Antiarrhythmic drugs: from mechanisms to clinical practice

A Narrative Review of Drug Therapy in Adult and Pediatric Cardiac Arrest

Drugs are used during cardiopulmonary resuscitation (CPR) in association with chest compressions and ventilation. The main purpose of drugs during resuscitation is either to improve coronary perfusion pressure and myocardial perfusion in order to achieve return of spontaneous circulation (ROSC). The aim of this up-to-date review is to provide an overview of the main drugs used during cardiac arrest (CA), highlighting their historical context, pharmacology, and the data to support them. Epinephrine remains the only recommended vasopressor. Regardless of the controversy about optimal dosage and interval between doses in recent papers, epinephrine should be administered as early as possible to be the most effective in non-shockable rhythms. Despite inconsistent survival outcomes, amiodarone and lidocaine are the only two recommended antiarrhythmics to treat shockable rhythms after defibrillation. Beta-blockers have also been recently evaluated as antiarrhythmic drugs and show promising results but further evaluation is needed. Calcium, sodium bicarbonate, and magnesium are still widely used during resuscitation but have shown no benefit. Available data may even suggest a harmful effect and they are no longer recommended during routine CPR. In experimental studies, sodium nitroprusside showed an increase in survival and favorable neurological outcome when combined with enhanced CPR, but as of today, no clinical data is available. Finally, we review drug administration in pediatric CA. Epinephrine is recommended in pediatric CA and, although they have not shown any improvement in survival or neurological outcome, antiarrhythmic drugs have a 2b recommendation in the current guidelines for shockable rhythms.

Synthesis and Antibacterial Activity of New Azole, Diazole and Triazole Derivatives Based on p-Aminobenzoic Acid

The p-aminobenzoic acid was applied for the synthesis of substituted 1-phenyl-5-oxopyrrolidine derivatives containing benzimidazole, azole, oxadiazole, triazole, dihydrazone, and dithiosemicarbazide moieties in the structure. All the obtained compounds were evaluated for their in vitro antimicrobial activity against Staphylococcus aureus, Bacillus cereus, Listeria monocytogenes, Salmonella enteritidis, Escherichia coli, and Pseudomonas aeruginosa by using MIC and MBC assays. This study showed a good bactericidal activity of γ-amino acid and benzimidazoles derivatives. The antimicrobial activity of the most promising compounds was higher than ampicillin. Furthermore, two benzimidazoles demonstrated good antimicrobial activity against L. monocytogenes (MIC 15.62 µg/mL) that was four times more potent than ampicillin (MIC 65 µg/mL). Further studies are needed to better understand the mechanism of the antimicrobial activity as well as to generate antimicrobial compounds based on the 1-phenyl-5-oxopyrrolidine scaffold.

Stress-Activated Kinase Mitogen-Activated Kinase Kinase-7 Governs Epigenetics of Cardiac Repolarization for Arrhythmia Prevention

BACKGROUND

Ventricular arrhythmia is a leading cause of cardiac mortality. Most antiarrhythmics present paradoxical proarrhythmic side effects, culminating in a greater risk of sudden death.

METHODS

We describe a new regulatory mechanism linking mitogen-activated kinase kinase-7 deficiency with increased arrhythmia vulnerability in hypertrophied and failing hearts using mouse models harboring mitogen-activated kinase kinase-7 knockout or overexpression. The human relevance of this arrhythmogenic mechanism is evaluated in human-induced pluripotent stem cell-derived cardiomyocytes. Therapeutic potentials by targeting this mechanism are explored in the mouse models and human-induced pluripotent stem cell-derived cardiomyocytes.

RESULTS

Mechanistically, hypertrophic stress dampens expression and phosphorylation of mitogen-activated kinase kinase-7. Such mitogen-activated kinase kinase-7 deficiency leaves histone deacetylase-2 unphosphorylated and filamin-A accumulated in the nucleus to form a complex with Krüppel-like factor-4. This complex leads to Krüppel-like factor-4 disassociation from the promoter regions of multiple key potassium channel genes (Kv4.2, KChIP2, Kv1.5, ERG1, and Kir6.2) and reduction of their transcript levels. Consequent repolarization delays result in ventricular arrhythmias. Therapeutically, targeting the repressive function of the Krüppel-like factor-4/histone deacetylase-2/filamin-A complex with the histone deacetylase-2 inhibitor valproic acid restores K⁺ channel expression and alleviates ventricular arrhythmias in pathologically remodeled hearts.

