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Goldenberg I, Aktas MK, Zareba W, Tsu-Chau Huang D, Rosero SZ, Younis A, McNitt S, Stockburger M, Steinberg JS, Buttar RS, Merkely B, Kutyifa V. QRS Morphology and the Risk of Ventricular Tachyarrhythmia in Cardiac Resynchronization Therapy Recipients. JACC Clin Electrophysiol 2024; 10:16-26. [PMID: 38032575 DOI: 10.1016/j.jacep.2023.09.018] [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: 05/08/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND There are conflicting data on the effect of cardiac resynchronization therapy with a defibrillator (CRT-D) on the risk of life-threatening ventricular tachyarrhythmia in heart failure patients. OBJECTIVES The authors aimed to assess whether QRS morphology is associated with risk of ventricular arrhythmias in CRT recipients. METHODS The study population comprised 2,862 patients implanted with implantable cardioverter defibrillator (ICD)/CRT-D for primary prevention who were enrolled in 5 landmark primary prevention ICD trials (MADIT-II [Multicenter Automated Defibrillator Implantation Trial], MADIT-CRT [Multicenter Automated Defibrillator Implantation Trial-Cardiac Resynchronization Therapy], MADIT-RIT [Multicenter Automated Defibrillator Implantation Trial-Reduction in Inappropriate Therapy], MADIT-RISK [Multicenter Automated Defibrillator Implantation Trial-RISK], and RAID [Ranolazine in High-Risk Patients With Implanted Cardioverter Defibrillators]). Patients with QRS duration ≥130 ms were divided into 2 groups: those implanted with an ICD only vs CRT-D. The primary endpoint was fast ventricular tachycardia (VT)/ventricular fibrillation (VF) (defined as VT ≥200 beats/min or VF), accounting for the competing risk of death. Secondary endpoints included appropriate shocks, any sustained VT or VF, and the burden of fast VT/VF, assessed in a recurrent event analysis. RESULTS Among patients with left bundle branch block (n = 1,792), those with CRT-D (n = 1,112) experienced a significant 44% (P < 0.001) reduction in the risk of fast VT/VF compared with ICD-only patients (n = 680), a significantly lower burden of fast VT/VF (HR: 0.55; P = 0.001), with a reduced burden of appropriate shocks (HR: 0.44; P < 0.001). In contrast, among patients with non-left bundle branch block (NLBBB) (N = 1,070), CRT-D was not associated with reduction in fast VT/VF (HR: 1.33; P = 0.195). Furthermore, NLBBB patients with CRT-D experienced a statistically significant increase in the burden of fast VT/VF events compared with ICD-only patients (HR: 1.90; P = 0.013). CONCLUSIONS Our data suggest a potential proarrhythmic effect of CRT among patients with NLBBB. These data should be considered in patient selection for treatment with CRT.
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Affiliation(s)
- Ido Goldenberg
- University of Rochester Medical Center, Rochester, New York, USA; Rochester General Hospital, Rochester, New York, USA.
| | - Mehmet K Aktas
- University of Rochester Medical Center, Rochester, New York, USA
| | - Wojciech Zareba
- University of Rochester Medical Center, Rochester, New York, USA
| | | | - Spencer Z Rosero
- University of Rochester Medical Center, Rochester, New York, USA
| | - Arwa Younis
- University of Rochester Medical Center, Rochester, New York, USA
| | - Scott McNitt
- University of Rochester Medical Center, Rochester, New York, USA
| | | | | | | | - Bela Merkely
- Semmelweis University, Heart Center, Budapest, Hungary
| | - Valentina Kutyifa
- University of Rochester Medical Center, Rochester, New York, USA; Semmelweis University, Heart Center, Budapest, Hungary
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Saljic A, Heijman J, Dobrev D. Recent Advances in Antiarrhythmic Drug Therapy. Drugs 2023; 83:1147-1160. [PMID: 37540446 PMCID: PMC10462572 DOI: 10.1007/s40265-023-01923-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/05/2023]
Abstract
Cardiac arrhythmias remain a common cause of death and disability. Antiarrhythmic drugs (AADs) and antiarrhythmic agents remain a cornerstone of current cardiac arrhythmia management, despite moderate efficacy and the potential for significant adverse proarrhythmic effects. Due to conceptual, regulatory and financial considerations, the number of novel antiarrhythmic targets and agents in the development pipeline has decreased substantially during the last few decades. However, several promising candidates remain and there are exciting developments in repurposing and reformulating already existing drugs for indications related to cardiac arrhythmias. This review discusses the key conceptual considerations for the development of new antiarrhythmic agents, summarizes new compounds and formulations currently in clinical development for rhythm control of atrial fibrillation, and highlights the potential for drug repurposing. Finally, future directions in AAD development are discussed. Together with an ever-increasing understanding of the molecular mechanisms underlying cardiac arrhythmias, these components support a cautiously optimistic outlook towards improved pharmacological treatment opportunities for patients suffering from cardiac arrhythmias.
