Current Cardiology Reports

, Volume 4, Issue 5, pp 434–440

Interactions of antiarrhythmic drugs and implantable devices in controlling ventricular tachycardia and fibrillation

  • Yadavendra S. Rajawat
  • Darryl Dias
  • Edward P. Gerstenfeld
  • Sanjay Dixit
  • Bindi Shah
  • Andrea M. Russo
  • Francis E. Marchlinski


Implantable cardioverter defibrillators (ICDs) have proven highly successful in the treatment of life-threatening ventricular arrhythmias. Despite the efficacy of the ICD in terminating ventricular arrhythmias, antiarrhythmic drugs remain an important adjunct to ICD therapy. The use of antiarrhythmic drug therapy in combination with the ICD is synergistic in terms of beneficial effects, but also has the potential for some adverse interactions. Knowledge and recognition of these potential interactions is important for any physician managing patients with an ICD. This review summarizes the benefits and adverse effects of ICD in combination with antiarrhythmic drug therapy, and provides guidelines to ensure safe application of this hybrid therapy.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Shah B, Russo A, Kuntz C, et al.: Changing patterns in antiarrhythmic drug use in implantable cardioverter defibrillator patients over the last decade [abstract]. PACE 2001, 24:649.Google Scholar
  2. 2.
    Sperry RE, Stambler BS, Wood M, et al.: Reduction of antiarrhythmic drug use in patients receiving implantable cardioverter defibrillators. PACE 1996, 19:61–64.PubMedGoogle Scholar
  3. 3.
    Movsowitz C, Marchlinski F: Interactions between implantable cardioverter-defibrillators and class III agents. Am J Cardiol 1998, 82:41I-48I. This paper gives an excellent review of interactions between ICDs and class III agents.PubMedCrossRefGoogle Scholar
  4. 4.
    Knilans TK, Prystowsky EN: Antiarrhythmic drug therapy in the management of cardiac arrest survivors. Circulation 1992, 85:I118.PubMedGoogle Scholar
  5. 5.
    Manz M, Jung W, Luderitz B: Interaction between drugs and devices: experimental and clinical studies. Am Heart J 1994, 127:978.PubMedCrossRefGoogle Scholar
  6. 6.
    Greene HL: Interaction between pharmalogical and nonpharmalogical antiarrhythmic therapy. Am J Cardiol 1996, 78:61–66.PubMedCrossRefGoogle Scholar
  7. 7.
    Echt D, Armstrong K, Schmidt P, et al.: Clinical experience, complications, and survival in 70 patients with automatic implantable cardioverter-defibrillator. Circulation 1985, 71:289–296.PubMedGoogle Scholar
  8. 8.
    Bardy GH, Troutman C, Poole JE, et al.: Clinical experience with a tiered therapy multiprogrammable antiarrhythmia device. Circulation 1992, 85:1689–1698.PubMedGoogle Scholar
  9. 9.
    Epstein AE, Ellenbogen KA, Kirk K, et al., and the high defibrillation threshold investigators: Clinical characteristics and outcome of patients with high defibrillation thresholds. Circulation 1992, 86:1206–1216.PubMedGoogle Scholar
  10. 10.
    Steinberg JS, Martins J, Sadanandan S, et al.: The AVID Investigators: antiarrhythmic drug use in the implantable defibrillator arm of the Antiarrhythmics Versus Implantable Defibrillators (AVID) Study. Am Heart J 2001, 142:520–529. An important prospective study investigating the need for, and effects of, concomitant antiarrhythmic drugs with the ICD.PubMedCrossRefGoogle Scholar
  11. 11.
    Gradaus R, Fiseifis F, Huber H, et al.: Mortality, morbidity, and complications in 3344 patients with implantable cardioverter-defibrillators: result from the Germany ICD registry EURID [abstract]. Circulation 2001, 104(Supp II):3098.Google Scholar
  12. 12.