CONCLUSIONS

Our findings unveil this new gene regulatory avenue as a new antiarrhythmic target where repurposing of the antiepileptic drug valproic acid as an antiarrhythmic is supported.

Arrhythmias in Cardiac Critical Care

OBJECTIVES

Here, we characterize the frequency, mechanisms, clinical impact, and potential treatment options for several arrhythmias commonly encountered in pediatric cardiac critical care.

DATA SOURCE

MEDLINE and PubMed.

CONCLUSIONS

Arrhythmias among children in the cardiac critical care setting are common and clinically important, associated independently with prolonged mechanical ventilation, critical care unit stay, and an increase in mortality. The precise characterization of an arrhythmia may provide clues as to an underlying mechanism as well as serve to guide treatment. Arrhythmia therapy, pharmacologic or otherwise, is directed toward addressing the underlying mechanism, and as such may be applicable to the treatment of more than one specific rhythm disturbance. Decisions concerning therapy must call into consideration an arrhythmia's underlying etiology, mechanism, and associated hemodynamic embarrassment, along with the potential for adverse effects of treatment.

Cellular and Molecular Mechanisms of Arrhythmia by Oxidative Stress

Current therapies for arrhythmia using ion channel blockade, catheter ablation, or an implantable cardioverter defibrillator have limitations, and it is important to search for new antiarrhythmic therapeutic targets. Both atrial fibrillation and heart failure, a condition with increased arrhythmic risk, are associated with excess amount of reactive oxygen species (ROS). There are several possible ways for ROS to induce arrhythmia. ROS can cause focal activity and reentry. ROS alter multiple cardiac ionic currents. ROS promote cardiac fibrosis and impair gap junction function, resulting in reduced myocyte coupling and facilitation of reentry. In order to design effective antioxidant drugs for treatment of arrhythmia, it is essential to explore the molecular mechanisms by which ROS exert these arrhythmic effects. Activation of Ca(2+)/CaM-dependent kinase II, c-Src tyrosine kinase, protein kinase C, and abnormal splicing of cardiac sodium channels are among the recently discovered molecular mechanisms of ROS-induced arrhythmia.

Effects of astragaloside IV on action potentials and ionic currents in guinea-pig ventricular myocytes

Astragaloside IV (AS-IV) is one of the main active constituents of Astragalus membranaceus, which has various actions on the cardiovascular system. However, its electrophysiological mechanisms are not clear. In the present study, we investigated the effects of AS-IV on action potentials and membrane currents using the whole-cell patch clamp technique in isolated guinea-pig ventricular myocytes. AS-IV prolonged the action potential duration (APD) at all three tested concentrations. The peak effect was achieved with 1×10(-6) M, at which concentration AS-IV significantly prolonged the APD at 95% repolarization from 313.1±38.9 to 785.3±83.7 ms. AS-IV at 1×10(-6) M also enhanced the inward rectifier K(+) currents (I(K1)) and inhibited the delayed rectifier K(+) currents (I(K)). AS-IV (1×10(-6) M) strongly depressed the peak of voltage-dependent Ca(2+) channel current (I(CaL)) from -607.3±37.5 to -321.1±38.3 pA. However, AS-IV was not found to affect the Na(+) currents. Taken together, AS-IV prolonged APD of guinea-pig ventricular myocytes, which might be explained by its inhibition of I(K). AS-IV also influences Ca(2+) signaling through suppressing ICaL.

Improved oral bioavailability of BCS class 2 compounds by self nano-emulsifying drug delivery systems (SNEDDS): the underlying mechanisms for amiodarone and talinolol

PURPOSE

Superior bioavailability of BCS Class 2 compounds incorporated into SNEDDS was previously reported. This study aims to elucidate the underlying mechanisms accountable for this phenomenon.

