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Yang PC, Giles WR, Belardinelli L, Clancy CE. Mechanisms of flecainide induced negative inotropy: An in silico study. J Mol Cell Cardiol 2021; 158:26-37. [PMID: 34004185 PMCID: PMC8772296 DOI: 10.1016/j.yjmcc.2021.05.007] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 11/27/2022]
Abstract
It is imperative to develop better approaches to predict how antiarrhythmic drugs with multiple interactions and targets may alter the overall electrical and/or mechanical function of the heart. Safety Pharmacology studies have provided new insights into the multi-target effects of many different classes of drugs and have been aided by the addition of robust new in vitro and in silico technology. The primary focus of Safety Pharmacology studies has been to determine the risk profile of drugs and drug candidates by assessing their effects on repolarization of the cardiac action potential. However, for decades experimental and clinical studies have described substantial and potentially detrimental effects of Na+ channel blockers in addition to their well-known conduction slowing effects. One such side effect, associated with administration of some Na+ channel blocking drugs is negative inotropy. This reduces the pumping function of the heart, thereby resulting in hypotension. Flecainide is a well-known example of a Na+ channel blocking drug, that exhibits strong rate-dependent block of INa and may cause negative cardiac inotropy. While the phenomenon of Na+ channel suppression and resulting negative inotropy is well described, the mechanism(s) underlying this effect are not. Here, we set out to use a modeling and simulation approach to reveal plausible mechanisms that could explain the negative inotropic effect of flecainide. We utilized the Grandi-Bers model [1] of the cardiac ventricular myocyte because of its robust descriptions of ion homeostasis in order to characterize and resolve the relative effects of QRS widening, flecainide off-target effects and changes in intracellular Ca2+ and Na+ homeostasis. The results of our investigations and predictions reconcile multiple data sets and illustrate how multiple mechanisms may play a contributing role in the flecainide induced negative cardiac inotropic effect.
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Affiliation(s)
- Pei-Chi Yang
- Department of Physiology and Membrane Biology, School of Medicine, University of California, Davis, United States of America
| | - Wayne R Giles
- Department of Physiology & Pharmacology, University of Calgary, Canada
| | | | - Colleen E Clancy
- Department of Physiology and Membrane Biology, School of Medicine, University of California, Davis, United States of America.
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2
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Rabêlo Evangelista AB, Monteiro FR, Nearing BD, Belardinelli L, Verrier RL. Flecainide-induced QRS complex widening correlates with negative inotropy. Heart Rhythm 2021; 18:1416-1422. [PMID: 33848647 DOI: 10.1016/j.hrthm.2021.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/30/2021] [Accepted: 04/05/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The negative inotropic effect of Class IC antiarrhythmic drugs limits their use for acute cardioversion of atrial fibrillation (AF). OBJECTIVE The purpose of this study was to examine, in an intact porcine model, the effects of pulmonary and intravenous (IV) administration of flecainide on left ventricular (LV) contractility and QRS complex width at doses that are effective in converting new-onset AF to sinus rhythm. METHODS Flecainide (1.5 mg/kg bolus) was delivered by intratracheal administration and compared to 2.0 mg/kg 10-minute IV administration (European Society of Cardiology guideline) and to 0.5 and 1.0 mg/kg 2-minute IV doses in 40 closed-chest, anesthetized Yorkshire pigs. Catheters were fluoroscopically positioned in the LV to monitor QRS complex width and contractility and at the bifurcation of the main bronchi to deliver intratracheal flecainide. RESULTS Peak flecainide plasma concentrations (Cmax) were similar, but the 30-minute area under the curve (AUC) of plasma levels was 1.4- to 2.8-fold greater for 2.0 mg/kg 10-minute IV infusion than for the lower, more rapidly delivered intratracheal and IV doses. AUC for LV contractility (ie, negative inotropic burden) was 2.2- to 3.6-fold greater for 2.0 mg/kg 10-minute IV dose than for the lower, more rapidly delivered doses. QRS complex widening by flecainide was highly correlated with the decrease in LV contractility (r2 = 0.890, P <.0001, for all IV doses; r2 = 0.812, P = .01, for intratracheal flecainide). CONCLUSION QRS complex widening in response to flecainide is strongly correlated with decrease in LV contractility. Rapid pulmonary or IV flecainide delivery reduces the negative inotropic burden while quickly achieving Cmax levels associated with conversion of AF.