    Zado E, Deely M, Jumper C, Marchlinski F: Symptoms after ICD discharge: correlation to symptoms before discharge and number of shocks [abstract]. PACE 1999, 2:152.Google Scholar
  13. 13.
    Exner D, Schron E, Yao Q, et al.: Defibrillator shocks and self-perceived quality of life in the antiarrhythmics versus implantable defibrillators (AVID) trial [abstract]. J Am Coll Cardiol 2000, 35:891–894.Google Scholar
  14. 14.
    Dunbar S, Zhang Z, Smith P: Quality of life outcomes for ventricular arrhythmia patients: the PRIDE Study. Circulation 2001, 104:(Supp II):3618.Google Scholar
  15. 15.
    Dougherty CM: Psychological reactions and family adjustment in shock versus no shock groups after implantation of internal cardioverter defibrillator. Heart Lung 1995, 24:281–291.PubMedCrossRefGoogle Scholar
  16. 16.
    Pacifico A, Hohnloser SH, Williams JH, et al., for the d, l-Sotalol Implantable Cardioverter-Defibrillator Study Group. Prevention of implantable-defibrillator shocks by pretreatment with sotalol. N Engl J Med 1999, 340:1855. An important double-blind study that assessed the value of sotalol treatment for the prevention of ICD shocks and improvement of survival.PubMedCrossRefGoogle Scholar
  17. 17.
    Kuhlkamp V, Mewis C, Mermi J, et al.: Suppression of sustained ventricular tachyarrhythmias: a comparison of d, I-sotalol with no antiarrhythmic drug treatment. J Am Coll Cardiol 1999, 33:46–52.PubMedCrossRefGoogle Scholar
  18. 18.
    O’Toole M, O’Neill G, Kluger J, et al.: Efficacy and safety of oral dofetilide in patients with an implantable defibrillator: a multicenter study [abstract]. Circulation 1999, 100:I-794.Google Scholar
  19. 19.
    Dorian P, Newman D: Effect of sotalol on ventricular fibrillation and defibrillation in humans. Am J Cardiol 1993, 72:72A-79A.PubMedCrossRefGoogle Scholar
  20. 20.
    Dorian P, Wang M, David I, Feindel C: Oral clofilium produces sustained lowering of defibrillation energy requirements in a canine model. Circulation 1991, 83:614–621.PubMedGoogle Scholar
  21. 21.
    Dorian P, Newman D, Sheahan R, et al.: d-Sotalol decreases defibrillation energy requirements in humans: a novel indication for drug therapy. J Cardiovasc Electrophysiol 1996, 7:952–961.PubMedCrossRefGoogle Scholar
  22. 22.
    Wang M, Dorian P: DL and D sotalol decrease defibrillation energy requirements. PACE 1989, 12:1522–1529.PubMedGoogle Scholar
  23. 23.
    Qi X, Newman D, Dorian P: Azimilide decreases defibrillation voltage requirements and increases spatial organization during ventricular fibrillation. J Intervent Cardiac Electrophysiol 1999, 3:61–67.CrossRefGoogle Scholar
  24. 24.
    Woolfolk DI, Chaffee WR, Cohen W, et al.: The effect of quinidine on electrical energy required for ventricular defibrillation. Am Heart J 1966, 72:659–663.PubMedCrossRefGoogle Scholar
  25. 25.
    Babbs CF, Yim GKW, Whistler SJ, et al.: Elevation of ventricular defibrillation threshold in dogs by antiarrhythmic drugs. Am Hear J 1979, 98:345–350.CrossRefGoogle Scholar
  26. 26.
    Dawson AK, Steinberg MI, Shapland JE, et al.: Effects of class I and class II drugs on current and energy required for internal defibrillation. Circulation 1985, 72:384.Google Scholar
  27. 27.
    Echt DS, Black JN, Barbey JJ, et al.: Evaluation of an antiarrhythmic drugs on defibrillation energy requirements in dogs: sodium channel block and action potential prolongation. Circulation 1989, 79:1106–1117.PubMedGoogle Scholar
  28. 28.
    Ware DL, Atkinson JB, Brooks MJ, et al.: Ventricular defibrillation in canines with chronic infarction, and effects of lidocaine and procainamide. PACE 1993, 16:337–346.PubMedGoogle Scholar
