Effects on rabbit cardiac potentials of aprindine and indecainide, a new antiarrhythmic agent, in normoxia and hypoxia

Profiles of aprindine, cibenzoline, pilsicainide and pirmenol in the framework of the Sicilian Gambit. The Guideline Committee for Clinical Use of Antiarrhythmic Drugs in Japan (Working Group of Arrhythmias of the Japanese Society of Electrocardiology)

The Vaughan Williams classification has been used widely by clinicians, cardiologists and researchers engaged in antiarrhythmic drug development and testing in many countries throughout the world since its initial proposal in the early 1970s. However, a major criticism of the Vaughan Williams system arose from the extent to which the categorization of drugs into classes I-IV led to oversimplified views of both shared and divergent actions. The Sicilian Gambit proposed a two-dimensional tabular framework for display of drug actions to solve these problems. From April to December 1996, members of the Guideline Committee met to discuss pharmacologic profiles of 4 antiarrhythmic drugs (aprindine, cibenzoline, pilsicainide, and pirmenol) that were not included in the original spreadsheet but are used widely in clinical practice in Japan. The discussion aimed to fit the drug profiles into the Gambit framework based on all the important literature published to date regarding the actions of the 4 drugs. This report is a summary of that deliberation.

Effects of hypoxia on the use-dependent inhibition of conduction velocity induced by cibenzoline in guinea pig ventricular myocardium

The use-dependent effects of cibenzoline, a new anti-arrhythmic drug, on the maximal rate of rise (Vmax) of the action potential and on conduction velocity, and their corresponding recovery kinetics were studied in isolated papillary muscles of guinea pigs under normal and hypoxic conditions. Standard microelectrode techniques were applied to monitor the action potential of the muscles and their conduction. Under control conditions, the amount of use-dependent block of Vmax, conduction velocity, and square of conduction velocity, induced by 10 mumol/L cibenzoline were 26.5 +/- 3.9, 13.8 +/- 1.4, and 25.6 +/- 2.4%, respectively; under hypoxic conditions, these values increased to 32.3 +/- 4.8, 19.7 +/- 1.2, and 35.5 +/- 2.0%, respectively. In the presence of 10 mumol/L cibenzoline, the mean values of time constants for the onset of the use-dependent inhibition of Vmax, conduction velocity, and the square of conduction velocity, during a 2-Hz stimulation, were 3.65 +/- 0.27, 2.77 +/- 0.33, and 2.56 +/- 0.26 seconds, respectively. Under hypoxic conditions, these values changed to 5.10 +/- 0.96, 3.05 +/- 0.44, and 2.84 +/- 0.39 seconds, respectively. The recovery time constants averaged 14.72 +/- 4.08 seconds (for Vmax), 22.23 +/- 3.78 seconds (for conduction velocity), and 23.17 +/- 13.38 seconds (for the square of conduction velocity) in the presence of 10 mumol/L cibenzoline, and 17.19 +/- 8.59 seconds (for Vmax), 15.77 +/- 2.37 seconds (for conduction velocity), and 16.82 +/- 2.61 seconds (for the square of conduction velocity) under hypoxic conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

Antiarrhythmic and hemodynamic evaluation of indecainide and procainamide in nonsustained ventricular tachycardia

The present trial was a placebo-controlled, randomized, parallel study comparing indecainide to procainamide. A 24-hour intravenous phase measured and compared invasive hemodynamics, followed by oral administration for assessment of arrhythmia suppression. Thirty-two patients (mean age 61 years) with asymptomatic or mildly symptomatic nonsustained ventricular tachycardia (VT) were evaluated, 15 while receiving indecainide and 17 while receiving procainamide. A total of 8 patients had serious toxicity during the intravenous phase; 6 receiving indecainide experienced increased left ventricular dysfunction or worsening arrhythmia (sustained VT, arrhythmic death) while 2 receiving procainamide developed serious hypotension. Proarrhythmia developed in 3 of 15 (20%) of the indecainide patients, but in no procainamide patient. In those tolerating indecainide, long-term suppression of ventricular premature complexes (VPCs) and of runs of VT was more consistent than with procainamide. While indecainide was a potent suppressor of spontaneous VPCs and VT, patients with significant left ventricular dysfunction could not tolerate it. The indecainide patients developing serious toxicity had a common hemodynamic profile: ejection fraction less than 25%, elevated left ventricular filling pressures, low cardiac and stroke volume index and minimal cardiac reserve. Indecainide has a poor risk-benefit ratio in patients similar to the current population, who have potentially lethal ventricular arrhythmias and severe left ventricular dysfunction.