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Affiliation(s)
- Arnela Saljic
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
| | - Jordi Heijman
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Dobromir Dobrev
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
- Montréal Heart Institute and University de Montréal, Medicine and Research Center, Montréal, Canada.
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, USA.
- , Hufelandstrasse 55, 45122, Essen, Germany.
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Bi X, Zhang S, Jiang H, Ma W, Li Y, Lu W, Yang F, Wei Z. Mechanistic Insights Into Inflammation-Induced Arrhythmias: A Simulation Study. Front Physiol 2022; 13:843292. [PMID: 35711306 PMCID: PMC9196871 DOI: 10.3389/fphys.2022.843292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 04/25/2022] [Indexed: 11/29/2022] Open
Abstract
Cardiovascular diseases are the primary cause of death of humans, and among these, ventricular arrhythmias are the most common cause of death. There is plausible evidence implicating inflammation in the etiology of ventricular fibrillation (VF). In the case of systemic inflammation caused by an overactive immune response, the induced inflammatory cytokines directly affect the function of ion channels in cardiomyocytes, leading to a prolonged action potential duration (APD). However, the mechanistic links between inflammatory cytokine-induced molecular and cellular influences and inflammation-associated ventricular arrhythmias need to be elucidated. The present study aimed to determine the potential impact of systemic inflammation on ventricular electrophysiology by means of multiscale virtual heart models. The experimental data on the ionic current of three major cytokines [i.e., tumor necrosis factor-α (TNF-α), interleukin-1 (IL-1β), and interleukin-6 (IL-6)] were incorporated into the cell model, and the effects of each cytokine and their combined effect on the cell action potential (AP) were evaluated. Moreover, the integral effect of these cytokines on the conduction of excitation waves was also investigated in a tissue model. The simulation results suggested that inflammatory cytokines significantly prolonged APD, enhanced the transmural and regional repolarization heterogeneities that predispose to arrhythmias, and reduced the adaptability of ventricular tissue to fast heart rates. In addition, simulated pseudo-ECGs showed a prolonged QT interval—a manifestation consistent with clinical observations. In summary, the present study provides new insights into ventricular arrhythmias associated with inflammation.
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Affiliation(s)
- Xiangpeng Bi
- College of Computer Science and Technology, Ocean University of China, Qingdao, China
| | - Shugang Zhang
- College of Computer Science and Technology, Ocean University of China, Qingdao, China
| | - Huasen Jiang
- College of Computer Science and Technology, Ocean University of China, Qingdao, China
| | - Wenjian Ma
- College of Computer Science and Technology, Ocean University of China, Qingdao, China
| | - Yuanfei Li
- College of Computer Science and Technology, Ocean University of China, Qingdao, China
| | - Weigang Lu
- Department of Educational Technology, Ocean University of China, Qingdao, China
| | - Fei Yang
- School of Mechanical, Electrical and Information Engineering, Shandong University, Weihai, China
| | - Zhiqiang Wei
- College of Computer Science and Technology, Ocean University of China, Qingdao, China
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Jordaan P, Dumotier B, Traebert M, Miller PE, Ghetti A, Urban L, Abi-Gerges N. Cardiotoxic Potential of Hydroxychloroquine, Chloroquine and Azithromycin in Adult Human Primary Cardiomyocytes. Toxicol Sci 2021; 180:356-368. [PMID: 33483756 PMCID: PMC7928616 DOI: 10.1093/toxsci/kfaa194] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Substantial efforts have been recently committed to develop coronavirus disease-2019 (COVID-19) medications, and Hydroxychloroquine alone or in combination with Azithromycin has been promoted as a repurposed treatment. Although these drugs may increase cardiac toxicity risk, cardiomyocyte mechanisms underlying this risk remain poorly understood in humans. Therefore, we evaluated the proarrhythmia risk and