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Affiliation(s)
- Ana B Rabêlo Evangelista
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Felipe R Monteiro
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Bruce D Nearing
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | | | - Richard L Verrier
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts.
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3
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Ibrahim OA, Belley-Côté EP, Um KJ, Baranchuk A, Benz AP, Dalmia S, Wang CN, Alhazzani W, Conen D, Devereaux PJ, Whitlock RP, Healey JS, McIntyre WF. Single-dose oral anti-arrhythmic drugs for cardioversion of recent-onset atrial fibrillation: a systematic review and network meta-analysis of randomized controlled trials. Europace 2021; 23:1200-1210. [PMID: 33723602 DOI: 10.1093/europace/euab014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/08/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS Single oral dose anti-arrhythmic drugs (AADs) are used to cardiovert recent-onset atrial fibrillation (AF); however, the optimal agent is uncertain. METHODS We performed a systematic review and network meta-analysis of randomized trials testing single oral dose AADs vs. any comparator to cardiovert AF <7 days duration. We searched MEDLINE, Embase, and CENTRAL to April 2020. The primary outcome was successful cardioversion at timepoint nearest 8 h after administration. RESULTS From 12 712 citations, 22 trials (2320 patients) were included. Thirteen trials included patients with some degree of heart failure; 19 included patients with some degree of ischaemic heart disease vs. placebo or rate-control (32% success) at 8 h, flecainide [73%, network odds ratio (OR) 7.6, 95% credible interval (CrI) 4.4-14.0], propafenone (70%, OR 4.6, CrI 2.9-7.3), and pilsicainide (59%, OR 10.0, CrI 1.8-69.0), but not amiodarone (28%, OR 1.0, CrI 0.4-2.8) were superior. Flecainide (OR 7.5, CrI 2.6-24.0) and propafenone (OR 4.5, CrI 1.6-13.0) were superior to amiodarone; propafenone vs. flecainide did not statistically differ (OR 0.6, CrI 0.3-1.1). At longest follow-up, amiodarone was superior to placebo (OR 11.0, CrI 3.2-41.0), flecainide vs. amiodarone (OR 0.79, CrI 0.19-3.1), and propafenone vs. amiodarone (OR 0.36, CrI 0.092-1.4) were not statistically different, and flecainide was superior to propafenone (OR 2.2, CrI 1.1-4.8). Atrial and ventricular tachyarrhythmias, bradyarrhythmias, and hypotension were rare with PO AADs. CONCLUSION Single oral dose Class 1C AADs are effective and safe for cardioversion of recent-onset AF. Flecainide may be superior to propafenone. Amiodarone is a slower acting alternative.
