Pharmacologic Management for Ventricular Arrhythmias: Overview of Anti-Arrhythmic Drugs

Abstract

Ventricular arrhythmias (Vas) are a life-threatening condition and preventable cause of sudden cardiac death (SCD). With the increased utilization of implantable cardiac defibrillators (ICD), the focus of VA management has shifted toward reduction of morbidity from VAs and ICD therapies. Anti-arrhythmic drugs (AADs) can be an important adjunct therapy in the treatment of recurrent VAs. In the treatment of VAs secondary to structural heart disease, amiodarone remains the most well studied and current guideline-directed pharmacologic therapy. Beta blockers also serve as an important adjunct and are a largely underutilized medication with strong evidentiary support. In patients with defined syndromes in structurally normal hearts, AADs can offer tailored therapies in prevention of SCD and improvement in quality of life. Further clinical trials are warranted to investigate the role of newer therapeutic options and for the direct comparison of established AADs.

Pharmacotherapy in Ventricular Arrhythmias

“…However, in another study, procainamide recipients who received more shocks and pharmacologic interventions and had lengthier resuscitations were less likely to survive hospital discharge, though these results were probably confounded by the administration of other cardiac medications [29]. Oral procainamide was also shown to reduce sustained VT and VF as well as ICD therapies in a small study of 34 patients [25]. Though 55% of these had a previous catheter ablation for VT, it was initiated after VT was inducible in these patients [25].…”

“…Oral procainamide was also shown to reduce sustained VT and VF as well as ICD therapies in a small study of 34 patients [25]. Though 55% of these had a previous catheter ablation for VT, it was initiated after VT was inducible in these patients [25]. Though this could be a confounding factor, it is not necessarily a negative study as a combination of anti-arrhythmias and catheter ablation are routinely used to decrease the burden of VT and ICD therapies in everyday practice.…”

“…In the 2022 ESC Guidelines for the management of VAs, it has a class IIa recommendation for acute management of idiopathic VT over other AADs like amiodarone and sotalol which are class IIb [14]. Being a sodium channel blocker like flecainide, it can unmask Brugada syndrome (BrS) and is used for provocative testing in patients with BrS [25].…”

“…However, its use in VAs is less established with mixed results in trials. It has been used in select settings for reducing ICD therapies as well as the recurrence of VT where other AADs have not been successful [25].…”

“…It increases QRS duration at higher heart rates but does not prolong QTc. In the VANISH trial, mexiletine and amiodarone were found to be inferior when compared to catheter ablation when compared for the composite outcome of death, electrical storm, or appropriate ICD shock [25].…”