inotropic effects of these drugs in the cardiomyocyte contractility-based model of the human heart. We found Hydroxychloroquine to have a low proarrhythmia risk, whereas Chloroquine and Azithromycin were associated with high risk. Hydroxychloroquine proarrhythmia risk changed to high with low level of K+, whereas high level of Mg2+ protected against proarrhythmic effect of high Hydroxychloroquine concentrations. Moreover, therapeutic concentration of Hydroxychloroquine caused no enhancement of elevated temperature-induced proarrhythmia. Polytherapy of Hydroxychloroquine plus Azithromycin and sequential application of these drugs were also found to influence proarrhythmia risk categorization. Hydroxychloroquine proarrhythmia risk changed to high when combined with Azithromycin at therapeutic concentration. However, Hydroxychloroquine at therapeutic concentration impacted the cardiac safety profile of Azithromycin and its proarrhythmia risk only at concentrations above therapeutic level. We also report that Hydroxychloroquine and Chloroquine, but not Azithromycin, decreased contractility while exhibiting multi-ion channel block features, and Hydroxychloroquine's contractility effect was abolished by Azithromycin. Thus, this study has the potential to inform clinical studies evaluating repurposed therapies, including those in the COVID-19 context. Additionally, it demonstrates the translational value of the human cardiomyocyte contractility-based model as a key early discovery path to inform decisions on novel therapies for COVID-19, malaria, and inflammatory diseases.
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Affiliation(s)
- Pierre Jordaan
- Chief Medical Officer and Patient Safety, Novartis AG, Basel, Switzerland
| | - Bérengère Dumotier
- Novartis Institutes for Biomedical Research, Preclinical Safety, Basel, Switzerland
| | - Martin Traebert
- Novartis Institutes for Biomedical Research, Preclinical Safety, Basel, Switzerland
| | - Paul E Miller
- AnaBios Corporation, San Diego, California 92109, USA
| | - Andre Ghetti
- AnaBios Corporation, San Diego, California 92109, USA
| | - Laszlo Urban
- Novartis Institutes for Biomedical Research, Preclinical Secondary Pharmacology, Cambridge, Massachusetts, USA
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Nordkin I, Levinas T, Rosenfeld I, Halabi M. Torsades de pointes after prolonged intravenous amiodarone therapy for atrial fibrillation. Clin Case Rep 2021; 9:391-394. [PMID: 33489188 PMCID: PMC7813084 DOI: 10.1002/ccr3.3539] [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] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/22/2020] [Accepted: 10/12/2020] [Indexed: 11/06/2022] Open
Abstract
Amiodarone can induce TdP; therefore, it should be avoided as a first choice for therapy in patients without heart disease. Careful QT interval monitoring, especially during intravenous use, can prevent development of this life-threatening arrhythmia.
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Affiliation(s)
- Irina Nordkin
- Ziv Medical CenterCardiology DepartmentTzfatIsrael
- The Azrieli Faculty of MedicineBar‐Ilan UniversityIsrael
| | - Tatyana Levinas
- The Azrieli Faculty of MedicineBar‐Ilan UniversityIsrael
- Ziv Medical CenterHeart Rehabilitation DepartmentTzfatIsrael
| | - Inna Rosenfeld
- Ziv Medical CenterCardiology DepartmentTzfatIsrael
- The Azrieli Faculty of MedicineBar‐Ilan UniversityIsrael
| | - Majdi Halabi
- Ziv Medical CenterCardiology DepartmentTzfatIsrael
- The Azrieli Faculty of MedicineBar‐Ilan UniversityIsrael
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Hagengaard L, Søgaard P, Espersen M, Sessa M, Lund PE, Krogager ML, Torp-Pedersen C, Kragholm KH, Polcwiartek C. Association between serum potassium levels and short-term mortality in patients with atrial fibrillation or flutter co-treated with diuretics and rate- or rhythm-controlling drugs. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 6:137-144. [DOI: 10.1093/ehjcvp/pvz024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/26/2019] [Accepted: 06/27/2019] [Indexed: 11/14/2022]
Abstract
Abstract
Aims
We investigated the association between potassium levels and 90-day all-cause mortality in atrial fibrillation or flutter (AF) patients co-treated with diuretics and rate- or rhythm-controlling drugs.