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Affiliation(s)
- Omar A Ibrahim
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - Kevin J Um
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | | | - Alexander P Benz
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - Shreyash Dalmia
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | | | - Waleed Alhazzani
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - David Conen
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - P J Devereaux
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
| | - William F McIntyre
- Population Health Research Institute, McMaster University, 20 Copeland Ave, Hamilton, ON, L8L2X2, Canada
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4
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Haffajee C, Tandon K. The Unpaceable Heart: Flecainide Toxicity? JACC Case Rep 2020; 2:598-599. [PMID: 34317302 PMCID: PMC8298776 DOI: 10.1016/j.jaccas.2020.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Charles Haffajee
- Beth Israel Deaconess Medical Center, Cardiovascular Division/Cardiovascular Institute, Boston, Massachusetts
| | - Kunal Tandon
- Beth Israel Deaconess Medical Center, Cardiovascular Division/Cardiovascular Institute, Boston, Massachusetts
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5
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Flecainide-Associated Cardiogenic Shock in a Patient with Atrial Fibrillation. Case Rep Cardiol 2019; 2019:4820652. [PMID: 31827935 PMCID: PMC6885768 DOI: 10.1155/2019/4820652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 10/31/2019] [Indexed: 11/30/2022] Open
Abstract
Flecainide is a frequently used antiarrhythmic drug, recommended by current guidelines as a first-line treatment option for restoring and maintaining sinus rhythm in patients with atrial fibrillation and no significant structural heart disease. In overdose, it can induce severe cardiogenic shock. Cardiogenic shock after a therapeutic dose of flecainide in patients without contraindication has not yet been reported in literature. Case Summary. We report a case of flecainide-associated cardiogenic shock in a 52-year-old woman with paroxysmal atrial fibrillation after a therapeutic dose of flecainide. Pharmacological cardioversion of symptomatic tachyarrhythmic atrial fibrillation with flecainide was unsuccessful and shortly after, she developed cardiogenic shock with severely reduced LVEF. Electrical cardioversion was also unsuccessful. Coronarography was unremarkable, and the cardiac MRI showed no signs of inflammation or fibrosis. After amiodarone loading, she converted to SR. This rare but severe complication despite adequate treatment could be explained by increased susceptibility to negative inotropic effect of flecainide as a consequence of marked tachycardia. Therefore, cautious monitoring after new administration of flecainide or the administration of a higher dose is advisable.
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Hemmeryckx B, Feng Y, Frederix L, Lox M, Trenson S, Vreeken R, Lu HR, Gallacher D, Ni Y, Lijnen HR. Evaluation of cardiac arrhythmic risks using a rabbit model of left ventricular systolic dysfunction. Eur J Pharmacol 2018; 832:145-155. [PMID: 29782862 DOI: 10.1016/j.ejphar.2018.05.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/17/2018] [Accepted: 05/17/2018] [Indexed: 12/13/2022]
Abstract
Patients with heart disease have a higher risk to develop cardiac arrhythmias, either spontaneously or drug-induced. In this study, we have used a rabbit model of myocardial infarction (MI) with severe left ventricular systolic dysfunction (LVSD) to study potential drug-induced cardiac risks with N-(piperidin-2-ylmethyl)-2,5-bis(2,2,2-trifluoroethoxy)benzamide (flecainide). Upon ligation of the left circumflex arteries, male New Zealand White rabbits developed a large MI and moderate or severe LVSD 7 weeks after surgery, in comparison to SHAM-operated animals. Subsequently, animals were exposed to escalating doses of flecainide (0.25-4 mg/kg) or solvent. Electrocardiograms (ECG) were recorded before surgery, 1 and 7 weeks after surgery and continuously during the drug protocol. The ECG biomarker iCEB (index of Cardio-Electrophysiological Balance = QT/QRS ratio) was calculated. During the ECG recording at week 1 and week 7 post MI, rabbits had no spontaneous cardiac arrhythmias. When rabbits were exposed to escalating doses of flecainide, 2 out of 5 rabbits with MI and moderate LVSD versus 0 out of 5 solvent-treated rabbits developed arrhythmias, such as ventricular tachycardia/ventricular fibrillation. These were preceded by a marked decrease of iCEB just before the onset (from 4.09 to 2.42 and from 5.56 to 2.25, respectively). Furthermore, 1 out of 5 MI rabbits with moderate LVSD and 1 out of 7 MI rabbits with severe LVSD developed total atrioventricular block after flecainide infusion and died. This rabbit model of MI and severe LVSD may be useful for preclinical evaluation of drug (similar mechanism as flecainide)-induced arrhythmic risks, which might be predicted by iCEB.
