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Alhourani N, Wolfes J, Könemann H, Ellermann C, Frommeyer G, Güner F, Lange PS, Reinke F, Köbe J, Eckardt L. Relevance of mexiletine in the era of evolving antiarrhythmic therapy of ventricular arrhythmias. Clin Res Cardiol 2024; 113:791-800. [PMID: 38353682 PMCID: PMC11108884 DOI: 10.1007/s00392-024-02383-9] [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: 11/12/2023] [Accepted: 01/19/2024] [Indexed: 05/22/2024]
Abstract
Despite impressive developments in the field of ventricular arrhythmias, there is still a relevant number of patients with ventricular arrhythmias who require antiarrhythmic drug therapy and may, e.g., in otherwise drug and/or ablation refractory situations, benefit from agents known for decades, such as mexiletine. Through its capability of blocking fast sodium channels in cardiomyocytes, it has played a minor to moderate antiarrhythmic role throughout the recent decades. Nevertheless, certain patients with structural heart disease suffering from drug-refractory, i.e., mainly amiodarone refractory ventricular arrhythmias, as well as those with selected forms of congenital long QT syndrome (LQTS) may nowadays still benefit from mexiletine. Here, we outline mexiletine's cellular and clinical electrophysiological properties. In addition, the application of mexiletine may be accompanied by various potential side effects, e.g., nausea and tremor, and is limited by several drug-drug interactions. Thus, we shed light on the current therapeutic role of mexiletine for therapy of ventricular arrhythmias and discuss clinically relevant aspects of its indications based on current evidence.
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Affiliation(s)
- Nawar Alhourani
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany.
| | - Julian Wolfes
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Hilke Könemann
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Christian Ellermann
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Gerrit Frommeyer
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Fatih Güner
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Philipp Sebastian Lange
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Florian Reinke
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Julia Köbe
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Lars Eckardt
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
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Könemann H, Güler-Eren S, Ellermann C, Frommeyer G, Eckardt L. Antiarrhythmic Treatment in Heart Failure. Curr Heart Fail Rep 2024; 21:22-32. [PMID: 38224446 PMCID: PMC10828006 DOI: 10.1007/s11897-023-00642-w] [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] [Accepted: 12/29/2023] [Indexed: 01/16/2024]
Abstract
PURPOSE OF REVIEW Arrhythmias are common in patients with heart failure (HF) and are associated with a significant risk of mortality and morbidity. Optimal antiarrhythmic treatment is therefore essential. Here, we review current approaches to antiarrhythmic treatment in patients with HF. RECENT FINDINGS In atrial fibrillation, rhythm control and ventricular rate control are accepted therapeutic strategies. In recent years, clinical trials have demonstrated a prognostic benefit of early rhythm control strategies and AF catheter ablation, especially in patients with HF with reduced ejection fraction. Prevention of sudden cardiac death with ICD therapy is essential, but optimal risk stratification is challenging. For ventricular tachycardias, recent data support early consideration of catheter ablation. Antiarrhythmic drug therapy is an adjunctive therapy in symptomatic patients but has no prognostic benefit and well-recognized (proarrhythmic) adverse effects. Antiarrhythmic therapy in HF requires a systematic, multimodal approach, starting with guideline-directed medical therapy for HF and integrating pharmacological, device, and interventional therapy.
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Affiliation(s)
- Hilke Könemann
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany.