Methods and results
During 2000–12, first-time AF patients treated with beta-blockers, amiodarone, sotalol, verapamil, or digoxin combined with any diuretic within 90 days post-AF discharge were included. Following co-treatment, a potassium measurement within 90 days after initiating diuretic treatment was required. Mortality risk associated with potassium <3.5, 3.5–3.7, 3.8–4.0, 4.5–4.7, 4.8–5.0, and >5.0 mmol/L (reference: 4.1–4.4 mmol/L) was assessed using multivariable Cox regression. In total, 14 425 AF patients were included (median age: 78 years; women: 52%). Patients most often received beta-blocker monotherapy (29%), beta-blockers and digoxin combined (25%), digoxin monotherapy (24%), amiodarone monotherapy (3%), and verapamil monotherapy (3%). Increased 90-day mortality risk was associated with <3.5 mmol/L [hazard ratio (HR) 2.05, 95% confidence interval (CI) 1.68–2.50], 3.5–3.7 mmol/L (HR 1.28, 95% CI 1.05–1.57), 4.5–4.7 mmol/L (HR 1.20, 95% CI 1.02–1.41), 4.8–5.0 mmol/L (HR 1.37, 95% CI 1.14–1.66), and >5.0 mmol/L: (HR 1.84, 95% CI 1.53–2.21). Compared with beta-blocker monotherapy, rate- or rhythm-controlling drugs did not modify the association between potassium groups and mortality risk.
Conclusion
In addition to hypo- and hyperkalaemia, low and high normal range potassium levels were associated with increased 90-day mortality risk in AF patients co-treated with diuretics and rate- or rhythm-controlling drugs. These associations were independent of rate- or rhythm-controlling drugs.
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Affiliation(s)
- Louise Hagengaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marie Espersen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Maurizio Sessa
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
- Department of Experimental Medicine, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Peter Enemark Lund
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Maria Lukács Krogager
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Kristian Hay Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
- Department of Cardiology, North Denmark Regional Hospital, Hjørring, Denmark
| | - Christoffer Polcwiartek
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
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Christophe B, Crumb WJ. Impact of disease state on arrhythmic event detection by action potential modelling in cardiac safety pharmacology. J Pharmacol Toxicol Methods 2018; 96:15-26. [PMID: 30580044 DOI: 10.1016/j.vascn.2018.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 12/11/2018] [Accepted: 12/17/2018] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The use of in silico cardiac action potential simulations is one of the pillars of the CiPA initiative (Comprehensive in vitro Proarrhythmia Assay) currently under evaluation designed to detect more accurately proarrhythmic liabilities of new drug candidate. In order to take into account the variability of clinical situations, we propose to improve this method by studying the impact of various disease states on arrhythmic events induced by 30 torsadogenic or non-torsadogenic compounds. METHOD In silico modelling was done on the human myocytes using the Dutta revised O'Hara-Rudy algorithm. Results were analysed using a new metric based on the compound IC50s against the seven cardiac ionic currents considered to be the most important by the CiPA initiative (IKr, IKs, INa, INaL, IK1, Ito, ICaL) and the minimal rate of action potential voltage decrease calculated at the early-afterdepolarization (EAD) take-off membrane voltage (Vmin). RESULTS The specific threshold at which each torsadogenic compounds induced EAD, was exacerbated by the presence of cardiac risk factors ranked as follows: congestive heart failure > hypertrophic cardiomyopathy > cardiac pause > no risk factor. Non-torsadogenic compounds induced no EAD even in the presence of cardiac risk factors. DISCUSSION The present study highlighted the impact of pre-existing cardiovascular disease on arrhythmic event detection suggesting that disease state modelling may need to be incorporated in order to fully realize the goal of the CiPA paradigm in a more accurate predictability of proarrhythmic liabilities of new drug candidate.
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Affiliation(s)
| | - William J Crumb
- Nova Research Laboratories LLC, 1441 Canal Street, New Orleans, LA 70112, USA.
