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Efficacy of Flecainide, Sotalol, and Verapamil in The

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Efficacy of Flecainide, Sotalol, and Verapamil in The 392 Br Heart J 1992;68:392-7 Efficacy of flecainide, sotalol, and verapamil in the treatment of right ventricular tachycardia in Br Heart J: first published as 10.1136/hrt.68.10.392 on 1 October 1992. Downloaded from patients without overt cardiac abnormality Jaswinder S Gill, Davendra Mehta, David E Ward, A John Camm Abstract associated with a clinically normal heart Objective-A comparison ofthe efficacy can be suppressed by flecainide, sotalol, of verapamil, sotalol, and flecainide to or verapamil. In individual patients suppress right ventricular tachycardia sotalol was the most frequently effective (VT) in patients with a clinically normal drug (effective in > 89% of patients) and heart. is a suitable choice for first line Design-Patients underwent treat- treatment. ment serially with verapamil (360 mg daily), sotalol (240 or 320 mg daily), and (Br Heart J 1992;68:392-7) flecainide (200 or 300 mg daily), (the Most patients presenting with ventricular larger dose was for patients heavier than tachycardia (VT) have easily detectable 80 kg) to suppress tachycardia. Each underlying cardiac disease, such as coronary drug was given orally for five half lives artery disease, cardiomyopathy, and valvar or before testing. congenital heart disease. Five to 10 percent of Patients-23 patients with right VT patients, however, are reported to have no associated with a clinically normal heart underlying heart disease as suggested by non- were studied. invasive and invasive assessment of left Outcome measures-The effects of ventricular function and coronary anatomy.`-3 drug treatment were examined by the These patients do, however, exhibit variable number of ventricular events on 24 hour degrees of histological abnormality on cardiac Holter monitoring, and the ability of interstitial and tachycardia to be induced by treadmill biopsy (60-90%), including perivascular fibrosis and vascular sclerosis, http://heart.bmj.com/ exercise testing (Bruce protocol) and acute or subacute myocarditis, and an increase programmed ventricular stimulation in interstitial adipose tissue.' The reports on (Wellens protocol), compared with drug the prognosis of such patients are contradic- free baseline tests. tory.7' Although most authors suggest that Setting-Patients were studied in a prognosis is good, there are several who tertiary referral centre. indicate that this may be a more common Results-All three drugs suppressed cause of sudden death in young patients than ventricular salvos ( > 3, < 5 consecutive previously proposed.'12 Even though treat- on September 27, 2021 by guest. Protected copyright. ventricular premature contractions) ment may not be indicated on prognostic (p < 0-01) and VT (p < 0 05) on Holter grounds, many of these patients are severely monitoring and did not differ statistically symptomatic and require treatment to control in efLect. Exercise induced VT was also the tachycardia. Most of the treatment data on suppressed by all three drugs (p < 0-01), these patients consist of short case series and and of these sotalo: was the most effective anecdotal reports,'1'5 and there has been although this was not statistically no adequate study of the efficacy of anti- significant (14/23 inducible when drug arrhythmic drugs in controlling this form of free, 4/23 on flecainide, 2/23 on sotalol, VT. Our study examines and compares the 5/23 on verapamil). Sustained and non- efficacy of flecainide, sotalol, and verapamil sustained VT induced by programmed in the treatment of VT in patients with stimulation was also suppressed by the apparently normal hearts. Department of three drugs (p < 0-01) and again sotalol Cardiological was the best of these though the differ- Sciences, St George's Hospital Medical ences did not achieve statistical sig- Patients and methods School, London nificance (17/23 inducible when drug free, PATIENTS J S Gill 4/17 on flecainide, 2/17 on sotalol, and 6/17 Twenty three patients with a clinical history of D Mehta of sustained VT 30 s) and a clinically normal D E Ward on verapamil). Proarrhythmic effects (> A J Camm drugs were found in a few patients. heart were studied. These patients came from a Correspondence to There was no difference in the efficacy of group of 26 consecutive patients with right Dr J S Gill, the drugs in patients with histological. ventricular tachycardia seen at our institution Departnent of Cardiological Sciences, St George's abnormalities of the myocardium when over two years. Two patients had had at least Hospital Medical School, compared with those of normal two of the drugs used in this study on a London SW17 ORE. histology. previous occasion and these were clinically Accepted for publication 8 April 