| | - Sati Güler-Eren
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Christian Ellermann
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Gerrit Frommeyer
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
| | - Lars Eckardt
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Münster, Germany
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Korthals D, Eckardt L. The new European Society of Cardiology guideline for the management of cardiomyopathies: key messages for cardiac electrophysiologists. Herzschrittmacherther Elektrophysiol 2023; 34:311-323. [PMID: 37973628 PMCID: PMC10682323 DOI: 10.1007/s00399-023-00975-y] [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] [Received: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 11/19/2023]
Abstract
Electrocardiographic findings and arrhythmias are common in cardiomyopathies. Both may be an early indication of a specific diagnosis or may occur due to myocardial fibrosis and/or reduced contractility. Brady- and tachyarrhythmias significantly contribute to increased morbidity and mortality in patients with cardiomyopathies. Antiarrhythmic therapy including risk stratification is often challenging and plays a major role for these patients. Thus, an "electrophysiological" perspective on guidelines on cardiomyopathies may be warranted. As the European Society of Cardiology (ESC) has recently published a new guideline for the management of cardiomyopathies, this overview aims to present key messages of these guidelines. Innovations include a new phenotype-based classification system with emphasis on a multimodal imaging approach for diagnosis and risk stratification. The guideline includes detailed chapters on dilated and hypertrophic cardiomyopathy and their phenocopies, arrhythmogenic right ventricular cardiomyopathy, and restrictive cardiomyopathy as well as syndromic and metabolic cardiomyopathies. Patient pathways guide clinicians from the initial presentation to diagnosis. The role of cardiovascular magnetic resonance imaging and genetic testing during diagnostic work-up is stressed. Concepts of rhythm and rate control for atrial fibrillation have led to new recommendations, and the role of defibrillator therapy in primary prevention is discussed in detail. Whilst providing general guidelines for management, the primary objective of the guideline is to ascertain the disease etiology and disease-specific, individualized management.
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Affiliation(s)
- Dennis Korthals
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Lars Eckardt
- Department of Cardiology II: Electrophysiology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
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Remme CA, Heijman J, Gomez AM, Zaza A, Odening KE. 25 years of basic and translational science in EP Europace: novel insights into arrhythmia mechanisms and therapeutic strategies. Europace 2023; 25:euad210. [PMID: 37622575 PMCID: PMC10450791 DOI: 10.1093/europace/euad210] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/19/2023] [Indexed: 08/26/2023] Open
Abstract
In the last 25 years, EP Europace has published more than 300 basic and translational science articles covering different arrhythmia types (ranging from atrial fibrillation to ventricular tachyarrhythmias), different diseases predisposing to arrhythmia formation (such as genetic arrhythmia disorders and heart failure), and different interventional and pharmacological anti-arrhythmic treatment strategies (ranging from pacing and defibrillation to different ablation approaches and novel drug-therapies). These studies have been conducted in cellular models, small and large animal models, and in the last couple of years increasingly in silico using computational approaches. In sum, these articles have contributed substantially to our pathophysiological understanding of arrhythmia mechanisms and treatment options; many of which have made their way into clinical applications. This review discusses a representative selection of EP Europace manuscripts covering the topics of pacing and ablation, atrial fibrillation, heart failure and pro-arrhythmic ventricular remodelling, ion channel (dys)function and pharmacology, inherited arrhythmia syndromes, and arrhythmogenic cardiomyopathies, highlighting some of the advances of the past 25 years. Given the increasingly recognized complexity and multidisciplinary nature of arrhythmogenesis and continued technological developments, basic and translational electrophysiological research is key advancing the field. EP Europace aims to further increase its contribution to the discovery of arrhythmia mechanisms and the implementation of mechanism-based precision therapy approaches in arrhythmia management.
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Affiliation(s)
- Carol Ann Remme
- Department of Experimental Cardiology, Amsterdam UMC location University of Amsterdam, Heart Centre, Academic Medical Center, Room K2-104.2, Meibergdreef 11, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure & Arrhythmias, Amsterdam, The Netherlands