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Shenthar J, Rachaiah JM, Pillai V, Chakali SS, Balasubramanian V, Chollenhalli Nanjappa M. Incidence of drug-induced torsades de pointes with intravenous amiodarone. Indian Heart J 2017; 69:707-713. [PMID: 29174246 PMCID: PMC5717288 DOI: 10.1016/j.ihj.2017.05.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 05/15/2017] [Accepted: 05/27/2017] [Indexed: 01/08/2023] Open
Abstract
AIM To define the incidence, presentation, and outcomes of drug-induced Torsades de Pointes (TdP) with intravenous (IV) amiodarone. METHODS From January 2014 to August 2016 a total of 268 patients received IV amiodarone, 142 for ventricular tachycardia, 104 for atrial flutter/fibrillation, and 22 for incessant atrial tachycardia. A uniform dosing of amiodarone to yield 1gm/day was used in all patients. RESULTS Four of the 268 patients (M:F 1:3) with mean age of 51.25+9.17years developed pause dependent TdP degenerating to VF, after a mean dose of 690+176.63mg, infused over 12+5.88h. The QTc that was 505+9.02ms at the time of TdP normalized to 433.75+6.13ms 48-72h after stopping amiodarone. There was no immediate or late mortality, and patients are well at 5-10 months of follow-up. None of the patients tested positive for LQTS genes. CONCLUSION The incidence of drug-induced TdP with IV amiodarone is about 1.5%. Risk factors include female sex, left ventricular dysfunction, electrolyte abnormalities, baseline prolonged QTc, concomitant beta-blocker, and digoxin therapy. Amiodarone induced TdP has favorable prognosis if recognized and treated promptly, and these patients should not receive amiodarone by any route in future.
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Affiliation(s)
- Jayaprakash Shenthar
- Sri Jayadeva Institute Of Cardiovascular Sciences and Research, 9th Block Jayanagar, Bannerghatta Road, Bengaluru 560069, India.
| | - Jayasheelan Mambally Rachaiah
- Sri Jayadeva Institute Of Cardiovascular Sciences and Research, 9th Block Jayanagar, Bannerghatta Road, Bengaluru 560069, India
| | - Vivek Pillai
- Sri Jayadeva Institute Of Cardiovascular Sciences and Research, 9th Block Jayanagar, Bannerghatta Road, Bengaluru 560069, India
| | - Siva Sankara Chakali
- Sri Jayadeva Institute Of Cardiovascular Sciences and Research, 9th Block Jayanagar, Bannerghatta Road, Bengaluru 560069, India
| | - Vidhyakar Balasubramanian
- Sri Jayadeva Institute Of Cardiovascular Sciences and Research, 9th Block Jayanagar, Bannerghatta Road, Bengaluru 560069, India
| | - Manjunath Chollenhalli Nanjappa
- Sri Jayadeva Institute Of Cardiovascular Sciences and Research, 9th Block Jayanagar, Bannerghatta Road, Bengaluru 560069, India
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Frommeyer G, Puckhaber D, Ellermann C, Dechering DG, Kochhäuser S, Leitz P, Reinke F, Eckardt L. Interactions of digitalis and class-III antiarrhythmic drugs: Amiodarone versus dronedarone. Int J Cardiol 2017; 228:74-79. [DOI: 10.1016/j.ijcard.2016.11.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 11/04/2016] [Indexed: 02/07/2023]
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Tereshchenko LG, Berger RD. Towards a better understanding of QT interval variability. Ther Adv Drug Saf 2014; 2:245-51. [PMID: 25083216 DOI: 10.1177/2042098611421209] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH) Guideline E14 recommends 'Thorough QT Study' as a standard assessment of drug-induced QT interval prolongation. At the same time, the value of drug-induced QTc prolongation as a surrogate marker for risk of life-threatening polymorphic ventricular tachycardia known as torsades des pointes remains controversial. Beat-to-beat variability of QT interval was recently proposed as an alternative metric. The following review addresses mechanisms of beat-to-beat QT variability, methods of QT interval variability measurements, and its prognostic value in clinical studies.
