Pharmacologic treatment of cardiac arrhythmias: 25 years of progress

Cardiac arrhythmia diagnosis

Cardiac dysfunction is often manifested as arrhythmia, with disruption of the normal periodicity and regularity of electromechanical activity. Cardiac arrhythmias, or abnormalities of cardiac rhythm, are associated with a diverse group of conditions, including congenital, metabolic, structural, physiological, and immunological, and infectious abnormalities. Dysarrhythmia may also be classified as primary because of endogenous electrical abnormalities, or secondary, because of exogenous influences such as ischemia or adrenergic stimuli. Clinical arrhythmia syndromes begin with a single asymptomatic abnormal complex that is benign, progressing to grouped, sustained complexes associated with worsened symptoms and outcome. Proper diagnosis of arrhythmia reflecting symptomology and outcome is essential in acute cardiac care.

Rate-dependent electrophysiological effects of OPC-8212: comparison to sotalol

The rate-dependent effects of OPC-8212 (6 microM), a new positive inotropic drug which lengthens cardiac action potential duration were studied in dog cardiac Purkinje fibers and compared to the effects of sotalol (30 microM), a class III antiarrhythmic using conventional microelectrode technique. Both OPC-8212 and sotalol lengthened action potential duration in a frequency-dependent manner. Both had a greater effect at slower pacing frequencies than at fast. The maximum rising velocity of the action potential upstroke was not affected by either compound at any of the pacing cycle lengths applied (300-2000 ms). The effects of OPC-8212 and sotalol on action potential duration and maximum rising velocity were also compared following abrupt changes in pacing cycle length (i.e. coupling intervals ranging between approximately 250-3000 ms). The effects of both OPC-8212 and sotalol following abrupt changes in pacing cycle length were similar to one another. Neither OPC-8212 nor sotalol altered the time constants for restitution of action potential duration or the kinetics for recovery of the maximum rising velocity of the action potential upstroke. These results indicate that the rate-dependent electrophysiological effects of OPC-8212 closely mimic those of sotalol and suggest that OPC-8212 may be an effective class III antiarrhythmic in addition to being a positive inotropic compound.

Ventricular arrhythmias in severe heart failure: incidence, significance, and effectiveness of antiarrhythmic therapy

Forty-three patients receiving maximal medical therapy for severe chronic heart failure from dilated cardiomyopathies (28 ischemic, 15 idiopathic) and ventricular premature beats (VPBs) on the 12-lead ECG had baseline 24-hour ambulatory ECG monitoring. Complex VPBs (multiform, repetitive--couplets, R on T phenomenon) and asymptomatic, nonsustained ventricular tachycardia were present in 38 patients (88%) and 22 patients (51%), respectively. Twenty-three patients (group I) were placed on long-term antiarrhythmic therapy (20 patients received procainamide and the remaining quinidine). Twenty patients (group II) did not receive antiarrhythmic therapy. At baseline, no significant differences between the two groups were noted for age, functional class, type of cardiomyopathy, medical therapy for heart failure, cardiothoracic ratio, radionuclide ejection fraction, or rate and complexity of the ventricular arrhythmias on the 24-hour ambulatory ECG tracings. At a mean follow-up period of 16 months (range 1 to 37), there were 16 deaths, 10 (62%) of which were sudden and unexpected. No significant differences in the incidence of sudden death and overall mortality were noted between the two groups. Among patients with nonsustained ventricular tachycardia, those who died suddenly had a lower mean left ventricular ejection fraction (0.15 +/- 0.01) when compared to the survivors (0.23 +/- 0.02; p less than 0.01). It is concluded that patients with severe heart failure have a high mortality from both sudden and nonsudden cardiac death, incidence of complex VPBs is very high, sudden death is more common when the left ventricular function is severely compromised, and apparently, therapeutic plasma levels of conventional antiarrhythmic drugs do not protect this group of patients from dying.