Use of class IC antiarrhythmic drugs in patients with structural heart disease and implantable cardioverter defibrillator

Maura M. Zylla1,2,3, Julian Wolfes4, Ruben Schleberger5,6,7, Dennis Lawin8, Meinhard Kieser9, Florian Reinke4, Lars Eckardt10, Andreas Rillig7,5, Christoph Stellbrink8, Dierk Thomas1,2,3, Norbert Frey1,3,2, Patrick Lugenbiel2,3,1
1HCR (Heidelberg Center for Heart Rhythm Disorders), Medical University Hospital, Heidelberg, Germany
2Department of Cardiology, Medical University Hospital, Heidelberg, Germany
3DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
4Department of Cardiology II – Electrophysiology, University Hospital Münster, Münster, Germany
5Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
6Department of Cardiology, Albertinen Heart and Vascular Center, Albertinen Hospital, Hamburg, Germany
7DZHK (German Center for Cardiovascular Research), partner site Hamburg/Lübeck/Kiel, Hamburg, Germany
8Department of Cardiology and Intensive Care Medicine, University Hospital OWL of Bielefeld University, Bielefeld, Germany
9Institute of Medical Biometry, Heidelberg University Hospital, Heidelberg, Germany
10Department of Cardiology II-Electrophysiology, University Hospital Münster, Münster, Germany

Tóm tắt

Due to suspected pro-arrhythmic effects and increased mortality associated with class-IC antiarrhythmic drugs (AADs) in previous trials, AAD therapy in structural heart disease (SHD) is mainly restricted to amiodarone. In the presence of diagnostic and therapeutic advancements in cardiovascular medicine, it remains unclear if previous studies adequately reflect contemporary patients. In clinical practice, class-IC-AADs are occasionally used in individual cases, particularly in patients with an implantable cardioverter defibrillator (ICD). This study retrospectively investigated outcome in ICD-carriers with SHD in whom class-IC-AADs were used as an individualized therapy due to failure, side effects, or unacceptable risk of alternative therapeutic options. Fifty patients from four tertiary centers were included (median age 48.5 years; 52% female). The most common underlying SHD were dilated (42%) or ischemic cardiomyopathy (26%) (median LVEF = 45%). Indications for AAD were sustained ventricular arrhythmias (VA) (58%), symptomatic premature ventricular contractions (26%), or atrial arrhythmias (16%). Median follow-up was 27.8 months. Freedom from sustained VA was 72%, and freedom from ICD therapy was 80%. In 19 patients (38%), AAD therapy was terminated. The most common reason was insufficient efficacy (n = 8). Pro-arrhythmia was suspected in three patients. Five patients died during follow-up (10.0%), two of cardiovascular cause (4.0%). In a multicenter cohort of ICD-carriers with SHD, class-IC-AADs were associated with a low rate of pro-arrhythmic effects or cardiovascular mortality. The majority of patients remained free from sustained VA during a follow-up of > 2 years. Further efforts should be made to evaluate the safety of class-IC-AADs in SHD patients receiving contemporary cardiovascular therapy.

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Tài liệu tham khảo

McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Bohm M et al (2021) 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 42:3599–3726 Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH et al (1991) Mortality and morbidity in patients receiving encainide, flecainide, or placebo. N Engl J Med 324:781–788 Ermakov S, Gerstenfeld EP, Svetlichnaya Y, Scheinman MM (2017) Use of flecainide in combination antiarrhythmic therapy in patients with arrhythmogenic right ventricular cardiomyopathy. Heart Rhythm 14:564–569 Chung R, Houghtaling PL, Tchou M, Niebauer MJ, Lindsay BD, Tchou PJ et al (2017) Left ventricular hypertrophy and antiarrhythmic drugs in atrial fibrillation: impact on mortality. Pacing Clin Electrophysiol 37:1338–1348 Burnham TS, May HT, Bair TL, Anderson JA, Crandall BG, Cutler MJ et al (2022) Long-term outcomes in patients treated with flecainide for atrial fibrillation with stable coronary artery disease. Am Heart J 243:127–139 Moffett BS, Valdes SO, Lupo PJ, DelaUz C, Miyake C, Krenek M et al (2015) Flecainide use in children with cardiomyopathy or structural heart disease. Pediatr Cardiol 36:146–150 Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA et al (2022) 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: developed by the task force for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death of the European Society of Cardiology (ESC) Endorsed by the Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 43:3997–4126 Mihajlovic M, Mihajlovic A, Marinkovic M, Kovacevic V, Simic J, Mujovic N et al (2021) Main determinants of physician-driven amiodarone discontinuation in clinical practice. Europace 23(Supplement_3):euab116.051 Lei M, Wu L, Terrar DA, Huang CL (2018) Modernized classification of cardiac antiarrhythmic drugs. Circulation 138:1879–1896 Lavalle C, Trivigno S, Vetta G, Magnocavallo M, Mariani MV, Santini L et al (2021) Flecainide in ventricular arrhythmias: from old myths to new perspectives. J Clin Med 10:3696 Ashraf H, Ko NK, Ladia V, Agasthi P, Prendiville T, O’Herlihy F et al (2021) Use of flecainide in stable coronary artery disease: an analysis of its safety in both nonobstructive and obstructive coronary artery disease. Am J Cardiovasc Drugs 21:563–572 Field ME, Holmes DN, Page RL, Fonarow GC, Matsouaka RA, Turakhia MP et al (2021) Guideline-concordant antiarrhythmic drug use in the get with the guidelines–atrial fibrillation registry. Circ Arrhythm Electrophysiol 14:e008961 Barnett AS, Kim S, Fonarow GC, Thomas LE, Reiffel JA, Allen LA et al (2017) Treatment of atrial fibrillation and concordance with the American Heart Association/American College of Cardiology/Heart Rhythm Society Guidelines: findings from ORBIT-AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation). Circ Arrhythm Electrophysiol 10:e005051 Doki K, Homma M, Kuga K, Aonuma K, Sakai S, Yamaguchi I et al (2007) Gender-associated differences in pharmacokinetics and anti-arrhythmic effects of flecainide in Japanese patients with supraventricular tachyarrhythmia. Eur J Clin Pharmacol 63:951–957 Rienstra M, Veldhuisen DJV, Hagens VE, Ranchor AV, Veeger NJGM, Crijns HJGM et al (2005) Gender-related differences in rhythm control treatment in persistent atrial fibrillation. J Am Coll Cardiol 46:1298–1306 Amuthan R, Curtis AB (2022) Sex-specific considerations in drug and device therapy of cardiac arrhythmias: JACC Focus Seminar 6/7. J Am Coll Cardiol 79:1519–1529 Legrand V, Materne P, Vandormael M, Collignon P, Kulbertus HE (1985) Comparative haemodynamic effects of intravenous flecainide in patients with and without heart failure and with and without beta-blocker therapy. Eur Heart J 6:664–671