METHODS

SNEDDS of amiodarone (AM) and talinolol were developed. Pharmacokinetic parameters were assessed in vivo. Effect on intestinal permeability, P-gp efflux and toxicity was evaluated in vitro (Caco-2) and ex vivo (Ussing). Solubilization was assessed in vitro (Dynamic Lipolysis Model). Effect on intraenterocyte metabolism was evaluated using CYP3A4 microsomes.

RESULTS

Oral administration of AM-SNEDDS and talinolol-SNEDDS resulted in higher and less variable AUC and Cmax. In vitro, higher talinolol-SNEDDS Papp indicated Pgp inhibition. Lipolysis of AM-SNEDDS resulted in higher AM concentration in the fraction available for absorption. Incubation of AM-SNEDDS with CYP3A4 indicated CYP inhibition. SNEDDS didn't alter mannitol Papp and TEER. SNEDDS effect was transient.

CONCLUSIONS

Multiple mechanisms are accountable for improved bioavailability and reduced variability of Class-2 compounds by SNEDDS: increased solubilization, reduced intraenterocyte metabolism and reduced P-gp efflux. SNEDDS effect is reversible and doesn't cause intestinal tissue or cell damage. These comprehensive findings can be used for intelligent selection of drugs for which oral bioavailability will improve upon incorporation into SNEDDS, based on recognition of the drug's absorption barriers and the ability of SNEDDS to overcome them.

Gene and cell therapies for the failing heart to prevent sudden arrhythmic death

Current therapies for treatment and prevention of sudden cardiac death have certain limitations, and a search for new therapeutic approaches is desirable to reduce the burden of sudden arrhythmic death. Gene therapy and stem cell therapy have been investigated as new, valuable tools in treating cardiac diseases such as arrhythmias. In this review, the basics of each modality, important related experimental and clinical studies, and potential advantages and limitations of these treatments will be discussed. The future success of gene and cell therapy to become practical clinical tools greatly depends on our understanding of the mechanisms of ventricular arrhythmia and the mechanisms of action of gene and cell therapy.

Invited commentary: sex-steroid hormones and QT-interval duration

In this issue of the Journal, Zhang et al. (Am J Epidemiol. 2011;174(4):403-411) make a substantial contribution to research in the area of hormonal influences on cardiac repolarization by demonstrating an inverse association between testosterone levels and the Bazett's adjusted QT interval (QTc) and RR-adjusted QT interval in men but not in postmenopausal women. They suggest that testosterone levels might explain the difference in QTc-interval duration between men and women and could contribute to population variability in QTc-interval duration among men. In this commentary, the gender difference and the role of testosterone in human cardiac repolarization are addressed. In addition, the gender differences in the congenital long-QT syndrome, drug-induced ventricular arrhythmias, and sudden cardiac death are discussed.

Disparities in management of new-onset atrial fibrillation in the emergency department despite adherence to the current guidelines: data from a large metropolitan area

Atrial Fibrillation management is still a matter for debate. Past research has largely been based on the outpatient setting in which patients are followed during ambulatory visits. Very little data exist on the optimal management of AF in the Emergency Department (ED). This study investigated which factors drive different AF treatments in the ED, describing their use in different hospitals. Finally, the efficacy of different strategies in terms of cardioversion in the ED was analyzed. Charts of patients treated for atrial fibrillation (AF) were collected in 6 EDs in a large metropolitan area over a 24-consecutive month period and were reviewed and analysed. Demographics, comorbidities, treatment strategy and ED outcome were collected. Inclusion criteria were symptom onset <3 weeks and stable hemodynamic conditions at presentation. A propensity score was used to adjust for baseline clinical characteristics and to compare the efficacy of different treatments. 3,085 patients were included in the analysis. Variables associated with a rhythm control strategy were onset of symptoms <48 h, age, dyspnea, palpitations, renal failure and the presence of a mechanical valve. Different EDs applied different strategies in terms of drugs used and the electrocardioversion rate, showing heterogeneity in AF management. Adjusting for the propensity score, electrocardioversion and antidysrhythmic drugs of class Ic were more effective than a wait-and-watch strategy in the ED. Despite international guidelines being respected, AF management is heterogeneous in different ED settings. A rhythm control strategy with electrocardioversion and Class Ic drugs is more effective than a wait-and watch approach during the ED visit. Further research, toward an evidence-based approach to the emergent management of AF in the ED, is still needed.