1992 Conclusions-Ventricular tachycardia ineffective. One patient was on amiodarone. Efficacy offlecainide, sotalol and verapamil in the treatment ofright ventricular tachycardia in patients without overt cardiac abnormality 393 These patients were excluded from our study. >3 beats to <30 s and terminating sponta- Patients gave informed consent to the protocol neously without haemodynamic compromise). for drug testing and were enrolled in the study Despite the non-sustained nature of the ar- on the basis of the following criteria: (a) rhythmia in many patients, all patients were Br Heart J: first published as 10.1136/hrt.68.10.392 on 1 October 1992. Downloaded from patients had no history of ischaemic heart severely symptomatic and merited treatment disease or congenital cardiac abnormality. (b) on this basis. The mean (SD) rate of tachy- All had chronic ventricular arrhythmia cardia was 212 (37-8) beats/min. Patients documented on multiple electrocardiographic underwent echocardiographic examination, leads either during a spontaneous episode or and all had normal left ventricular function and during an exercise test. Arrhythmia was defined dimensions. The findings for the right ven- as chronic when there was a minimum of two tricular examination have been published documented episodes at least one month apart. already in a larger group of such patients.'6 (c) Patients had a normal clinical examination, Signal averaged electrocardiography was per- normal chest radiograph (cardiothoracic ratio formed on admission and patients also under- < 50%), and normal resting electrocardiogram went full electrophysiological evaluation before (apart from T wave abnormalities). Patients entry in the study. Ventricular endomyocardial with intraventricular conduction abnor- biopsies were taken and subjected to routine malities, left or right ventricular hypertrophy, histopathological studies. and prolongation of the QT interval were excluded. (d) No patient had angiographic DRUG TREATMENT evidence of coronary artery disease, reduced Many of the patients had already received ejection fraction of the left ventricle, or abnor- treatment for their tachycardia, but in all, mality of regional wall motion during left treatment was stopped at least 72 hours before ventricular cineangiography as assessed by two admission and evaluation of the patient in a independent observers. drug free state. No patient had received All patients had episodes ofpalpitation, eight amiodarone within three months of assess- had experienced syncope and an additional 11 ment. Patients received verapamil (360 mg had had presyncope. The duration of symp- daily in three divided doses), sotalol (240 mg or toms ranged from two weeks to 20 years. The 320 mg), and flecainide (200 or 300 mg) daily in documented spontaneous arrhythmia was of divided doses. The larger doses were given to right ventricular tachycardia (left bundle patients Who weighed more than 80 kg. The branch block-like morphology) in all 23 drugs were given serially and maintained for a patients (QRS complex > 120 ms and minimum of five half lives to allow stable predominently negative in lead VI, fig). The concentrations to be reached before evaluation frontal plane axis ofthe clinical tachycardia was of efficacy. At least five half lives were allowed defined from the limb leads as leftward between drugs to wash out the previous drug. (<-30°), rightward (> + 900), or normal This is therefore an open, non-randomised, (-30° to + 90°) from the vector perpendicular fixed sequence drug study. This design was http://heart.bmj.com/ to the lead with the most isoelectric QRS accepted because of clinical and administrative complexes. The history of palpitations was limitations. A fully randomised double blind suggestive of sustained episodes of VT in all study would have required matching tablets to patients with either documented arrhythmia, be given in random order. Five half lives of the syncope, or presyncope. The episodes of clini- drug with the longest half life would have been cal tachycardia were documented as sustained necessary at each stage to load and wash out the in 10 patients (spontaneous arrhythmia of drugs. This would result in a prohibitively long on September 27, 2021 by guest. Protected copyright. uniform QRS morphology lasting >30 s or admission for the patient. The use of the drugs requiring termination because of haemo- with the shorter half lives initially allowed dynamic compromise) and non-sustained in rapid loading and washout of the drug, reduc- the rest (uniform broad QRS complexes lasting ing the time necessary for the study. aVR vi V4 EVALUATION OF TREATMENT Patients were evaluated with Holter monitor- ing, exercise testing, and programmed ven- YAYYAA}A tricular stimulation when drug free and on each of the three drug treatments. For drug free had been on no
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