. [DOI: 10.1111/jce.13708] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 07/31/2018] [Accepted: 08/03/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Victor Z. de Antonio
- Beth Israel Deaconess Medical CenterBoston Massachusetts
- Department of Environmental SciencesHarvard School of Public HealthBoston Massachusetts
- Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | - Anderson C. Silva
- Beth Israel Deaconess Medical CenterBoston Massachusetts
- Department of Environmental SciencesHarvard School of Public HealthBoston Massachusetts
- Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | - Fernando G. Stocco
- Beth Israel Deaconess Medical CenterBoston Massachusetts
- Department of Environmental SciencesHarvard School of Public HealthBoston Massachusetts
- Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | - Bruna A. Silva
- Beth Israel Deaconess Medical CenterBoston Massachusetts
- Department of Environmental SciencesHarvard School of Public HealthBoston Massachusetts
- Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | - Alexandre A. Marum
- Beth Israel Deaconess Medical CenterBoston Massachusetts
- Department of Environmental SciencesHarvard School of Public HealthBoston Massachusetts
- Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | - Alexandre L. Bortolotto
- Beth Israel Deaconess Medical CenterBoston Massachusetts
- Department of Environmental SciencesHarvard School of Public HealthBoston Massachusetts
- Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | | | - Richard L. Verrier
- Beth Israel Deaconess Medical CenterBoston Massachusetts
- Department of Environmental SciencesHarvard School of Public HealthBoston Massachusetts
- Department of MedicineHarvard Medical SchoolBoston Massachusetts
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