Skip to main content
SpringerLink
Log in

The Role of EP-Guided Therapy in Ventricular Arrhythmias: Beta-Blockers, Sotalol, and ICD's

  • Published:
Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Arrhythmic death can be reduced by antiarrhythmic drugs to a range of 2—4%. Electrophysiologic study by testing noninducibility of ventricular arrhythmia represents the classic method for evaluating the effectiveness of drug therapy.

Several clinical studies have shown thaat sotalol suppresses VT induction and prevents arrhythmias recurrences at long term follow-up in 23% to 67% of patients. The efficacy of sotalol EP guided therapy in preventing VT/VF is not necessarily related to prevention of sudden death. In the ESVEM study the superiority of d,l-sotalol to other antiarrhythmic drugs was confirmed. The response to programmed ventricular stimulation was found to be strongly predictive for arrhythmia free state while the failure of sotalol therapy to suppress VT at the EP study was associated with an high recurrence rate (40%). However, EP study failes to predict freedom from sudden death. The beta-blocking activity of racemic sotalol may account for some of the observed survival benefit.

Beta-blockers therapy reduces mortality in patients after myocardial infarction primarily by a reduction of sudden death. A reduction of death, worsening heart failure and life threatening ventricular arrhythmias was shown in a recent study on carvedilol. In the prospective study of Steinbeck the EP guided-therapy did not improve the overall outcome when compared to metoprolol. Suppression of inducible arrhythmias by antiarrhythmic drugs was associated with a better outcome. The effectiveness of defibrillator therapy in reducing overall mortality, has been uncertain since great clinical trials have been concluded. MADIT, AVID and CASH trials confirmed the superiority of ICD therapy over antiarrhythmic drugs therapy: ICD should be considered the first choice therapy in post-cardiac arrest patients.

The ongoing BEST Trial will give us further responses about the interaction between EP study and metoprolol effect compared to ICD in patients post myocardial infarction also focusing on tolerability and compliance of the beta-blocking therapy in patients with low ejection fraction. In this study will be useful to optimize therapy in patients at high risk of sudden death

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Wilber DJ, Garan H, Finkelstein D, et al. Out-of-hospital cardiac arrest-Use of electrophysiologic testing in the prediction of long-term outcome. N Eng J Med 1988;318:19–24.

    Google Scholar 

  2. Prystowsky EN. Electrophysiologic-electropharmacologic testing in patients with ventricular arrhythmias. PACE 1988;11:225–251.

    Google Scholar 

  3. Borggrefe M, Trampisch HJ, Breithard G. Reappraisal of criteria for assessing drug efficacy in patients with ventricular tachyarrhythmias: Complete versus partial suppression of inducible arrhythmias. J Am Coll Cardiol 1988;12:140–149.

    Google Scholar 

  4. Waller TJ, Kay HR, Spielman SR. Reduction in sudden death and total mortality in patients with sustained ventricular tachyarrhythmias. J Am Coll Cardiol 1987;10:83–89.

    Google Scholar 

  5. Mitchell LB, Sheldon RS, Gillis AM, et al. Definition of predicted effective antiarrhythmic drug therapy for ventricular tachyarrhythmias by the electrophysiologic study approach: Randomized comparison of patient response criteria. J Am Coll Cardiol 1997;30:1346–1353.

    Google Scholar 

  6. Graboy TB, Lown B, Podrid PJ, et al. Long term survival of patients with malignant ventricular arrhythmias treatd with antiarrhythmic drugs. Am J Cardiol 1982;50:438–443.

    Google Scholar 

  7. Baum RS, Alvarez H, Cobb LA. Survival after resuscitation from out-of-hospital vantricular fibrillation. Circulation 1974;50:1231–1235.

    Google Scholar 

  8. Bardy GH, Hofer B, Johnson G. Implantable transvenous cardioverter-defibrillators. Circulation 1993;87:1152–1168.

    Google Scholar 

  9. Siebels J, Kuch K. Implantible cardioverter defibrillator compared with antiarrhythmic drug treatment in cardiac arrest survivors (the Cardiac Arrest Study Hamburg). Am Heart J 1994;127:1139–1144.

    Google Scholar 

  10. Myerburg RJ, Kessler KM, Estes D, et al. Long-term survival after out-of-hospital cardiac arrest. Analysis of outcome during 8 years study. Circulation 1984;70:538–546.

    Google Scholar 

  11. Rodriguez LM, Smeets J, O'Hara GE, et al. Incidence and timing of recurrences of sudden death and ventricular tachycardia during antiarrhythmic drug treatment after myocardial infarction. Am J Cardiol 1992;69:1403–1406.

    Google Scholar 

  12. Furukawa T, Rozansky JJ, Nogami A, et al. Time dependent risk of and predictors for cardiac arrest recurrences in survivors of out-of-hospital cardiac arrest with chronic coronary artery disease. Circulation 1989;80:599–608.

    Google Scholar 

  13. Mason JW. A comparison of electrophysiologic testing with Holter monitoring to predict antiarrhythmic drug efficacy for ventricular tachyarrhythmias. N Eng J Med 1993;329: 445–451.

    Google Scholar 

  14. Ruskin JN, DiMarco JP, Garan H. Out-of-hospital cardiac arrest: Electrophysiologic observations and selection of long term antiarrhythmic therapy. N Eng J Med 1980;303: 607–612.