Pharmacologic Conversion of Atrial Fibrillation and Atrial Flutter

Atrial fibrillation and atrial flutter are common arrhythmias in everyday clinical settings. Pharmacologic cardioversion (CV) is a simple and widely used strategy for the treatment of these arrhythmias, and many drugs are currently available. The choice of drug is strongly influenced by the time elapsed from atrial fibrillation onset and by a patient's clinical subset. Electrical direct-current CV is the treatment of choice in long-lasting forms; nevertheless, some agents also show efficacy in this setting. In addition, promising results come from studies on the efficacy and safety of new antiarrhythmic drugs and from therapeutic approaches that reduce the need for hospitalization and improve quality of life.

Rhythm control agents and adverse events in patients with atrial fibrillation

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.

Pharmacokinetics of desethylamiodarone in the rat after its administration as the preformed metabolite, and after administration of amiodarone

The pharmacokinetics of desethylamiodarone (DEA), the active metabolite of amiodarone (AM), were studied in the rat after administration of AM or preformed metabolite. Rats received 10 mg/kg of either intravenous or oral AM HCl or DEA base. Blood samples were obtained via a surgically implanted jugular vein cannula. Plasma concentrations were measured by a validated LC/MS method. In all AM treated rats, AM plasma concentrations greatly exceeded those of the formed DEA. The fraction of AM converted to DEA after i.v. administration was 14%. Amiodarone had a significantly lower (approximately 50%) clearance than DEA, although the volume of distribution and terminal phase half-life did not differ significantly. The hepatic extraction ratio of DEA was 0.48, similar to that of AM (0.51). Oral AM demonstrated higher plasma AUC (5.6 fold) and higher C(max) (6.1 fold) than oral DEA and oral bioavailability of AM (46%) was greater than DEA (17%). The estimated fraction of the oral dose of AM converted to DEA was 4.5 fold higher than after i.v. administration, suggesting first-pass formation of DEA from AM. Amiodarone and DEA differed in their pharmacokinetic characteristics mostly due to a higher CL of DEA. With oral dosing, AM appeared to undergo significant presystemic first-pass metabolism within the intestinal tract.

Cardiac Na+ channels as therapeutic targets for antiarrhythmic agents

There are many factors that influence drug block of voltage-gated Na+ channels (VGSC). Pharmacological agents vary in conformation, charge, and affinity. Different drugs have variable affinities to VGSC isoforms, and drug efficacy is affected by implicit tissue properties such as resting potential, action potential morphology, and action potential frequency. The presence of polymorphisms and mutations in the drug target can also influence drug outcomes. While VGSCs have been therapeutic targets in the management of cardiac arrhythmias, their potential has been largely overshadowed by toxic side effects. Nonetheless, many VGSC blockers exhibit inherent voltage- and use-dependent properties of channel block that have recently proven useful for the diagnosis and treatment of genetic arrhythmias that arise from defects in Na+ channels and can underlie idiopathic clinical syndromes. These defective channels suggest themselves as prime targets of disease and perhaps even mutation specific pharmacological interventions.

Sex differences in ventricular repolarization: from cardiac electrophysiology to Torsades de Pointes