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Affiliation(s)
- Bianca Hemmeryckx
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
| | - Yuanbo Feng
- Radiology, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.
| | - Liesbeth Frederix
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
| | - Marleen Lox
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
| | - Sander Trenson
- Cardiology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
| | - Rob Vreeken
- Metabolomics, Pharmacokinetics, Dynamics and Metabolism Discovery Sciences, Janssen Pharmaceutical NV, Beerse, Belgium.
| | - Hua Rong Lu
- Translational Sciences, Safety Pharmacology Research, Janssen Research & Development, Janssen Pharmaceutical NV, Beerse, Belgium.
| | - David Gallacher
- Translational Sciences, Safety Pharmacology Research, Janssen Research & Development, Janssen Pharmaceutical NV, Beerse, Belgium.
| | - Yicheng Ni
- Radiology, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.
| | - H Roger Lijnen
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
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7
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Derangeon M, Montnach J, Cerpa CO, Jagu B, Patin J, Toumaniantz G, Girardeau A, Huang CLH, Colledge WH, Grace AA, Baró I, Charpentier F. Transforming growth factor β receptor inhibition prevents ventricular fibrosis in a mouse model of progressive cardiac conduction disease. Cardiovasc Res 2017; 113:464-474. [PMID: 28339646 DOI: 10.1093/cvr/cvx026] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 02/16/2017] [Indexed: 01/12/2023] Open
Abstract
Aims Loss-of-function mutations in SCN5A, the gene encoding NaV1.5 channel, have been associated with inherited progressive cardiac conduction disease (PCCD). We have proposed that Scn5a heterozygous knock-out (Scn5a+/-) mice, which are characterized by ventricular fibrotic remodelling with ageing, represent a model for PCCD. Our objectives were to identify the molecular pathway involved in fibrosis development and prevent its activation. Methods and results Our study shows that myocardial interstitial fibrosis occurred in Scn5a+/- mice only after 45 weeks of age. Fibrosis was triggered by transforming growth factor β (TGF-β) pathway activation. Younger Scn5a+/- mice were characterized by a higher connexin 43 expression than wild-type (WT) mice. After the age of 45 weeks, connexin 43 expression decreased in both WT and Scn5a+/- mice, although the decrease was larger in Scn5a+/- mice. Chronic inhibition of cardiac sodium current with flecainide (50 mg/kg/day p.o) in WT mice from the age of 6 weeks to the age of 60 weeks did not lead to TGF-β pathway activation and fibrosis. Chronic inhibition of TGF-β receptors with GW788388 (5 mg/kg/day p.o.) in Scn5a+/- mice from the age of 45 weeks to the age of 60 weeks prevented the occurrence of fibrosis. However, current data could not detect reduction in QRS duration with GW788388. Conclusion Myocardial fibrosis secondary to a loss of NaV1.5 is triggered by TGF-β signalling pathway. Those events are more likely secondary to the decreased NaV1.5 sarcolemmal expression rather than the decreased Na+ current per se. TGF-β receptor inhibition prevents age-dependent development of ventricular fibrosis in Scn5a+/- mouse.
