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Steinberg BA, Holubkov R, Deering T, Groh CA, Mittal S, Kennedy R, Pokharel P, Perez M, Savona S, Verma N, Watt K, Piccini JP, Bunch TJ. Expedited loading with intravenous sotalol is safe and feasible-primary results of the Prospective Evaluation Analysis and Kinetics of IV Sotalol (PEAKS) Registry. Heart Rhythm 2024; 21:1134-1142. [PMID: 38417598 PMCID: PMC11222028 DOI: 10.1016/j.hrthm.2024.02.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Loading of oral sotalol for atrial fibrillation requires 3 days, frequently in the hospital, to achieve steady state. The Food and Drug Administration approved loading with intravenous (IV) sotalol through model-informed development, without patient data. OBJECTIVE We present results of the first multicenter evaluation of this recent labeling for IV sotalol. METHODS The Prospective Evaluation Analysis and Kinetics of IV Sotalol (PEAKS) Registry was a multicenter observational registry of patients undergoing elective IV sotalol load for atrial arrhythmias. Outcomes, measured from hospital admission until first outpatient follow-up, included adverse arrhythmia events, efficacy, and length of stay. RESULTS Of 167 consecutively enrolled patients, 23% were female; the median age was 68 (interquartile range, 61-74) years, and the median CHA2DS2-VASc score was 3 (interquartile range, 2-4). Overall, 99% were admitted for sotalol initiation (1% for dose escalation), with a target oral sotalol dose of either 80 mg twice daily (85 [51%]) or 120 mg twice daily (78 [47%]); 62 patients (37%) had an estimated creatinine clearance ≤90 mL/min. On presentation, 40% of patients were in sinus rhythm, whereas 26% underwent cardioversion before sotalol infusion. In 2 patients, sotalol infusion was stopped for bradycardia or hypotension. In 6 patients, sotalol was discontinued before discharge because of QTc prolongation (3), bradycardia (1), or recurrent atrial arrhythmia (2). The mean length of stay was 1.1 days, and 95% (n = 159) were discharged within 1 night. CONCLUSION IV sotalol loading is safe and feasible for atrial arrhythmias, with low rates of adverse events, and yields shorter hospitalizations. More data are needed on the minimal duration required for monitoring in the hospital.
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Affiliation(s)
- Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, Utah.
| | - Richard Holubkov
- Data Coordinating Center, Department of Pediatrics, Spencer Eccles Fox School of Medicine, University of Utah, Salt Lake City, Utah
| | | | - Christopher A Groh
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, Utah
| | | | | | | | - Marco Perez
- Department of Medicine, Stanford University, Stanford, California
| | - Salvatore Savona
- Department of Medicine, The Ohio State University, Columbus, Ohio
| | - Nishant Verma
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kevin Watt
- Division of Clinical Pharmacology, Department of Pediatrics, Spencer Eccles Fox School of Medicine, University of Utah, Salt Lake City, Utah
| | - Jonathan P Piccini
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - T Jared Bunch
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, Utah
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Batra AS, Silka MJ, Borquez A, Cuneo B, Dechert B, Jaeggi E, Kannankeril PJ, Tabulov C, Tisdale JE, Wolfe D. Pharmacological Management of Cardiac Arrhythmias in the Fetal and Neonatal Periods: A Scientific Statement From the American Heart Association: Endorsed by the Pediatric & Congenital Electrophysiology Society (PACES). Circulation 2024; 149:e937-e952. [PMID: 38314551 DOI: 10.1161/cir.0000000000001206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
Disorders of the cardiac rhythm may occur in both the fetus and neonate. Because of the immature myocardium, the hemodynamic consequences of either bradyarrhythmias or tachyarrhythmias may be far more significant than in mature physiological states. Treatment options are limited in the fetus and neonate because of limited vascular access, patient size, and the significant risk/benefit ratio of any intervention. In addition, exposure of the fetus or neonate to either persistent arrhythmias or antiarrhythmic medications may have yet-to-be-determined long-term developmental consequences. This scientific statement discusses the mechanism of arrhythmias, pharmacological treatment options, and distinct aspects of pharmacokinetics for the fetus and neonate. From the available current data, subjects of apparent consistency/consensus are presented, as well as future directions for research in terms of aspects of care for which evidence has not been established.
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Geanacopoulos AT, Zielonka B, Fox MT, Kerr S, Chambers KD, Przybylski R, Burns MM. Pediatric antiarrhythmics and toxicity: A clinical review. J Am Coll Emerg Physicians Open 2024; 5:e13090. [PMID: 38371660 PMCID: PMC10869663 DOI: 10.1002/emp2.13090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 02/20/2024] Open
Abstract
Antiarrhythmic medications are fundamental in the acute and chronic management of pediatric arrhythmias. Particularly in the pediatric patient population, associated antiarrhythmic toxicities represent important potential adverse effects. Emergency medicine clinicians must be skilled in the detection, workup, and management of antiarrhythmic toxicity. This is a clinical review of the indications, pharmacology, adverse effects, and toxicologic treatment of antiarrhythmics commonly used in the pediatric patient population.