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Affiliation(s)
- Larisa G Tereshchenko
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ronald D Berger
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Carnegie 592, 600 N. Wolfe St., Baltimore, MD 21287, USA
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Coppini R, Ferrantini C, Mazzoni L, Sartiani L, Olivotto I, Poggesi C, Cerbai E, Mugelli A. Regulation of intracellular Na(+) in health and disease: pathophysiological mechanisms and implications for treatment. Glob Cardiol Sci Pract 2013; 2013:222-42. [PMID: 24689024 PMCID: PMC3963757 DOI: 10.5339/gcsp.2013.30] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 09/01/2013] [Indexed: 12/19/2022] Open
Abstract
Transmembrane sodium (Na+) fluxes and intracellular sodium homeostasis are central players in the physiology of the cardiac myocyte, since they are crucial for both cell excitability and for the regulation of the intracellular calcium concentration. Furthermore, Na+ fluxes across the membrane of mitochondria affect the concentration of protons and calcium in the matrix, regulating mitochondrial function. In this review we first analyze the main molecular determinants of sodium fluxes across the sarcolemma and the mitochondrial membrane and describe their role in the physiology of the healthy myocyte. In particular we focus on the interplay between intracellular Ca2+ and Na+. A large part of the review is dedicated to discuss the changes of Na+ fluxes and intracellular Na+ concentration([Na+]i) occurring in cardiac disease; we specifically focus on heart failure and hypertrophic cardiomyopathy, where increased intracellular [Na+]i is an established determinant of myocardial dysfunction. We review experimental evidence attributing the increase of [Na+]i to either decreased Na+ efflux (e.g. via the Na+/K+ pump) or increased Na+ influx into the myocyte (e.g. via Na+ channels). In particular, we focus on the role of the “late sodium current” (INaL), a sustained component of the fast Na+ current of cardiac myocytes, which is abnormally enhanced in cardiac diseases and contributes to both electrical and contractile dysfunction. We analyze the pathophysiological role of INaL enhancement in heart failure and hypertrophic cardiomyopathy and the consequences of its pharmacological modulation, highlighting the clinical implications. The central role of Na+ fluxes and intracellular Na+ physiology and pathophysiology of cardiac myocytes has been highlighted by a large number of recent works. The possibility of modulating Na+ inward fluxes and [Na+]i with specific INaL inhibitors, such as ranolazine, has made Na+a novel suitable target for cardiac therapy, potentially capable of addressing arrhythmogenesis and diastolic dysfunction in severe conditions such as heart failure and hypertrophic cardiomyopathy.
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Affiliation(s)
- Raffaele Coppini
- Department NeuroFarBa, Division of Pharmacology, University of Florence, Italy
| | - Cecilia Ferrantini
- Department of Clinical and Experimental Medicine, division of Physiology, University of Florence, Italy
| | - Luca Mazzoni
- Department NeuroFarBa, Division of Pharmacology, University of Florence, Italy
| | - Laura Sartiani
- Department NeuroFarBa, Division of Pharmacology, University of Florence, Italy
| | - Iacopo Olivotto
- Referral Center for Cardiomyopathies, Careggi University Hospital, Florence, Italy
| | - Corrado Poggesi
- Department of Clinical and Experimental Medicine, division of Physiology, University of Florence, Italy
| | - Elisabetta Cerbai
- Department NeuroFarBa, Division of Pharmacology, University of Florence, Italy
| | - Alessandro Mugelli
- Department NeuroFarBa, Division of Pharmacology, University of Florence, Italy
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12
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Nadarasa K, Williams MJA. Single high oral dose amiodarone for cardioversion of recent onset atrial fibrillation. Heart Lung Circ 2012; 21:444-8. [PMID: 22554874 DOI: 10.1016/j.hlc.2012.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 03/15/2012] [Accepted: 03/18/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Selection of a pharmacological agent and mode of administration for cardioversion is a challenging task in recent onset atrial fibrillation. AIM To report our experience using single high dose oral amiodarone for the cardioversion of recent onset atrial fibrillation to sinus rhythm in patient presenting with symptoms within 48 h. METHODS We retrospectively studied 48 patients with recent onset symptomatic atrial fibrillation presenting to the emergency department. These patients were admitted to the cardiology ward and treated with single high oral dose (30 mg/kg) amiodarone. RESULTS The mean ± SD age of patients was 60.1 ± 4.4 years and 54% were male. Forty-two (90%) of them had symptoms <24h. The common risk factor for atrial fibrillation was hypertension (73%). Of 48 patients, 47 (98%) were chemically cardioverted to sinus rhythm in 6.3 ± 0.8h. The mean pre-treatment heart rate and blood pressure were 154/min and 159.3/88.0 mmHg. The lowest heart rate and blood pressure were 43/min and 122.5/80.9 mmHg respectively. High dose amiodarone was overall well tolerated except in three patients having self-limited gastrointestinal symptoms. Hospital discharge occurred in less than 24h after presentation in all but one patient. CONCLUSION Single high dose oral amiodarone is safe and highly effective for patients with recent onset atrial fibrillation eligible for acute chemical cardioversion.