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Affiliation(s)
- Mickael Derangeon
- INSERM, UMR1087, l'institut du thorax, quai Moncousu, Nantes F-44000, France.,CNRS, UMR6291, quai Moncousu, Nantes F-44000, France.,Université de Nantes, quai Moncousu, Nantes F-44000, France
| | - Jérôme Montnach
- INSERM, UMR1087, l'institut du thorax, quai Moncousu, Nantes F-44000, France.,CNRS, UMR6291, quai Moncousu, Nantes F-44000, France.,Université de Nantes, quai Moncousu, Nantes F-44000, France
| | - Cynthia Ore Cerpa
- INSERM, UMR1087, l'institut du thorax, quai Moncousu, Nantes F-44000, France.,CNRS, UMR6291, quai Moncousu, Nantes F-44000, France.,Université de Nantes, quai Moncousu, Nantes F-44000, France
| | - Benoit Jagu
- INSERM, UMR1087, l'institut du thorax, quai Moncousu, Nantes F-44000, France.,CNRS, UMR6291, quai Moncousu, Nantes F-44000, France.,Université de Nantes, quai Moncousu, Nantes F-44000, France
| | - Justine Patin
- INSERM, UMR1087, l'institut du thorax, quai Moncousu, Nantes F-44000, France.,CNRS, UMR6291, quai Moncousu, Nantes F-44000, France.,Université de Nantes, quai Moncousu, Nantes F-44000, France
| | - Gilles Toumaniantz
- INSERM, UMR1087, l'institut du thorax, quai Moncousu, Nantes F-44000, France.,CNRS, UMR6291, quai Moncousu, Nantes F-44000, France.,Université de Nantes, quai Moncousu, Nantes F-44000, France
| | - Aurore Girardeau
- INSERM, UMR1087, l'institut du thorax, quai Moncousu, Nantes F-44000, France.,CNRS, UMR6291, quai Moncousu, Nantes F-44000, France.,Université de Nantes, quai Moncousu, Nantes F-44000, France
| | - Christopher L H Huang
- The Section of Cardiovascular Biology, Departments of Biochemistry and Physiology, University of Cambridge, Downing street, Cambridge CB23EG, UK
| | - William H Colledge
- The Section of Cardiovascular Biology, Departments of Biochemistry and Physiology, University of Cambridge, Downing street, Cambridge CB23EG, UK
| | - Andrew A Grace
- The Section of Cardiovascular Biology, Departments of Biochemistry and Physiology, University of Cambridge, Downing street, Cambridge CB23EG, UK
| | - Isabelle Baró
- INSERM, UMR1087, l'institut du thorax, quai Moncousu, Nantes F-44000, France.,CNRS, UMR6291, quai Moncousu, Nantes F-44000, France.,Université de Nantes, quai Moncousu, Nantes F-44000, France
| | - Flavien Charpentier
- INSERM, UMR1087, l'institut du thorax, quai Moncousu, Nantes F-44000, France.,CNRS, UMR6291, quai Moncousu, Nantes F-44000, France.,Université de Nantes, quai Moncousu, Nantes F-44000, France.,CHU Nantes, Alexis Ricordeau, Nantes F-44000, France
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8
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Flecainide-Induced Left Ventricular Dysfunction: Fact or Fiction? Cardiovasc Toxicol 2017; 17:494-495. [PMID: 28534245 DOI: 10.1007/s12012-017-9410-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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9
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Chouchoulis K, Chiladakis J, Koutsogiannis N, Davlouros P, Kaza M, Alexopoulos D. Impact of QT interval prolongation following antiarrhythmic drug therapy on left ventricular function. Future Cardiol 2016; 13:13-22. [PMID: 27990843 DOI: 10.2217/fca-2016-0052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM We assessed whether antiarrhythmic drug-induced QT interval prolongation affects left ventricular function. METHODS Study population included 54 patients with symptomatic recent onset atrial fibrillation spontaneously cardioverted to sinus rhythm. Electrocardiographic and echocardiographic studies were done before initiating and after achieving drug's steady state. RESULTS Significantly prolonged corrected QT interval (QTc) was noticed following only sotalol and amiodarone. The corrected precontraction time increased after sotalol (p = 0.005) and amiodarone (p = 0.017), not propafenone (p = 0.139). Analysis results between ΔEF and ΔQTc, ΔEF and ΔQTc(p), ΔE/e' and ΔQTc, ΔE/e' and ΔQTc(p) for amiodarone group were (p = 0.66, p = 0.20, p = 0.66, p = 0.33), for sotalol (p = 0.36, p = 0.51, p = 0.44, p = 0.33) and for propafenone (p = 0.38, p = 0.12, p = 0.89, p = 0.61), respectively. CONCLUSION QT interval prolongation following antiarrhythmic therapy does not affect significantly left ventricular function.