| | - Jordi Heijman
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine and Life Sciences, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Ana M Gomez
- Signaling and Cardiovascular Pathophysiology, UMR-S 1180, Inserm, Université Paris-Saclay, 91400 Orsay, France
| | - Antonio Zaza
- Department of Biotechnology and Biosciences, University of Milano-Bicocca, 20126 Milan, Italy
| | - Katja E Odening
- Translational Cardiology, Department of Cardiology and Department of Physiology, Inselspital University Hospital Bern, University of Bern, 3012 Bern, Switzerland
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Bode N, Hochadel M, Andresen D, Zahn R, Spitzer SG, Brachmann J, Stellbrink C, Jung W, Gonska BD, Reinke F, Senges J, Eckardt L. Cardiac glycosides are not associated with increased mortality or hospitalization rates in ICD and CRT-ICD patients after adjustment for baseline-characteristics at one-year follow-up: Results from the German DEVICE registry. Int J Cardiol 2021; 338:109-114. [PMID: 34087337 DOI: 10.1016/j.ijcard.2021.05.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 05/23/2021] [Accepted: 05/26/2021] [Indexed: 12/28/2022]
Abstract
AIMS Despite lacking supporting randomized trials, cardiac glycosides (CGs) are widely used in heart failure and/or atrial fibrillation. Moreover, several pro- and retrospective studies and registry-data have recently raised serious concerns in terms of efficacy and safety of CGs in this field. We have therefore examined the association between CGs and clinical outcome of implantable cardioverter-defibrillator (ICD) and cardiac resynchronization (CRT-ICD) patients of the large German DEVICE registry. METHODS AND RESULTS Between 2007 and 2014, 3782 ICD and 1529 CRT-ICD patients were enrolled in the German DEVICE registry. Those two groups were analyzed independently according to medication with or without CGs. After adjustment for patient characteristics, CGs were not significantly associated with increased one-year mortality (HR 1.27, 95%-CI 0.91-1.76, p = 0.162), major adverse cardiac and cerebrovascular events (OR 1.36, 95%-CI 0.98-1.89, p = 0.063), ICD-shocks (OR 1.29, 95%-CI 0.95-1.74, p = 0.104) or the need for rehospitalization in ICD patients at one-year-follow-up. Similar findings were obtained in CRT-ICD patients. Regarding possible determinants for glycoside treatment, atrial fibrillation at enrollment was found to be most strongly associated with the prescription of glycosides in ICD (adjusted OR 3.25, 95%-CI 2.63-4.02) and CRT-ICD patients (adjusted OR 3.17, 95%-CI 2.39-4.19). CONCLUSION Overall harmful effects of CGs in ICD- and CRT-ICD patients could not be confirmed in DEVICE. Further large and randomized-controlled trials that investigate dose-dependent effects of CGs in addition to contemporary therapy of heart failure and atrial fibrillation are needed.
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Affiliation(s)
- Niklas Bode
- Clinic for Cardiology II - Electrophysiology, University Hospital Münster, Münster, Germany.
| | - Matthias Hochadel
- Stiftung Institut für Herzinfarktforschung (IHF), Ludwigshafen am Rhein, Germany
| | - Dietrich Andresen
- Department of Cardiology, Evangelisches Krankenhaus Hubertus, Berlin, Germany
| | - Ralf Zahn
- Department of Cardiology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Stefan G Spitzer
- Praxisklinik Herz und Gefäße, Dresden, Germany; Brandenburgische Technische Universität Cottbus-Senftenberg, Institut für Medizintechnologie, Senftenberg, Germany
| | | | | | - Werner Jung
- Department of Cardiology, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | | | - Florian Reinke
- Clinic for Cardiology II - Electrophysiology, University Hospital Münster, Münster, Germany
| | - Jochen Senges
- Stiftung Institut für Herzinfarktforschung (IHF), Ludwigshafen am Rhein, Germany
| | - Lars Eckardt
- Clinic for Cardiology II - Electrophysiology, University Hospital Münster, Münster, Germany
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Frommeyer G, Wolfes J, Ellermann C, Kochhäuser S, Dechering DG, Eckardt L. Acute electrophysiologic effects of the polyphenols resveratrol and piceatannol in rabbit atria. Clin Exp Pharmacol Physiol 2020; 46:94-98. [PMID: 29956844 DOI: 10.1111/1440-1681.13005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 06/26/2018] [Accepted: 06/27/2018] [Indexed: 11/28/2022]
Abstract
The natural polyphenol resveratrol and its analogue piceatannol have various beneficial effects including antiarrhythmic properties. The aim of the present study was to examine potential electrophysiologic effects in an experimental whole-heart model of atrial fibrillation (AF). Simultaneous infusion of resveratrol (50 μmol/L) or piceatannol (10 μmol/L) in rabbit hearts resulted in an increase in atrial refractory period. Both agents induced a significant slowing of atrial conduction and of intrinsic heart rate. In both groups, a trend toward a reduction in AF and a regularization of AF was observed.