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Lewalter T. [Rhythm---control in atrial fibrillation]. MMW Fortschr Med 2012; 154:55-7. [PMID: 22624266 DOI: 10.1007/s15006-012-0307-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- T Lewalter
- Klinik für Kardiologie und Internistische Intensivmedizin Isar Herz Zentrum, Isarkliniken GmbH, München.
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Lewalter T. [Prophylaxis of stroke and embolisms in atrial fibrillation--what is new in the guidelines?]. MMW Fortschr Med 2012; 154:50-54. [PMID: 22624265 DOI: 10.1007/s15006-012-0306-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- T Lewalter
- Klinik für Kardiologie und Internistische Intensivmedizin Isar Herz Zentrum, Isarkliniken GmbH, München.
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Mihálcz A, Ábrahám P, Kardos A, Földesi C, Szili-Török T. Cardiac resynchronization therapy for patients with atrial fibrillation. Orv Hetil 2011; 152:1757-63. [DOI: 10.1556/oh.2011.29204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Atrial fibrillation and chronic heart failure are two major and even growing cardiovascular conditions that often coexist. Cardiac resynchronization therapy is an important, device-based, non-pharmacological approach in a selected group of chronic heart failure patients that has been shown to improve left ventricular function and to reduce both morbidity and mortality in large randomized trials. The latest European and American guidelines have considered atrial fibrillation patients with heart failure eligible for cardiac resynchronization therapy. This review summarizes current literature concerning the following topics: prognostic relevance of atrial fibrillation in heart failure, effects of cardiac resynchronization therapy in atrial fibrillation, relevance and strategies of rhythm and rate control in this group of patients. Authors explain how atrial fibrillation may interfere with the delivery of adequate cardiac resynchronization therapy, how to reduce the burden of atrial tachyarrhythmias, and finally present a brief overview. Orv. Hetil., 2011, 152, 1757–1763.
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Affiliation(s)
- Attila Mihálcz
- Gottsegen György Országos Kardiológiai Intézet Budapest Haller u. 29. 1096
| | - Pál Ábrahám
- Gottsegen György Országos Kardiológiai Intézet Budapest Haller u. 29. 1096
| | - Attila Kardos
- Gottsegen György Országos Kardiológiai Intézet Budapest Haller u. 29. 1096
| | - Csaba Földesi
- Gottsegen György Országos Kardiológiai Intézet Budapest Haller u. 29. 1096
| | - Tamás Szili-Török
- Gottsegen György Országos Kardiológiai Intézet Budapest Haller u. 29. 1096
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Yip A, Bajorek BV. Identifying Temporal Changes to the Prescribing of Anti-Arrhythmics for Atrial Fibrillation. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2010. [DOI: 10.1002/j.2055-2335.2010.tb00561.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Annie Yip
- Faculty of Pharmacy; University of Sydney
| | - Beata V Bajorek
- Faculty of Pharmacy; University of Sydney, and Department of Pharmacy and Clinical Pharmacology, Royal North Shore Hospital; St Leonards New South Wales
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A Randomized Invasive Cardiac Electrophysiology Study of the Combined Ion Channel Blocker AZD1305 in Patients After Catheter Ablation of Atrial Flutter. J Cardiovasc Pharmacol 2010; 56:300-8. [DOI: 10.1097/fjc.0b013e3181ed0859] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Taylor CJ, Hodgkinson J, Hobbs FDR. Rhythm control agents and adverse events in patients with atrial fibrillation. Int J Clin Pract 2010; 64:1069-75. [PMID: 20487051 DOI: 10.1111/j.1742-1241.2010.02426.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the commonest rhythm disorder and has major impact on patients. Controversy remains about the best treatment strategy between rate and rhythm control (in addition to adequate thromboprophylaxis). Rhythm control agents are associated with clinically important adverse events. AIM The aim of this study was to assess the risk of adverse events in patients with AF receiving rhythm control agents. DESIGN OF STUDY This is a retrospective case control note review and outcome linkage analysis. SETTING Setting of this study included patients with a diagnosis of AF receiving amiodarone, flecainide or sotalol in practices registered with the General Practice Research Database (GPRD) in the UK. METHOD This is a retrospective case control note review and outcome linkage analysis on the GPRD routine clinical dataset to evaluate the adverse events and predictors of treatment discontinuation in patients using licenced rhythm modifying medication. RESULTS Adverse events are more common in patients currently or previously taking amiodarone, flecainide or sotalol than age- and gender-matched controls. All three antiarrhythmics were associated with increased all-cause mortality. Congestive heart failure was more common in all amiodarone and sotalol users as well as past users of flecainide. Thyroid disease was more common in patients treated with amiodarone and sotalol but only amiodarone had an increased risk of pulmonary toxicity. The number of patients with liver failure was too small in all cases for statistical analysis. CONCLUSION The rhythm control agents amiodarone, flecainide and sotalol have significant adverse effects which can lead to discontinuation of their use. This should be considered when deciding the most appropriate treatment option for patients with AF.