A number of non-cardiovascular drugs have been withdrawn from clinical use due to unacceptable adverse cardiac side-effects involving drug-induced Torsades de Pointes (TdP)--a rare, life-threatening polymorphic ventricular tachycardia associated with prolongation of the action potential duration of ventricular myocytes and, hence, prolongation of the QT interval, of the electrocardiogram (ECG), which measures the total time for activation of the ventricles and their recovery to the resting state. Research has suggested that women are more prone to develop TdP than men during administration of medicines that share the potential to prolong the QT interval, with 65-75% of drug-induced TdP occurring in women. Clinical and experimental studies show that female sex demonstrate differences in the electrocardiographic pattern of ventricular repolarization in human and other animal species and is associated with a longer rate-corrected QT (QTc) interval at baseline than males. Reports of a similar propensity towards drug-induced TdP in both premenopausal and postmenopausal women support factors in addition to those of female sex hormones eliciting sex-based differences in ventricular repolarization. However, conflicting evidence suggests sex hormones may have a role in increasing the susceptibility of women or ultimately reducing the susceptibility of men to TdP. Cyclical variations in hormone levels during the menstrual cycle have been associated with an increased and reduced risk of TdP. In contradiction to this finding, the male sex hormone is thought to be beneficial. Modulation of the ventricular repolarization by testosterone may explain why the QTc interval shortens at puberty, and might account for the tendency towards an age-dependent reduction in the incidence of drug-induced TdP in men. Mechanisms underlying these differences are not fully understood but a case for the involvement of gonadal steroids is obviously strong. Therefore, further non-clinical/clinical investigations ought to be a necessary step to elucidate any sex differences in cardiac repolarization characteristics, QT interval prolongation and susceptibility to cardiac arrhythmias. This may have implications for the development of the safest medicinal products and for the clinical management of cardiac arrhythmias.

Ventricular fibrillation: basic concepts

This brief overview serves as an introduction to the vast array of basic and clinical concepts that are pertinent to the basic understanding of ventricular fibrillation, its genesis, and its clinical management.

Torsades de pointes following cardioversion: case history and literature review

Torsades de pointes (TDP) is a relatively uncommon but potentially fatal cardiac arrhythmia which occurs in patients with long QT syndromes (LQTS). This literature review and case history investigate the causes, symptoms, presentation and treatment of torsades, focusing on drug induced torsades developing after successful cardioversion. In torsades, imbalanced positive ion flows result in early after-depolarisations (EADs) and increased variability in repolarisation rates. These combine to create an unstable re-entrant polymorphic ventricular tachycardia (VT) which can cause patients to suffer symptoms progressing from syncope to ventricular fibrillation (VF) arrest. Typically, torsades has a twisting morphological presentation on rhythm strips due to the irregularity of its re-entry pattern. The arrhythmia is more common in women. Intravenous magnesium is the initial emergency treatment in torsades. The case history illustrates the progressive acquisition of risk factors for drug induced torsades in a patient treated with sotalol following cardioversion. Typical progressive rhythm strip, electrocardiograph (ECG), and QT & corrected QT interval (QTc) interval changes occurring with the arrhythmia are presented.

K+ channel structure-activity relationships and mechanisms of drug-induced QT prolongation

Pharmacological intervention, often for the purpose of treating syndromes unrelated to cardiac disease, can increase the vulnerability of some patients to life-threatening rhythm disturbances. This may be due to an underlying propensity stemming from genetic defects or polymorphisms, or structural abnormalities that provide a substrate allowing for the initiation of arrhythmic triggers. A number of pharmacological agents that have proven useful in the treatment of allergic reactions, gastrointestinal disorders, and psychotic disorders, among others, have been shown to reduce repolarizing K(+) currents and prolong the QT interval on the electrocardiogram. Understanding the structural determinants of K(+) channel blockade may provide new insights into the mechanism and rate-dependent effects of drugs on cellular physiology. Drug-induced disruption of cellular repolarization underlies electrocardiographic abnormalities that are diagnostic indicators of arrhythmia susceptibility.

Electrical heterogeneity and arrhythmogenesis: importance of conduction velocity dispersion