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Affiliation(s)
| | - John Chiladakis
- Cardiology Department, University Hospital of Patras, Rion, Patras, Greece
| | | | - Periklis Davlouros
- Cardiology Department, University Hospital of Patras, Rion, Patras, Greece
| | - Maria Kaza
- School of Medicine, University of Patras, Rion, Patras, Greece
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10
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Apps A, Miller CP, Fellows S, Jones M. Cardiac devices with class 1C antiarrhythmics: a potentially toxic combination. BMJ Case Rep 2015; 2015:bcr-2015-210598. [PMID: 26286909 DOI: 10.1136/bcr-2015-210598] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A patient taking regular flecainide for paroxysmal atrial fibrillation presented with broad complex tachycardia and circulatory compromise. With no history of pacemaker insertion and no pacing spikes visible on the ECG, this was presumed to be ventricular tachycardia and treated with electrical cardioversion, leading to p-wave asystole. An indwelling pacemaker was now recognised and ventricular capture was eventually attained by significantly increasing ventricular lead output. Invasive haemodynamic support was required due to new ventricular systolic dysfunction. Pacing thresholds and ventricular function normalised within 72 h consistent with flecainide toxicity; levels were shown to be toxic. Pacemaker interrogation revealed evidence of an undiagnosed atrial flutter, at presentation this was likely slowed by flecainide toxicity to a rate below the pacemaker mode switch, such that it was tracked in the ventricle at the upper tracking rate (120 bpm). Cardioversion terminated the arrhythmia but raised the capture threshold of the ventricle above the maximum lead output.
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Affiliation(s)
- Andrew Apps
- Department of Cardiology, Buckinghamshire Healthcare NHS Trust, High Wycombe, Bucks, UK
| | | | - Sarah Fellows
- Department of Cardiology, Buckinghamshire Healthcare NHS Trust, High Wycombe, Bucks, UK
| | - Michael Jones
- Department of Cardiology, John Radcliffe Hospital, Oxford, UK
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11
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Qu Y, Fang M, Gao B, Amouzadeh HR, Li N, Narayanan P, Acton P, Lawrence J, Vargas HM. Itraconazole decreases left ventricular contractility in isolated rabbit heart: Mechanism of action. Toxicol Appl Pharmacol 2013; 268:113-22. [DOI: 10.1016/j.taap.2013.01.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 01/18/2013] [Accepted: 01/31/2013] [Indexed: 11/25/2022]
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12
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Comparison of the Intrinsic Vasorelaxant and Inotropic Effects of the Antiarrhythmic Agents Vernakalant and Flecainide in Human Isolated Vascular and Cardiac Tissues. J Cardiovasc Pharmacol 2013. [DOI: 10.1097/fjc.0b013e31827afd29] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Camm AJ. Safety considerations in the pharmacological management of atrial fibrillation. Int J Cardiol 2008; 127:299-306. [PMID: 18191470 DOI: 10.1016/j.ijcard.2007.11.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Accepted: 11/02/2007] [Indexed: 01/08/2023]
Abstract
The pharmacological management of atrial fibrillation (AF) requires careful consideration from a safety perspective. This article focuses primarily on maintenance therapy using antiarrhythmic drugs (AADs). The foremost safety issue for AADs is the propensity of class IA and III agents to cause torsade de pointes arrhythmias. Class IA drugs, particularly quinidine, can induce torsade de pointes at low or subtherapeutic doses, but higher doses are not necessarily associated with an increased incidence. 'Pure' class III drugs such as dofetilide induce torsade de pointes in a dose-related manner, but some class III agents with more complex actions such as amiodarone have a markedly lower potential to cause this arrhythmia. The risk of torsade de pointes precludes the use of class IA and 'pure' class III agents in patients with left ventricular hypertrophy and bradycardia. Class IC agents may cause sustained monomorphic ventricular tachycardias and are generally precluded in ischaemic and structural heart disease. Advanced heart failure patients may be treated with amiodarone or dofetilide, but most other AADs are unsuitable. The most important extracardiac toxicities occurring with AADs are those of amiodarone. Drug interactions are a significant safety issue in the management of AF, including pharmacokinetic interactions in which plasma levels of the AAD are raised - increasing the risk of proarrhythmia - and concomitant use of drugs that prolong the QT interval. Notwithstanding these considerations, most patients with AF can be considered for rhythm control, provided there is adequate pre-treatment assessment and protocols for initiation, dosing and monitoring are followed with care.