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Affiliation(s)
- C J Taylor
- Primary Care Clinical Sciences, School of Health and Population Sciences, University of Birmingham, Birmingham, UK.
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Intracardiac QT variability in patients with structural heart disease on class III antiarrhythmic drugs. J Electrocardiol 2009; 42:505-10. [PMID: 19700170 DOI: 10.1016/j.jelectrocard.2009.07.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2009] [Indexed: 11/24/2022]
Abstract
We previously showed that increased intracardiac repolarization lability predicts life-threatening ventricular arrhythmias in patients with structural heart disease. Patients with structural heart disease frequently take antiarrhythmic drugs (AADs), which directly affect repolarization. The effect of AADs on the predictive value of repolarization lability is unknown. We hypothesized that increased intracardiac beat-to-beat QT variability predicts sustained ventricular tachyarrhythmias in structural heart disease patients on class III AADs. Intracardiac electrograms and surface electrocardiogram were simultaneously recorded at rest for 5 minutes in 500 patients (mean +/- SD age, 61 +/- 14 years; 368 male [74%]) with implanted implantable cardioverter-defibrillator for primary (295 patients, or 79%) or secondary prevention of sudden cardiac death. Mean (SD) follow-up currently reached 24.8 (11.7) months. Intracardiac QT variability index was an independent predictor of ventricular tachycardia/ventricular fibrillation events and fast ventricular arrhythmias with cycle length of 240 ms or less in the multivariate Cox model. Intracardiac QT variability was higher in patients on class III AADs than in those not taking these drugs. Increased intracardiac QT variability after adjustment for class III AADs use carried independent risk of life-threatening ventricular tachyarrhythmias.
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Abstract
Atrial fibrillation and congestive heart failure are frequently associated with complex interactions. Patients with both diseases bear a sophisticated therapeutic challenge for the attending physician. The approach to treat atrial fibrillation differs for patients with and without heart failure in several aspects. Basic requirements are the treatment of the underlying diseases and prophylaxis of thromboembolic complications. Rate and rhythm control are the two main therapeutic strategies for atrial fibrillation according to the current guidelines. Large trials including the recently published AF-CHF study (Atrial Fibrillation - Congestive Heart Failure) failed to demonstrate a difference in mortality for both strategies. Thus, the therapeutic decision is mainly based on the patient's symptoms to improve quality of life. Rate control should be applied to asymptomatic patients or if rhythm control has already failed. If beta-blockers and digoxin have failed to control heart rate, His ablation with pacemaker implantation can be considered. In patients without heart disease, class I antiarrhythmic drugs and, in case of ineffectiveness, amiodarone or catheter ablation are recommended for rhythm control. First data concerning catheter ablation of atrial fibrillation in heart failure are promising and randomized studies are on the way. Rhythm control remains first-line therapy in recent-onset or highly symptomatic paroxysmal or persistent atrial fibrillation patients with and without heart failure.
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Tebbenjohanns J, Willems S, Antz M, Pfeiffer D, Seidl KH, Lewalter T. Kommentar zu den „ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death – executive summary“. KARDIOLOGE 2008. [DOI: 10.1007/s12181-008-0112-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Lewalter T, Tebbenjohanns J, Wichter T, Antz M, Geller C, Seidl KH, Gulba D, Röhrig F, Willems S. Kommentar zu „ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation – executive summary“. DER KARDIOLOGE 2008. [DOI: 10.1007/s12181-008-0080-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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