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Affiliation(s)
- Gerrit Frommeyer
- Clinic for Cardiology II - Electrophysiology, University Hospital of Münster, Münster, Germany
| | - Julian Wolfes
- Clinic for Cardiology II - Electrophysiology, University Hospital of Münster, Münster, Germany
| | - Christian Ellermann
- Clinic for Cardiology II - Electrophysiology, University Hospital of Münster, Münster, Germany
| | - Simon Kochhäuser
- Clinic for Cardiology II - Electrophysiology, University Hospital of Münster, Münster, Germany
| | - Dirk G Dechering
- Clinic for Cardiology II - Electrophysiology, University Hospital of Münster, Münster, Germany
| | - Lars Eckardt
- Clinic for Cardiology II - Electrophysiology, University Hospital of Münster, Münster, Germany
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Digitalis therapy is associated with higher comorbidities and poorer prognosis in patients undergoing ablation of atrial arrhythmias: data from the German Ablation Registry. Clin Res Cardiol 2019; 108:1083-1092. [PMID: 30798346 DOI: 10.1007/s00392-019-01442-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 02/18/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Digitalis glycosides are employed for rate control of atrial fibrillation. Recent studies suggested potential harmful effects of digitalis monotherapy and combination with antiarrhythmic drugs. The aim of the present study was to assess the prevalence and potential impact of digitalis therapy on outcome in patients undergoing catheter ablation of supraventricular arrhythmias. METHODS AND RESULTS The German Ablation Registry is a nationwide, prospective registry with a 1-year follow-up investigating 12,566 patients receiving catheter ablations of supraventricular arrhythmias in 52 German centres. The present analysis focussed on pharmacotherapy in 8608 patients undergoing catheter ablation of atrial tachycardia, atrial fibrillation, or atrial flutter. Patients receiving digitalis therapy (n = 417) were older and presented a significantly increased prevalence of comorbidities including coronary artery disease, heart failure, diabetes, and pulmonary disease. One-year mortality was significantly higher in digitalis-treated patients (4.7% vs. 1.3%, p < 0.001), most strikingly in patients undergoing ablation of atrial flutter. This effect was maintained after adjustment for important risk factors. Similar results were obtained for as the combined endpoint of death, myocardial infarction, stroke and major bleeding (6.6% vs. 2.7%, p < 0.001), and non-fatal rehospitalisations (54.1% vs. 45.1%, p = 0.001). CONCLUSION In the present study of patients undergoing catheter ablation of supraventricular arrhythmias, an association of digitalis therapy with increased mortality and an increased rate of other severe adverse events were observed. The results from this 'real-life' registry are consistent with previously published studies. However, whether digitalis therapy promotes a poorer prognosis or may just serve as a marker for this aspect cannot be thoroughly interpreted.
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Ellermann C, Wolfes J, Puckhaber D, Bögeholz N, Leitz P, Lange PS, Eckardt L, Frommeyer G. Digitalis Promotes Ventricular Arrhythmias in Flecainide- and Ranolazine-Pretreated Hearts. Cardiovasc Toxicol 2018; 19:237-243. [DOI: 10.1007/s12012-018-9494-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Abstract
The history of digitalis is rich and interesting, with the first use usually attributed to William Withering and his study on the foxglove published in 1785. However, some knowledge of plants with digitalis-like effects used for congestive heart failure (CHF) was in evidence as early as Roman times. The active components of the foxglove (Digitalis purpurea and Digitalis lanata) are classified as cardiac glycosides or cardiotonic steroids and include the well-known digitalis leaf, digitoxin, and digoxin; ouabain is a rapid-acting glycoside usually obtained from Strophanthus gratus. These drugs are potent inhibitors of cellular membrane sodium-potassium adenosine triphosphatase (Na+/K+-ATPase). For most of the twentieth century, digitalis and its derivatives, especially digoxin, were the available standard of care for CHF. However, as the century closed, many doubts, especially regarding safety, were raised about their use as other treatments for CHF, such as decreasing the preload of the left ventricle, were developed. Careful attention is needed to maintain the serum digoxin level at ≤ 1.0 ng/ml because of the very narrow therapeutic window of the medication. Evidence for benefit exists for CHF with reduced ejection fraction (EF), also referred to as heart failure with reduced EF (HFrEF), especially when considering the combination of mortality, morbidity, and decreased hospitalizations. However, the major support for using digoxin is in atrial fibrillation (AF) with a rapid ventricular response when a rate control approach is planned. The strongest support of all for digoxin is for its use in rate control in AF in the presence of a marginal blood pressure, since all other rate control medications contribute to additional hypotension. In summary, these days, digoxin appears to be of most use in HFrEF and in AF with rapid ventricular response for rate control, especially when associated with hypotension. The valuable history of the foxglove continues; it has been modified but not relegated to the garden or the medical history book, as some would advocate.