  29. 29.
    Echt DS, Gremillion ST, Lee JT, et al.: Effects of procainamide and lidocaine on defibrillation energy requirements in patients receiving implantable cardioverter defibrillator devices. J Cardiovasc Electrophysiol 1994, 5:752–760.PubMedCrossRefGoogle Scholar
  30. 30.
    Dorian P, Fain ES, Davy JM, et al.: Lidocaine causes a reversible, concentration-dependent increase in defibrillation energy requirements. J Am Coll Cardiol 1986, 8:327–332.PubMedCrossRefGoogle Scholar
  31. 31.
    Topham S, Cha YM, Peters BB, et al.: Effects of lidocaine on relation between defibrillation threshold and upper limit of vulnerability in open-chest dogs. Circulation 1992, 85:1146–1151.PubMedGoogle Scholar
  32. 32.
    Senatore G, Coltorti F, Giordano B, Nocerino P, Stabile G, Simone A, Caprioli V, Chiariello M: Defibrillation threshold in patients with ICD and concomitant antiarrhythmic therapy [abstract]. PACE 1999, 22:413.Google Scholar
  33. 33.
    Szabo T, Jones D, McQuinn R, Klein G: Flecainide acetate does not alter the energy requirements for direct ventricular defibrillation using sequential pulse defibrillation in pigs. J Cardiovasc Pharmacol 1988, 12:377–383.PubMedCrossRefGoogle Scholar
  34. 34.
    Natale A, Jones D, Kleinstiver P, et al.: Effects of flecainide on defibrillation threshold in pigs. J Cardiovasc Pharmacol 1993, 21:573–577.PubMedCrossRefGoogle Scholar
  35. 35.
    Hernandez R, Mann DE, Breckinridge S: Effects of flecainide on defibrillation threshold in the anesthetized dog. J Am Coll Cardiol 1989, 14:777–781.PubMedCrossRefGoogle Scholar
  36. 36.
    Ujhelyi M, O’Rangers E, Kluger J, et al.: Defibrillation energy requirements during moricizine and moricizine-lidocaine therapy. J Cardiovasc Pharmacol 1992, 20:932–939.PubMedCrossRefGoogle Scholar
  37. 37.
    Avitall B, Hare J, Zander G, et al.: Cardioversion, defibrillation and overdrive pacing of ventricular arrhythmias: the effect of moricizine in dogs with sustained monomorphic ventricular tachycardia. PACE 1993, 16:2092–2097.PubMedGoogle Scholar
  38. 38.
    Stevens S, Haffajee C, Naccarelli G, et al.: Effect of oral propafenone on defibrillation and pacing thresholds in patients receiving implantable cardioverter-defibrillators. J Am Coll Cardiol 1996, 28:418–422.PubMedCrossRefGoogle Scholar
  39. 39.
    Bailey WM, Fukaye E, Weinberger J, et al.: MK-499, a new class III agent, reduces defibrillation threshold in patients with chronically implanted defibrillators [abstract]. PACE 1995, 18:835.Google Scholar
  40. 40.
    Gremillion ST, Echt DS, Smith NA, et al.: Beneficial effect of intravenous dofetilide in patients undergoing ventricular defibrillation testing [abstract]. Circulation 1992, 86:I-264.Google Scholar
  41. 41.
    Fain ES, Lee JT, Winkle RA: Effect of acute intravenous and chronic oral amiodarone on defibrillation energy requirements. Am Heart J 1987, 114:8–17.PubMedCrossRefGoogle Scholar
  42. 42.
    Kopp D, Kall J, Kinder C, et al.: Effect of amiodarone and left ventricular mass on defibrillation energy requirements: monophasic versus biphasic shocks [abstract]. PACE 1995, 18:872.Google Scholar
  43. 43.
    Haberman RJ, Veltri EP, Mower MM: The effect of amiodarone on defibrillation threshold. J Electrophysiol 1998, 2:415–423.Google Scholar
  44. 44.
    Jung W, Manz M, Pizzulli L, et al.: Effects of chronic amiodarone therapy on defibrillation threshold. Am J Cardiol 1992, 70:1023–1027.PubMedCrossRefGoogle Scholar
  45. 45.