An experimental model of conduction velocity (CV) and refractory period dispersion was established to determine which variable is a determinant of myocardial vulnerability. Anesthetized swine were instrumented with a left anterior descending coronary artery catheter for regional infusion of lidocaine (n = 6), low-dose d-sotalol (n = 4), high-dose d-sotalol (n = 6), or saline (n = 6), to create dispersion in CV (lidocaine), refractoriness (d-sotalol), or neither (saline). Ventricular fibrillation thresholds (VFTs) and refractory periods were determined at five sites (one drug perfused, four non-drug perfused). CV was determined in one drug-perfused area (left ventricular epicardial apex) and one non-drug perfused area (right ventricular epicardial base). Lidocaine and low- and high-dose d-sotalol increased VFT when stimuli were delivered in the drug-perfused area. However, lidocaine decreased VFT when stimuli were delivered at non-drug perfused areas by an average of 52%. Neither d-sotalol dose affected VFT when stimuli were delivered in non-drug perfused areas. Lidocaine increased CV dispersion by 18-26 cm/s but did not alter refractoriness. Both d-sotalol doses increased dispersion in refractoriness by 15-27 ms but did not alter CV. Saline did not affect either variable. Regional lidocaine had profibrillatory effects when stimuli were delivered in non-drug perfused areas, whereas regional d-sotalol did not. Hence, CV dispersion is a more likely determinant of myocardial vulnerability than refractoriness.

Expression and activity of potassium ion channels in human prostate cancer

Four normal and 79 human prostate cancer (Pca) specimens were examined, by immunohistochemistry, for expression of voltage-gated potassium ion channels. Strong immunostaining (for Kv1.3) was observed in the normal and 47% (37/79) of Pca specimens. Twenty-nine percent (23/79) Pca specimens showed moderate and 24% (19/79) displayed low staining. Three potassium channel-openers at a concentration of 10 microg/mL, minoxidil (47.8 microM), 1-Ethyl-2-benzimidazolinone (EBIO) (61.7 microM) and diazoxide (43.3 microM), increased growth of PC3 cells by 30-50%. Potassium channel-blockers, dequalinium, amiodarone and glibenclamide, caused a dose-dependent, growth inhibition of four human Pca cell lines. Apoptosis occurred within 4h of treatment of PC3 cells with dequalinium (0.5 microg/mL, 0.9 microM), amiodarone (5 microg/mL, 7.3 microM) or glibenclamide (50 microg/mL, 0.1mM).

The effect of isoproterenol on the class III effect of azimilide in humans

BACKGROUND

Many class III antiarrhythmic agents lose efficacy under beta-adrenergic stimulation and at high heart rates (reverse rate dependence). This effect is thought to be due to selective blockade of the rapidly (I(Kr)), but not the slowly (I(Ks)), activating component of the delayed inward rectifier potassium current. Azimilide is an investigational class III antiarrhythmic agent that blocks both IKr and IKs.

METHODS

We investigated the electrophysiologic effect of azimilide with and without beta-adrenergic stimulation in humans. Right ventricular effective refractory period at cycle lengths of 600 and 400 milliseconds and monophasic right ventricular action potential duration at 90% repolarization at cycle lengths of 250, 300, 400, 500 and 600 milliseconds were measured in 13 patients at baseline. Isoproterenol was then infused to increase the heart rate to 125% of baseline, and the pacing protocol was repeated. Patients then received, in a single-blind randomized manner, azimilide dihydrochloride (4.5 mg/kg intravenous loading dose followed by 0.625 mg/kg/h) plus either isoproterenol at the previous dose, or saline. After measurements were taken, treatment groups were crossed over, the azimilide infusion was continued and the procedure repeated.

RESULTS

Azimilide significantly (P < 0.05) prolonged monophasic action potential duration compared to baseline at all cycle lengths except for the 250 millisecond cycle length. In the presence of isoproterenol, azimilide maintained its class III effect, prolonging the action potential duration at 90% repolarization by a mean of 8.7 +/- 3.9 milliseconds, (3.7 +/- 1.7%), whereas isoproterenol alone shortened the action potential duration at 90% repolarization by -2.6 +/- 3.2 milliseconds (-1.2 +/- 1.4%) (P = 0.0051). Isoproterenol alone shortened the right ventricular effective refractory period by -13.6 +/- 3.4 milliseconds, whereas with isoproterenol in the presence of azimilide, the right ventricular effective refractory period was essentially unaffected (-1.4 +/- 3.4 milliseconds, P = 0.0085).

CONCLUSIONS

Azimilide maintained its class III effect in the presence of isoproterenol and at increased heart rates, suggesting that IKs block may be of particular benefit in these circumstances.