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The anti-influenza drug oseltamivir reduces atrial fibrillation in an experimental whole-heart model. Naunyn Schmiedebergs Arch Pharmacol 2017; 390:1155-1161. [PMID: 28780600 DOI: 10.1007/s00210-017-1415-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 08/01/2017] [Indexed: 10/19/2022]
Abstract
Recent experimental studies suggested direct effects of the anti-influenza drug oseltamivir on cardiac electrophysiology. We therefore aimed at analyzing potential antiarrhythmic effects of oseltamivir on atrial fibrillation (AF) in an experimental whole-heart model. Twelve rabbit hearts were isolated and Langendorff perfused. Thereafter, hearts were paced at cycle lengths of 350, 250, and 200 ms in the atrium. A standardized protocol employing atrial burst pacing induced AF in 4 of 12 hearts under baseline conditions (33%, 11 episodes). Subsequently, a combination of acetylcholine (1 μM) and isoproterenol (1 μM) was administered to increase AF occurrence. Two monophasic action potential recordings on the left and two on the right atrial epicardium displayed a decrease of atrial action potential duration (aAPD, -38 ms, p < 0.01) and atrial effective refractory period (aERP; -20 ms, p < 0.05). Under the influence of acetylcholine/isoproterenol AF was inducible in 8 of 12 hearts (66%; 69 episodes). Additional infusion of oseltamivir (100 μM) resulted in a significant increase of both aAPD (+ 29 ms, p < 0.05) and aERP (+ 40 ms, p < 0.01) leading to an increase of atrial post-repolarization refractoriness (aPRR). Under the influence of oseltamivir only 3 of 12 hearts (25%, 8 episodes) remained inducible. In six additional hearts oseltamivir (50 μM and 100 μM) did not significantly alter ventricular APD, QRS duration and QT interval but induced a significant increase of ventricular ERP. In the present experimental study, acute infusion of the anti-influenza drug oseltamivir reduced atrial fibrillation. The antiarrhythmic effect can be explained by a significant increase in aERP and aPRR. These results suggest an antiarrhythmic potential of oseltamivir in atrial arrhythmias.
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Frommeyer G, Weller J, Ellermann C, Bögeholz N, Leitz P, Dechering DG, Kochhäuser S, Wasmer K, Eckardt L. Ivabradine Reduces Digitalis-induced Ventricular Arrhythmias. Basic Clin Pharmacol Toxicol 2017. [PMID: 28627809 DOI: 10.1111/bcpt.12829] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The I(f) channel inhibitor ivabradine is recommended for treatment of heart failure but also affects potassium currents and thereby prolongs ventricular repolarization. The aim of this study was to examine the electrophysiological effects of ivabradine on digitalis-induced ventricular arrhythmias. Thirteen rabbit hearts were isolated and Langendorff-perfused. After obtaining baseline data, the digitalis glycoside ouabain was infused (0.2 μM). Monophasic action potentials and ECG showed a significant abbreviation of QT interval (-34 ms, p < 0.05) and action potential duration (APD90 ; -27 ms, p < 0.05). The shortening of ventricular repolarization was accompanied by a reduction in effective refractory period (ERP; -27 ms, p < 0.05). Thereafter, hearts were additionally treated with ivabradine (5 μM). Of note, this did not exert significant effects on QT interval (-4 ms, p = ns) or APD90 (-15 ms, p = ns) but resulted in an increase in ERP (+17 ms, p < 0.05). This led to a significant increase in post-repolarization refractoriness (PRR, +32 ms, p < 0.01) as compared with sole ouabain treatment. Under baseline conditions, ventricular fibrillation (VF) was inducible by a standardized pacing protocol including programmed stimulation and burst stimulation in four of 13 hearts (31%; 15 episodes). After application of 0.2 μM ouabain, eight of 13 hearts were inducible (62%, 49 episodes). Additional infusion of 5 μM ivabradine led to a significant suppression of VF. Only four episodes could be induced in two of 13 hearts (15%). In this study, ivabradine reduced digitalis-induced ventricular arrhythmias. Ivabradine did not affect ventricular repolarization in the presence of digitalis treatment but demonstrated potent anti-arrhythmic properties based on an increase in both ERP and PRR. The study further characterizes the beneficial electrophysiological profile of ivabradine.