    Manz M, Jung W, Luderitz B: Interaction between drugs and device: experimental and clinical studies. Am Heart J 1994, 127(Suppl):978–984.PubMedCrossRefGoogle Scholar
  46. 46.
    Frame L: The effect of chronic oral and acute intravenous amiodarone administration on ventricular defibrillation threshold using implantable electrodes in dogs. PACE 1989, 12:339–346.PubMedGoogle Scholar
  47. 47.
    Klein RC, Gold M, Higgins S, et al.: The low energy safety study: Baseline characteristics and results of defibrillation testing. Circulation 2001, 104(Supp II):3091.PubMedGoogle Scholar
  48. 48.
    Zhou l, Chen B, Kluger J, et al.: Effects of amiodarone and its active metabolite desethylamiodarone on the ventricular defibrillation threshold. J Am Coll Cardiol 1998, 31:1672–1678.PubMedCrossRefGoogle Scholar
  49. 49.
    Hook BG, Perlman RL, Callans DJ, et al.: Acute and chronic cycle length dependent increase in ventricular pacing threshold. PACE 1992, 15:1437–1444.PubMedGoogle Scholar
  50. 50.
    Hellestrand KJ, Nathan AW, Bexton RS, et al.: Electrophysiologic effects of flecainide acetate on sinus node function, anomalous atrioventricular connections and pacemakers thresholds. Am J Cardiol 1984, 53:30B-38B.PubMedCrossRefGoogle Scholar
  51. 51.
    Marchlinski FE, Buxton AE, Kindwall KE, et al.: Comparision of individual and combined effects of procainamide and amiodarone in patients with sustained ventricular tachyarrhythmias. Circulation 1988, 78:583–591.PubMedGoogle Scholar
  52. 52.
    Grimm W, Cho JG, Marchlinski FE: Effects of incremental doses of procainamide in patients with sustained uniform ventricular tachycardia. J Card Electrophysiol 1994, 5:313–322.CrossRefGoogle Scholar
  53. 53.
    Farre J, Grande A, Albo PS, et al.: Arrhythmogenic effects of antiarrhythmic drugs in patients with an old myocardial infarction and asymptomatic ventricular ectopic activity as studied by programmed electrical stimulation. Eur Heart J 1987, 8(Suppl A):113–119.PubMedGoogle Scholar
  54. 54.
    Wellens HJJ, Brugada P, Farre J: Ventricular arrhythmias: mechanism and actions of antiarrhythmic drugs. Am Heart J 1984, 107:1053–1057.PubMedCrossRefGoogle Scholar
  55. 55.
    Mazur A, Anderson M, Bonney S, Roden D: Pause-dependent polymorphic ventricular tachycardia during long-term treatment with dofetilide. J Am Coll Cardiol 2001, 37:1100–1105.PubMedCrossRefGoogle Scholar
  56. 56.
    Johnson N, Marchlinski FE: The need to enhance diagnostic specificity to avoid device response to supraventricular rhyyhms and risk of induced ventricular arrhythmias. J Am Coll Cardiol 1991, 18:1418–1422.PubMedCrossRefGoogle Scholar
  57. 57.
    Marchlinski FE, Zado E, Callans DJ, et al.: Hybrid therapy for ventricular arrhythmia management. In Cardiology Clinics: Ventricular Arrhythmias. Edited by Miller JM. Philadelphia: WB Saunders; 1999:391–406.Google Scholar
  58. 58.
    Wilbur SL, Marchlinski FE: Implantable cardioverterdefibrillator follow-up: what every physician should know. Cardiol Rev 1999, 7:9. This review summarizes routine device follow-up, provides instructions regarding emergency ICD deactivation, and discusses common complications and how to detect them.CrossRefGoogle Scholar
  59. 59.
    Lindsay B: Troubleshooting new ICD system. J Intervent Cardiol 1994, 7:473–485.PubMedGoogle Scholar

Copyright information

© Current Science Inc 2002

Authors and Affiliations

  • Yadavendra S. Rajawat
    • 1
  • Darryl Dias
    • 1
  • Edward P. Gerstenfeld
    • 1
  • Sanjay Dixit
    • 1
  • Bindi Shah
    • 1
  • Andrea M. Russo
    • 1
  • Francis E. Marchlinski
    • 1
  1. 1.University of PennsylvaniaPhiladelphiaUSA

Personalised recommendations