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Ventricular Arrhythmias in Heart Failure
Published in Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Heart Failure, 2023
Antonis S. Manolis, Antonis A. Manolis, Theodora A. Manolis
Among the standard HF therapies, beta-blockers, angiotensin system blockers (ACEi/ARBs), ARNIs, and MRAS play a protective role against VTA and SCD. Conventional antiarrhythmic drugs and other potentially proarrhythmic extracardiac drugs (e.g., QTc-prolonging agents) should be avoided. In HF patients, only amiodarone, as the antiarrhythmic drug which is devoid of a negative inotropic effect and has the least proarrhythmic risk, may be used to reduce VTA, albeit with some concern about its long-term impact on survival. For symptomatic sustained VTA and/or aborted SCD, ICDs have the greatest benefit for secondary prevention, while primary prevention is currently based on an LVEF ≤30–35% justifying prophylactic ICD implantation in both ischemic CM and NICM. When indicated, CRT has been associated with a reduction in ventricular tachyarrhythmias and consequent ICD therapies as it improves LV function. For patients with LVEF >35% and/or HFpEF, the target remains to treat comorbidities and selectively implant an ICD as based on the results of an EP study (inducible sustained VTA) and/or genetics (e.g., lamin A/C CM); CMR-detected myocardial fibrosis is emerging as a new and potent SCD risk marker and stratifier. The role of catheter ablation is important in cases of VA-induced CM and is lifesaving in cases of an electrical storm. Finally, in cases of intractable and progressive pump failure and/or refractory VTA, heart transplantation and durable mechanical circulatory support with LVADs play an important role, as long as these high-risk patients are reasonable candidates for these surgical therapies.
Management strategies
Published in Gregory YH Lip, Atrial Fibrillation in Practice, 2020
As previously mentioned, the inappropriate use of antiarrhythmic drugs could lead to unwanted consequences including proarrhythmia and death, and hence these drugs have to be used with great caution after adequate consideration of the risk and benefits of the drug in the individual patient. Antiarrhythmic agents that reduce mortality include amiodarone and beta-blockers, although this evidence is based on trials of treatment of congestive heart failure, rather than in AF per se. Indeed, the vast majority of these patients will have been in sinus rhythm. There is no evidence that any of the other antiarrhythmic agents lower mortality in AF. There is some evidence that some are associated with increased mortality.
In Vivo and In Vitro Cardiac Preparations Used in Antiarrhythmic Assays
Published in John H. McNeill, Measurement of Cardiovascular Function, 2019
Any assessment of an antiarrhythmic drug should include assessment of its proarrhythmic (arrhythmogenic) actions. This is difficult since the conditions under which the proarrhythmic potential is manifest may be very specific, but still clinically relevant. For example, the occurrence of Torsade de Pointes is associated with bradycardia, a long QTc interval, hypomagnesemia, and hypokalemia.7
Evaluating posaconazole, its pharmacology, efficacy and safety for the prophylaxis and treatment of fungal infections
Published in Expert Opinion on Pharmacotherapy, 2022
Paraskevi Panagopoulou, Emmanuel Roilides
Cardiotoxicity (QTc prolongation, atrial fibrillation, Torsades des Pointes) is another recognized side effect of azoles. Although not observed in healthy subjects [27], oral suspension was associated with QTc prolongation and arrythmias in 4% and <1% of neutropenic patients respectively [64]. The risk is smaller (<1%) for the DRT or IV formulations [56]. Although some authors have reported higher rates in patients with myeloid malignancies without differences between formulations [75] others, have not substantiated this association, for hematological patients [170] or lung transplant recipients [72]. Special attention is warranted for patients with known proarrhythmic conditions (i.e. cardiomyopathy). Correction of electrolytes (potassium, magnesium, calcium) is advised during posaconazole treatment [27].
Cardiac arrhythmias in pregnant women: need for mother and offspring protection
Published in Current Medical Research and Opinion, 2020
Theodora A. Manolis, Antonis A. Manolis, Evdoxia J. Apostolopoulos, Despoina Papatheou, Helen Melita, Antonis S. Manolis
Quinidine (former FDA category C) has the longest record of use in pregnancy. There are reports of preterm labor, thrombocytopenia, and fetal acoustic nerve injury and ototoxicity noted at high doses61,120. Teratogenicity has not been reported for quinidine. Quinidine has been used successfully for both maternal and, due to the ease of placental transfer, fetal ventricular and supraventricular arrhythmias118,121. Serum-level monitoring is required to avoid proarrhythmia. Procainamide is also considered safe to use during pregnancy and has been used frequently, however its use has been limited to acute therapy, due to the high likelihood of drug-induced lupus reported with chronic use. Particular attention should be paid to monitor for hypotension during its IV administration; slow infusion rate at ≤20–50 mg/min is recommended. Experience with disopyramide in pregnancy is limited.
Current pharmacotherapeutic strategies for cardiac arrhythmias in heart failure
Published in Expert Opinion on Pharmacotherapy, 2020
Ashish Correa, Yogita Rochlani, Wilbert S. Aronow
Cardiac arrhythmias are frequently seen in patients with HF. These rhythm disturbances can be related to the underlying pathology that causes the HF (such as atrial myopathy, ischemic cardiomyopathy, and scar related arrhythmia). Conversely, the arrhythmia itself can precipitate HF, such as with tachycardia-mediated cardiomyopathy. Regardless of the etiology, arrhythmias often lead to worsening of HF and are the leading cause of death in this patient population. It is important to treat these arrhythmias to control symptoms, slow disease progression and prevent sudden death. Management depends on the type of arrhythmia (atrial or ventricular), the stage of HF and other comorbidities. Antiarrhythmic agents are often used along with device therapy and catheter ablation. However, antiarrhythmic agents come with their own problems, such as proarrhythmic and negative inotropic effects. The knowledge of cardiac arrhythmias seen in HF patients and their evidence-based pharmacologic management strategies are important for physicians caring for these patients.