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Affiliation(s)
- Gerrit Frommeyer
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | - Jan Weller
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | - Christian Ellermann
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | - Nils Bögeholz
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | - Patrick Leitz
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | - Dirk G Dechering
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | - Simon Kochhäuser
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | - Kristina Wasmer
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | - Lars Eckardt
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
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Frommeyer G, Sterneberg M, Dechering DG, Ellermann C, Bögeholz N, Kochhäuser S, Pott C, Fehr M, Eckardt L. Effective suppression of atrial fibrillation by ivabradine: Novel target for an established drug? Int J Cardiol 2017; 236:237-243. [DOI: 10.1016/j.ijcard.2017.02.055] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/25/2017] [Accepted: 02/15/2017] [Indexed: 12/28/2022]
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Eckardt L, Deneke T, Diener HC, Hindricks G, Hoffmeister HM, Hohnloser SH, Kirchhof P, Stellbrink C. Kommentar zu den 2016 Leitlinien der Europäischen Gesellschaft für Kardiologie (ESC) zum Management von Vorhofflimmern. KARDIOLOGE 2017. [DOI: 10.1007/s12181-017-0141-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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14
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Frommeyer G, Sterneberg M, Dechering DG, Kaese S, Bögeholz N, Pott C, Fehr M, Bogossian H, Milberg P, Eckardt L. Effective suppression of atrial fibrillation by the antihistaminic agent antazoline: First experimental insights into a novel antiarrhythmic agent. Cardiovasc Ther 2017; 35. [PMID: 28039911 DOI: 10.1111/1755-5922.12244] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The antihistaminic antazoline (ANT) was reported to be highly effective and safe for rapid conversion of atrial fibrillation (AF). We therefore analyzed underlying mechanisms in an experimental whole-heart model. METHODS AND RESULTS Isolated and retrogradely perfused rabbit hearts underwent a standardized protocol employing atrial burst pacing-induced AF in five of 20 hearts under baseline conditions (seven episodes). Thereafter, a combination of acetylcholine and isoproterenol was employed to enhance AF occurrence. Two monophasic action potential recordings on the left- and two on the right atrial epicardium showed a decrease in atrial action potential duration (aAPD, -25 msec, P<.05) and atrial effective refractory period (aERP; -52 msec, P<.01) after infusion of acetylcholine (1 μmol/L) and isoproterenol (1 μmol/L). This led to induction of AF in 14 of 20 hearts (145 episodes). Simultaneous infusion of ANT (20 μmol/L) led to a complete suppression of AF in all inducible hearts. Treatment with ANT also led to a significant increase in aAPD (+41 msec, P<.01) and aERP (+74 msec, P<.05), leading to a marked increase in atrial postrepolarization refractoriness (aPRR, +33 msec, P<.01). Results were compared to 13 rabbits treated with flecainide. Flecainide induced a significant increase in aPRR and resulted in induction of AF in seven of 13 hearts (51 episodes) while 11 of 13 hearts were inducible with acetylcholine and isoproterenol (93 episodes). CONCLUSION Administration of ANT was highly effective in suppressing AF. The antiarrhythmic effect could be explained by a significant increase in postrepolarization refractoriness as a result of a more marked increase in aERP as compared with aAPD.