Indecainide for treatment of ventricular ectopic depolarizations: efficacy, pharmacokinetics, hemodynamic effects and safety

Ten patients were treated with oral indecainide for frequent ventricular ectopic depolarizations during a short-term, dose-ranging, single blind inpatient trial followed by open label long-term therapy for 2 years. During dose ranging, patients received placebo followed by 50, 75 and 100 mg of indecainide three times daily. Eight of the 10 patients achieved greater than or equal to 80% reduction in ventricular ectopic depolarizations during inpatient therapy. Mean ventricular ectopic depolarizations decreased from 15,792/24 h to 2,357/24 h on optimal dosage (p less than 0.01). Nine patients had paired ventricular ectopic depolarizations; four of the nine had greater than or equal to 99% reduction of these beats. Among seven patients with nonsustained ventricular tachycardia, five had 100% elimination of these events with indecainide and all had greater than or equal to 90% reduction in these events. Indecainide prolonged the PR interval 44 +/- 27 ms (p less than 0.0001) and the QRS interval 11 +/- 9 ms (p less than 0.0001) from baseline without prolongation of the QTc or JTc interval. The mean trough plasma level of indecainide on optimal dosage was 409 +/- 173 ng/ml and the mean plasma elimination half-life was 10.3 +/- 2.3 h (range 7.1 to 14.2). No adverse hemodynamic effects of indecainide were detected. Side effects during short-term therapy were mild and did not require discontinuation of the drug. Efficacy was maintained for some patients during long-term therapy for 2 years, although five patients discontinued therapy because of loss of efficacy or side effects. Indecainide is a highly effective and well tolerated antiarrhythmic drug for suppression of frequent and repetitive ventricular ectopic depolarizations.

Noninvasive evaluation of indecainide for serious ventricular tachyarrhythmia

Indecainide, a new class 1C agent, was administered to 16 patients with a history of ventricular fibrillation or ventricular tachycardia. Evaluation of drug effect consisted of acute testing with 125 mg followed by a period of maintenance therapy. Efficacy, as evaluated with both ambulatory monitoring and exercise testing, was defined as total elimination of runs of ventricular tachycardia, greater than 90% reduction in couplets and greater than 50% decrease in ventricular premature complex. During acute drug testing 9 of the 16 patients responded to the drug. Four patients did not receive maintenance therapy with indecainide, because of toxic side effects. Of the remaining 12 patients, 7 responded to indecainide based on monitoring, 5 responded judged by exercise testing and 4 when both monitoring and exercise testing were considered. There was no correlation between dose, blood level of drug and effect on arrhythmia. In this small group acute drug testing did not appear to predict the response to the drug during maintenance therapy. Neurologic side effects were reported by 5 patients. Aggravation of arrhythmia occurred in 5 patients, 3 of whom had this complication during acute drug testing and 2 during maintenance therapy. Left ventricular ejection fraction, measured before and during therapy, decreased from an average of 43% to 35% (p less than 0.005). A reduction was observed irrespective of baseline left ventricular function. Indecainide is an effective antiarrhythmic agent in a small number of highly selected patients with serious ventricular arrhythmia, but potentially serious side effects limit its usefulness.

Indecainide compared with quinidine for chronic stable ventricular arrhythmias secondary to coronary artery disease or to cardiomyopathy

Indecainide, a new type Ic antiarrhythmic agent, and quinidine sulfate were compared in a randomized double-blind parallel study. Cardiac patients with greater than or equal to 30 ventricular premature complexes per hour hour received indecainide, 50 mg, or quinidine, 200 mg every 6 hours, and the doses were increased until more than 80% suppression was noted, adverse effects occurred or a maximal dose of 100 mg of indecainide or 400 mg of quinidine given every 6 hours. Efficacy was achieved in 8 of 10 taking indecainide (p less than 0.05) and 7 of 9 taking quinidine (p less than 0.05). At least 90% of episodes of ventricular tachycardia were suppressed in 4 of 7 patients taking indecainide and 1 of 4 taking quinidine. No adverse effects were observed in the 7 patients who responded to indecainide and the 4 who responded quinidine, resulting in short-term efficacy without adverse effects in 7 patients (70%) taking indecainide and 4 (44%) taking quinidine. The effective or maximal mean daily indecainide and quinidine doses were 190 +/- 32 mg and 1,022 +/- 291 mg, respectively; mean trough indecainide and quinidine concentrations were 617 +/- 247 ng/ml and 3.3 +/- 1.4 micrograms/ml, respectively. Indecainide prolonged mean PR and QRS intervals (p less than 0.05), but not QT and QTc intervals. Quinidine did not change PR or QRS intervals but prolonged QTc interval (p less than 0.05). During dosing, 1 patient discontinued indecainide treatment because of nausea; 3 discontinued quinidine because of gastrointestinal complaints.(ABSTRACT TRUNCATED AT 250 WORDS)