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Affiliation(s)
- A John Camm
- Department of Cardiological Sciences, St George's University of London, Cranmer Terrace, London SW17 0RE, United Kingdom.
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14
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Abstract
The efficacy and safety of the single oral loading dose of flecainide for cardioversion of recent-onset atrial fibrillation was examined by reviewing the trials on the subject identified through a comprehensive literature search. Most of the trials used a single dose of 300 mg for oral loading. The success rate ranged from 57 to 68% at 2-4 h and 75 to 91% at 8 h after drug administration. The conversion time ranged from 110+/-82 to 190+/-147 min, depending on the duration of observation after drug administration, which in most trials was of 8 h. Single oral loading regimen of flecainide was significantly more efficacious than placebo, and was as efficacious as the single oral loading regimen of propafenone. Both the single oral loading and the intravenous loading regimens of flecainide were equally efficacious but the intravenous regimen resulted in an earlier conversion. Adverse effects reported were mild non-cardiac side effects, reversible QRS complex widening, transient arrhythmias and left ventricular decompensation. The transient arrhythmias were chiefly at the time of conversion and included appearance of atrial flutter and sinus pauses. No life-threatening ventricular arrhythmia or death was reported. The single dose oral loading regimen of flecainide appears to be effective for cardioversion of recent-onset atrial fibrillation with a relatively rapid effect within 2-4 h, and is free of serious complications in patients without structural heart disease. Patients with substantial structural heart disease were excluded from most of the trials.
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Affiliation(s)
- Ijaz A Khan
- Divisions of Cardiology, Creighton University School of Medicine, 3006 Webster Street, Omaha, NE 68131, USA.
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Khan IA. Single oral loading dose of propafenone for pharmacological cardioversion of recent-onset atrial fibrillation. J Am Coll Cardiol 2001; 37:542-7. [PMID: 11216976 DOI: 10.1016/s0735-1097(00)01116-5] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The efficacy and safety of the single dose oral loading regimen of propafenone for pharmacological cardioversion of recent-onset atrial fibrillation (AFib) was evaluated by analyzing the trials on the subject identified through a comprehensive literature search. Most of the trials used a single dose of 600 mg for oral loading. The success rates ranged from 56% to 83%, depending on the duration of AFib and follow-up after drug administration. The conversion time ranged from 110 +/- 59 to 287 +/- 352 min, depending on the duration of observation after drug administration. The single dose oral loading regimen of propafenone was significantly more efficacious than placebo in the first 8 h after administration but not at 24 h. Compared with the intravenous regimen, the oral regimen resulted in fewer conversions in the first 2 h, but both regimens were equally efficacious afterward. The oral propafenone regimen was as efficacious as the single dose oral loading regimen of flecainide but was superior to those of quinidine and amiodarone. The adverse effects reported were transient arrhythmia, reversible QRS-complex widening, transient hypotension and mild noncardiac side effects. The transient arrhythmias were chiefly at the time of conversion and included appearance of atrial flutter, bradycardia, pauses and junctional rhythm. No life-threatening proarrhythmic adverse effects were reported. The single oral loading dose of propafenone appears to be highly effective for conversion of recent-onset AFib, with a relatively rapid effect within 2 to 3 h and freedom from serious adverse effects.
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Affiliation(s)
- I A Khan
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska 68131-2044, USA.
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