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Affiliation(s)
- Gerrit Frommeyer
- Division of Clinical and Experimental Electrophysiology, Department of Cardiology and Angiology, University Hospital of Münster, Münster, Germany
| | - Magdalena Sterneberg
- Division of Clinical and Experimental Electrophysiology, Department of Cardiology and Angiology, University Hospital of Münster, Münster, Germany
| | - Dirk G Dechering
- Division of Clinical and Experimental Electrophysiology, Department of Cardiology and Angiology, University Hospital of Münster, Münster, Germany
| | - Sven Kaese
- Division of Clinical and Experimental Electrophysiology, Department of Cardiology and Angiology, University Hospital of Münster, Münster, Germany
| | - Nils Bögeholz
- Division of Clinical and Experimental Electrophysiology, Department of Cardiology and Angiology, University Hospital of Münster, Münster, Germany
| | - Christian Pott
- Division of Clinical and Experimental Electrophysiology, Department of Cardiology and Angiology, University Hospital of Münster, Münster, Germany
| | - Michael Fehr
- Clinic of Exotic Pets, Reptiles, Exotic and Feral Birds, University of Hanover, Hanover, Germany
| | - Harilaos Bogossian
- Märkische Kliniken GmbH, Department of Cardiology and Angiology, Klinikum Lüdenscheid, University of Witten-Herdecke, Witten, Germany
| | - Peter Milberg
- Division of Clinical and Experimental Electrophysiology, Department of Cardiology and Angiology, University Hospital of Münster, Münster, Germany
| | - Lars Eckardt
- Division of Clinical and Experimental Electrophysiology, Department of Cardiology and Angiology, University Hospital of Münster, Münster, Germany
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15
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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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16
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Abstract
Dronedarone is the newest antiarrhythmic drug approved for the maintenance of sinus rhythm in patients with nonpermanent atrial fibrillation (AF). It is a multi-channel blocker with diverse electrophysiologic properties. Dronedarone decreases the incidence of AF recurrence and the ventricular rate during recurrence. Dronedarone decreases rates of cardiovascular hospitalizations in patients with paroxysmal and persistent AF. Dronedarone increases mortality in patients with permanent AF and those with moderate-severe heart failure, and should thus be avoided in these populations. Dronedarone is less effective than amiodarone but also has less toxicity. Direct comparison with other antiarrhythmic drugs is not available.
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Affiliation(s)
- Rafik Tadros
- Department of Medicine, Université de Montréal and Montreal Heart Institute, 5000 Rue Belanger, Montreal, Québec H1T 1C8, Canada
| | - Stanley Nattel
- Department of Medicine, Université de Montréal and Montreal Heart Institute, 5000 Rue Belanger, Montreal, Québec H1T 1C8, Canada
| | - Jason G Andrade
- Department of Medicine, Université de Montréal and Montreal Heart Institute, 5000 Rue Belanger, Montreal, Québec H1T 1C8, Canada; Heart Rhythm Services, Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada.
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17
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Malik M. Drug-Induced QT/QTc Interval Shortening: Lessons from Drug-Induced QT/QTc Prolongation. Drug Saf 2016; 39:647-59. [DOI: 10.1007/s40264-016-0411-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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18
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Frommeyer G, Eckardt L. Drug-induced proarrhythmia: risk factors and electrophysiological mechanisms. Nat Rev Cardiol 2015; 13:36-47. [PMID: 26194552 DOI: 10.1038/nrcardio.2015.110] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Drug-induced ventricular tachyarrhythmias can be caused by cardiovascular drugs, noncardiovascular drugs, and even nonprescription agents. They can result in arrhythmic emergencies and sudden cardiac death. If a new arrhythmia or aggravation of an existing arrhythmia develops during therapy with a drug at a concentration usually considered not to be toxic, the situation can be defined as proarrhythmia. Various cardiovascular and noncardiovascular drugs can increase the occurrence of polymorphic ventricular tachycardia of the 'torsade de pointes' type. Antiarrhythmic drugs, antimicrobial agents, and antipsychotic and antidepressant drugs are the most important groups. Age, female sex, and structural heart disease are important risk factors for the occurrence of torsade de pointes. Genetic predisposition and individual pharmacodynamic and pharmacokinetic sensitivity also have important roles in the generation of arrhythmias. An increase in spatial or temporal dispersion of repolarization and a triangular action-potential configuration have been identified as crucial predictors of proarrhythmia in experimental models. These studies emphasized that sole consideration of the QT interval is not sufficient to assess the proarrhythmic risk. In this Review, we focus on important triggers of proarrhythmia and the underlying electrophysiological mechanisms that can enhance or prevent the development of torsade de pointes.
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Affiliation(s)
- Gerrit Frommeyer
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Albert-Schweitzer Strasse 33, D-48149 Münster, Germany
| | - Lars Eckardt
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Albert-Schweitzer Strasse 33, D-48149 Münster, Germany
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