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Effects of cardioactive medications on retrograde conduction: Continuing relevance for current devices

Journal of Interventional Cardiac Electrophysiology volume 15, pages 49–55 (2006)Cite this article

Abstract

Introduction. Retroconduction (ventriculo-atrial conduction) remains a problem for patients with implanted cardiac rhythm devices. Pacemaker algorithms can detect and terminate endless loop tachycardia (ELT), but actual prevention of ELT may require anti-arrhythmic drugs (AADs). Similarly, AADs can affect ICD rhythm discrimination algorithms that depend on atrio-ventricular ratios. There is concern whether these drugs remain effective during stress situations.

Methods. Electrophysiologic studies that included retroconduction testing using slow ramp pacing were done in 1332 patients. The presence or absence of retroconduction at baseline and with drug was recorded, as was the rate at block. As a stress surrogate, isoproterenol was used to test retroconduction and reversal of drug-induced block.

Results. Procainamide, mexiletine, phenytoin, disopyramide, quinidine, beta-blockers, encainide, and amiodarone caused complete retrograde block or decreased the rate at which block occurred (mean 76% of patients, p < 0.008), whereas digoxin, lidocaine, diltiazem, and verapamil did not. Isoproterenol (in the absence of AADs) increased the rate at block in 82% of 404 patients with retroconduction at baseline (p < 0.005). Of 319 patients without retroconduction at baseline, 134 (42%) developed retroconduction after isoproterenol. Isoproterenol reversed retrograde block in 39% of patients with block on an AAD. Amiodarone, digoxin, and the combination of digoxin plus a beta-blocker were most effective at resisting this reversal of ventriculo-atrial block (80%, 68%, and 75% respectively).

Conclusion. Most of the AADs reviewed increase the cycle length at block or abolish retroconduction, while isoproterenol has the opposite effect. Anti-arrhythmic medications, particularly amiodarone, digoxin, and the combination of digoxin plus a beta-blocker may be considered for a patient with multiple ELT episodes or certain ICD detection problems.

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Affiliations

  1. Department of Medicine, Cardiology Division, Arrhythmia Service, Montefiore Medical Center and the Albert Einstein College of Medicine, New York

    John E. O’Mara, John D. Fisher, Sue J. Goldie, Soo G. Kim, Kevin J. Ferrick, Jay N. Gross & Eugen C. Palma

  2. Montefiore Hospital, Cardiology N-2, Arrhythmia Offices, 111 E. 210th Street, Bronx, NY, 10467

    John D. Fisher

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  1. John E. O’Mara
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  2. John D. Fisher
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Correspondence to John D. Fisher.

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O’Mara, J.E., Fisher, J.D., Goldie, S.J. et al. Effects of cardioactive medications on retrograde conduction: Continuing relevance for current devices. J Interv Card Electrophysiol 15, 49–55 (2006). https://doi.org/10.1007/s10840-006-7621-z

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  • DOI: https://doi.org/10.1007/s10840-006-7621-z

Keywords

  • Pacemaker
  • Endless loop tachycardia
  • Pacemaker-mediated tachycardia
  • Anti-arrhythmic drugs
  • Retrograde conduction
  • ICD detection algorithm