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Drugs in pregnancy and lactation
Published in Evelyne Jacqz-Aigrain, Imti Choonara, Paediatric Clinical Pharmacology, 2021
Evelyne Jacqz-Aigrain, Imti Choonara
Antiarrhythmic drugs are usually administered to the mother for fetal treatment. The selection of the drug is based on antiarrhythmic efficacy, pharmacokinetics, potential maternal and fetal toxic effects [15]. The drug administered as first choice is usually digoxin and the control of the arrhythmia is obtained in only 30 to 40% of cases. When return to sinus rhythm is not obtained, various other drugs are additionally prescribed, including amiodarone [15,16]. Sotalol has excellent placental transfer and is effective in the treatment of fetal arrhythmia [17].
Minimally Invasive Atrial Ablation Surgery
Published in Theo Kofidis, Minimally Invasive Cardiac Surgery, 2021
Edgerton et al. reported 30 patients (10 persistent, 20 long-standing persistent) who were followed for 6 months with ECG and 14- to 21-day auto-triggered monitors. Three (10%) patients required pacemakers. At 6 months, the overall success rate was 58% off antiarrhythmic drugs and 80% with or without antiarrhythmic drugs, as assessed by long-term (14- to 21-day) event monitoring [17].
Management strategies
Published in Gregory YH Lip, Atrial Fibrillation in Practice, 2020
The objectives of management of paroxysmal AF are the suppression of paroxysms and the long-term maintenance of sinus rhythm, as well as appropriate thromboprophylaxis. Many patients with paroxysmal AF are young and ‘lone AF’ is more common when compared to sustained AF. If a patient is experiencing only mild and infrequent symptoms, it may be possible to avoid antiarrhythmic drugs and their potential for toxicity.
Indications for mexiletine in the new ESC guidelines and beyond
Published in Expert Opinion on Pharmacotherapy, 2023
Mate Vamos, Elod-Janos Zsigmond, Stefan H. Hohnloser
The first class of the conventional Vaughan-Williams antiarrhythmic drug classification consists of sodium-channel blockers. Blocking Na-channels basically yields a stabilization of the cell membrane thereby achieving an antiarrhythmic effect (i.e. greater depolarization potential is required to open enough Na+ channels to overcome K+ currents at the resting membrane potential) [6]. Of note, there is also a modernized classification of current AADs, but this does not affect the categorization of mexiletine [7]. Unlike class IA or IC drugs, mexiletine rather shortens than prolongs action potential duration; therefore, it is less prone to proarrhythmic effects associated with QT or QRS prolongation (Table 1) [6,7]. This is mainly due to the fact that IB AADs preferentially block the late inward Na+ current [6].
Gene therapy to terminate tachyarrhythmias
Published in Expert Review of Cardiovascular Therapy, 2022
Kohei Kawajiri, Kensuke Ihara, Tetsuo Sasano
Gene therapy targeting cardiac arrhythmias has been studied for many years, but few clinical applications have been made. Currently, the most commonly used treatments for cardiac arrhythmia are antiarrhythmic drugs, ablative therapy, and implantable devices. Antiarrhythmic drugs, which have been studied for a long time, have shown some efficacy in treating tachyarrhythmias [1]. Ablative therapy is making progress and is particularly effective in treating paroxysmal and early stage of supraventricular arrhythmias [2]. Implantable devices are used to prevent sudden death [3,4]. However, it is difficult to treat all arrhythmias effectively with these therapies [5]. In particular, persistent atrial fibrillation (AF), which is often encountered in daily practice, is difficult to treat using the methods listed above [6], and the treatment of catheter ablation or antiarrhythmic drugs may lead to iatrogenic arrhythmias [7–9]. Once implanted, Implantable Cardioverter-Defibrillators (ICDs) are effective in preventing sudden death from ventricular tachycardia (VT) and ventricular fibrillation (VF), but it is difficult to treat the arrhythmia itself and suppress its onset. It can also cause device infections in the long term [10].
Clinical outcomes following rhythm control for atrial fibrillation: is early better?
Published in Expert Review of Cardiovascular Therapy, 2021
Agnieszka Kotalczyk, Wern Yew Ding, Dhiraj Gupta, David Justin Wright, Gregory Y. H. Lip
The CABANA trial was a recently published RCT, including 2204 patients with paroxysmal or persistent AF with a median age of 68 years, comparing outcomes of catheter ablation vs. antiarrhythmic drug therapy [25]. Patients had a median time since AF onset of 1.1 years, and more than half the patients had non-paroxysmal AF. Over a median follow-up of 48.5 months, the use of catheter ablation did not significantly reduce the combined primary endpoint of death, disabling ischemic stroke, major bleeding, or cardiac arrest (8.0% vs 9.2%; HR: 0.86; 95% CI: 0.65–1.15). The risk of death or cardiovascular hospitalization (HR: 0.83; 95% CI: 0.74–0.93) and the risk of AF recurrence (HR: 0.52; 95% CI: 0.45–0.60) was significantly lower in the ablation group as compared to the drug therapy group [25]. However, almost 10% patients randomized to the catheter ablation group did not undergo the procedure, whereas 27.5% of patients assigned to the drug therapy group received catheter ablation. Such significant cross-over may have introduced bias to the results and in fact, the ‘as-treated’ analysis demonstrated catheter ablation to be superior to medical therapy. Indeed, a subsequent ‘real-world’ study revealed that catheter ablation was related to a reduction in the composite endpoint of death, disabling ischemic stroke, major bleeding, or cardiac arrest (HR: 0.75; 95% CI: 0.70–0.81); and that the benefit was more significant in the CABANA-eligible patients (HR 0.70, 95% CI 0.63–0.77) compared with the medical therapy group [26].