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Affiliation(s)
- Alexandra T. Geanacopoulos
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | - Benjamin Zielonka
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
- Department of CardiologyBoston Children's HospitalBostonMassachusettsUSA
| | - Miriam T. Fox
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | - Sarah Kerr
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | | | - Robert Przybylski
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
- Department of CardiologyBoston Children's HospitalBostonMassachusettsUSA
| | - Michele M. Burns
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
- Harvard Medical Toxicology ProgramBoston Children's HospitalBostonMassachusettsUSA
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Oeffl N, Schober L, Faudon P, Schweintzger S, Manninger M, Köstenberger M, Sallmon H, Scherr D, Kurath-Koller S. Antiarrhythmic Drug Dosing in Children-Review of the Literature. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050847. [PMID: 37238395 DOI: 10.3390/children10050847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 04/27/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023]
Abstract
Antiarrhythmic drugs represent a mainstay of pediatric arrhythmia treatment. However, official guidelines and consensus documents on this topic remain scarce. There are rather uniform recommendations for some medications (including adenosine, amiodarone, and esmolol), while there are only very broad dosage recommendations for others (such as sotalol or digoxin). To prevent potential uncertainties and even mistakes with regard to dosing, we summarized the published dosage recommendations for antiarrhythmic drugs in children. Because of the wide variations in availability, regulatory approval, and experience, we encourage centers to develop their own specific protocols for pediatric antiarrhythmic drug therapy.
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Affiliation(s)
- Nathalie Oeffl
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, 8036 Graz, Austria
| | - Lukas Schober
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, 8036 Graz, Austria
| | - Patrick Faudon
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, 8036 Graz, Austria
| | - Sabrina Schweintzger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, 8036 Graz, Austria
| | - Martin Manninger
- Division of Cardiology, Department of Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Martin Köstenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, 8036 Graz, Austria
| | - Hannes Sallmon
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, 8036 Graz, Austria
| | - Daniel Scherr
- Division of Cardiology, Department of Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Stefan Kurath-Koller
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of Graz, 8036 Graz, Austria
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Feuerborn ML, Dechand J, Vadlamudi RS, Torre M, Freedman RA, Groh C, Navaravong L, Ranjan R, Varela D, Bunch TJ, Steinberg BA. Protocol Development and Initial Experience With Intravenous Sotalol Loading for Atrial Arrhythmias. Crit Pathw Cardiol 2023; 22:1-4. [PMID: 36812336 PMCID: PMC9977272 DOI: 10.1097/hpc.0000000000000308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
BACKGROUND Oral sotalol is a class III antiarrhythmic commonly used for the maintenance of sinus rhythm in patients with atrial fibrillation (AF). Recently, the Food and Drug Administration (FDA) approved the use of IV sotalol loading, based primarily on modeling data for the infusion. We aimed to describe a protocol and experience with IV sotalol loading for elective treatment of adult patients with AF and atrial flutter (AFL). METHODS We present our institutional protocol and retrospective review of initial patients treated with IV sotalol for AF/AFL at the University of Utah Hospital between September 2020 and April 2021. RESULTS Eleven patients received IV sotalol for initial loading or dose escalation. All patients were male, aged 56-88 years (median 69). Mean QT interval (QTc) intervals increased from baseline (mean 384 ms) immediately after infusion of IV sotalol (mean change 42ms), but no patient required discontinuation of the medication. Six patients were discharged after 1 night; 4 patients were discharged after 2 nights; and 1 patient was discharged after 4 nights. Nine patients underwent electrical cardioversion prior to discharge (2 prior to load; 7 post-load on the day of discharge). There were no adverse events during the infusion or within 6 months of discharge. Persistence of therapy was 73% (8 of 11) at mean 9.9 weeks to follow up, with no discontinuations for adverse effects. CONCLUSIONS We employed a streamlined protocol that was successfully implemented to facilitate the use of IV sotalol loading for atrial arrhythmias. Our initial experience suggests feasibility, safety, and tolerability while reducing hospitalization duration. Additional data are needed to augment this experience as IV sotalol use is broadened across different patient populations.
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Affiliation(s)
- Melissa L Feuerborn
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - John Dechand
- Department of Pharmacy Services, University of Utah Health, Salt Lake City, UT, USA
| | - Rohith S Vadlamudi
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Michael Torre
- Department of Population Health, University of Utah School of Medicine, Salt Lake City, UT
| | - Roger A. Freedman
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Christopher Groh
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Ravi Ranjan
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Daniel Varela
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - T. Jared Bunch
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Benjamin A. Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
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Rizkallah DH, Refaat MM. Safety and effect on length of stay of intravenous sotalol initiation for arrhythmia management. J Cardiovasc Electrophysiol 2023; 34:1324-1325. [PMID: 36738140 DOI: 10.1111/jce.15852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Diane H Rizkallah
- Department of Internal Medicine, Division of Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marwan M Refaat
- Department of Internal Medicine, Division of Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
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7
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Malloy‐Walton LE, Von Bergen NH, Balaji S, Fischbach PS, Garnreiter JM, Asaki SY, Moak JP, Ochoa LA, Chang PM, Nguyen HH, Patel AR, Kirk C, Sherman AK, Avari Silva JN, Saul JP. IV Sotalol Use in Pediatric and Congenital Heart Patients: A Multicenter Registry Study. J Am Heart Assoc 2022; 11:e024375. [PMID: 35491986 PMCID: PMC9238590 DOI: 10.1161/jaha.121.024375] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background There is limited information regarding the clinical use and effectiveness of IV sotalol in pediatric patients and patients with congenital heart disease, including those with severe myocardial dysfunction. A multicenter registry study was designed to evaluate the safety, efficacy, and dosing of IV sotalol. Methods and Results A total of 85 patients (age 1 day–36 years) received IV sotalol, of whom 45 (53%) had additional congenital cardiac diagnoses and 4 (5%) were greater than 18 years of age. In 79 patients (93%), IV sotalol was used to treat supraventricular tachycardia and 4 (5%) received it to treat ventricular arrhythmias. Severely decreased cardiac function by echocardiography was seen before IV sotalol in 7 (9%). The average dose was 1 mg/kg (range 0.5–1.8 mg/kg/dose) over a median of 60 minutes (range 30–300 minutes). Successful arrhythmia termination occurred in 31 patients (49%, 95% CI [37%–62%]) with improvement in rhythm control defined as rate reduction permitting overdrive pacing in an additional 18 patients (30%, 95% CI [19%–41%]). Eleven patients (16%) had significant QTc prolongation to >465 milliseconds after the infusion, with 3 (4%) to >500 milliseconds. There were 2 patients (2%) for whom the infusion was terminated early. Conclusions IV sotalol was safe and effective for termination or improvement of tachyarrhythmias in 79% of pediatric patients and patients with congenital heart disease, including those with severely depressed cardiac function. The most common dose, for both acute and maintenance dosing, was 1 mg/kg over ~60 minutes with rare serious complications.
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Affiliation(s)
| | | | | | | | | | - S. Yukiko Asaki
- University of Utah/Primary Children's Hospital Salt Lake City UT
| | | | | | - Philip M. Chang
- University of Florida/Shands Children`s Hospital Gainesville FL
| | | | | | | | | | | | - J. Philip Saul
- Department of Pediatrics West Virginia University School of Medicine Morgantown WV
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8
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Valdés SO, Howard TS, Pham TDN, Lemming KI, Rochelson E, Backes ER, Lam WW, Patel R, Miyake CY, Kim JJ. When Adenosine is Not Enough. Heart Rhythm 2022; 19:1015-1016. [PMID: 35144018 DOI: 10.1016/j.hrthm.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Santiago O Valdés
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
| | - Taylor S Howard
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Tam Dan N Pham
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | | | - Ellis Rochelson
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Emily R Backes
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Wilson W Lam
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | | | | | - Jeffrey J Kim
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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9
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Rochelson E, Valdés SO, Asadourian V, Patel R, Lemming K, Howard TS, Pham TDN, Miyake CY, Kim JJ. Sotalol versus amiodarone for postoperative junctional tachycardia after congenital heart surgery. Heart Rhythm 2021; 19:450-456. [PMID: 34801734 DOI: 10.1016/j.hrthm.2021.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/29/2021] [Accepted: 11/15/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Junctional ectopic tachycardia (JET) is a common arrhythmia after congenital heart disease surgery. There is variability in the choice of antiarrhythmic therapy, with amiodarone used commonly. Intravenous (IV) sotalol is a newly available agent that may be useful for JET. OBJECTIVE The purpose of this study was to evaluate the safety and efficacy of IV sotalol for postoperative JET and compare outcomes with IV amiodarone. METHODS This is a retrospective single-center study of all patients who received IV sotalol or IV amiodarone for postoperative JET at Texas Children's Hospital from December 15, 2015, to December 15, 2020. Data included antiarrhythmic efficacy, hemodynamics, and adverse effects. Successful JET control was defined as a decrease in JET rate to <170 beats/min (or decrease by >20%), or conversion to sinus rhythm, with persistent control over 24 hours without requiring alternative antiarrhythmics or mechanical support. RESULTS A total of 32 patients (median age 71 days; interquartile range 17-221 days) received IV amiodarone (n = 20 [62%]) or IV sotalol (n = 12 [38%]) for postoperative JET. Amiodarone was successful in treating JET in 75% of cases; sotalol was successful in 83%. The JET rate decreased faster over the first 90 minutes after a sotalol bolus (25 beats/min per hour) than after an amiodarone bolus (8 beats/min per hour) (P < .01); no heart rate difference was seen after 24 hours. Amiodarone infusion was discontinued early because of hypotension/bradycardia in 2 patients; this was not required in any patients receiving sotalol. CONCLUSION For children with postoperative JET, both IV sotalol and amiodarone are safe and efficacious. IV sotalol may lead to a faster improvement in heart rate.
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Affiliation(s)
- Ellis Rochelson
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
| | - Santiago O Valdés
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | | | | | - Katherine Lemming
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Taylor S Howard
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Tam Dan N Pham
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Christina Y Miyake
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Jeffrey J Kim
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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