    Google Scholar 

  15. Roy D, Waxman HL, Kienzle MG, et al. Clinical characteristics and long-term follow-up in 119 survivors of cardiac arrest: Relation to inducibility at electrophysiologic testing. Am J Cardiol 1983;52:969–974.

    Google Scholar 

  16. Zoni-Berisso M, Molini D, Mel GS, et al. value of programmed ventricular stimulation in predicting sudden death and sustained ventricular tachycardia in survivors of acute myocardial infarction. Am J Cardiol 1996;77:673.

    Google Scholar 

  17. Pedretti R, Etro, MD, Laporta A, et al. Prediction of late arrhythmic events after acute myocardial infarction from combined use of noninvasive prognostic variables and inducibility of sustained monomorphic ventricular tacycardia. Am J Cardiol 1993;71:1131.

    Google Scholar 

  18. Das SK, Morady F, DiCarlo, L, et al. Prognostic usefulness of programmed ventricular stimulation in idiopathic dilated cardiomyopathy without symptomatic ventricular arrhythmias. Am J Cardiol 1986;58:998.

    Google Scholar 

  19. Poll DS, Marchlinski FE, Buxton AE, et al. Usefulness of programmed stimulation in idiopathic dilated cardiomyopathy. Am J Cardiol 1986;58:992.

    Google Scholar 

  20. Hammill SC, Tresty JM, Wood DL, et al. Influence of ventricular function and presence or absence of coronary artery disease on results of electrophysiologic testing for asymptomatic nonsustained ventricular tachycardia. Am J Cardiol 1990;65:772.

    Google Scholar 

  21. Kowey PR, Taylor JE, Marinchak RA, Rialos SJ. Does programmed stimulation really help in the evaluation of patients with nonsustained ventricular tachycardia? Results of a meta-analysis. Am Heart J 1992;123:481.

    Google Scholar 

  22. Haverkamp W, Martinez-Rubio A, Hief C, et al. Efficacy and safety of d,l-sotalol in patients with ventricular tachycardia and in survivors of cardiac arrest. J Am Coll Cardiol 1997; 30:487–495.

    Google Scholar 

  23. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: Effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression aftermyocardial infarction. N Eng J Med 1989; 321:406–412.

    Google Scholar 

  24. The Cardiac Arrhythmia Suppression Trial II Investigators. Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. N Eng J Med 1992;327:227–233.

    Google Scholar 

  25. Waldo AL, Camm AJ, deRuyter H, et al., for the SWORD Investigators. Effect of d-sotalol on mortality in patients with left ventricular dysfunction after recent and remote myocardial infarction. Lancet 1996;348:7–12.

    Google Scholar 

  26. Teo KK, Yusuf S, Furberg CD. Effects of prophylactic antiarrhythmic drug therapy in acutemyocardial infarction. an overview of results from randomized controlled trials. JAMA 1993;270:1589–1595.

    Google Scholar 

  27. Ruder MA, Ellis T, Lebsack C, et al. Clinical experience with sotalol in patients with drug-refractory ventricular arrhythmias. J Am Coll Cardiol 1989;13:145–152.

    Google Scholar 

  28. Gonzales R, Scheinman MM, Herre JM, et al. Usefulness of sotalol for drug-refractory malignant ventricular arrhythmias. J Am Coll Cardiol 1988;12:1568–1572.

    Google Scholar 

  29. Steinbeck G, Bach P, Haberl R. Electrophysiologic and antiarrhythmic efficacy of oral sotalol for sustained ventricular tachyarrhythmias: evaluation by programmed stimulation and ambulatory electrocardiogram. J Am Coll Cardiol 1986;8:949–958.

    Google Scholar 

  30. Kehoe RF, Zheutlin TA, Dunnington CS, et al. Safety and efficacy of sotalol in patients with drug refractory ventricular tachyarrhythmias. Am J Cardiol 1990;65:58A-64A.

    Google Scholar 

  31. Mason JW, for the ESVEM Investigators. A comparison of seven antiarrhythmic drugs. N Eng J Med 1993;329:452–458.

    Google Scholar 

  32. Jazayeri MR, Wyhe G, Avitall B, et al. Isoproterenol reversal of antiarrhythmic effects in patients with inducible sustained ventricular tachyarrhythmias. J Am Coll Cardiol 1989;14:705–711.

    Google Scholar 

  33. Calkins H, Sousa J, el-Atassi, et al. Reversal of antiarrhythmic drug effects by epinephrine: quinidine vs amiodarone. J Am Coll Cardiol 1992;19:347–352.

    Google Scholar 

  34. Hallstrom AP, Cobb LA, Yu BH, et al. An antiarrhythmic drug experience in 941 patients resuscitated from initial cardiac arrest between 1970 and 1985. Am J Cardiol 1991; 68:1025–1031.

    Google Scholar 

  35. Julian DG, Prescott RJ, Jackson FS, et al. Controlled trial of sotalol for one year after myocardial infarction. Lancet 1982; 12:1142–1147.

    Google Scholar 

  36. CIBIS Investigators and Committees. A randomized trial of beta-blockade in heart failure. The Cardiac Insufficiency Bisoprolol Study (CIBIS). Circulation 1994;90:1765–1773.

    Google Scholar 

  37. Underwood RD Sra J, Akhtar M. Evaluation and treatment in patients at high risk of sudden death post myoxardial infarction. Clin Cardiol 1997;20:753–758.

    Google Scholar 

  38. Steinberck G, Andresen D, Bach P, et al. A comparison of electrophysiologically guided antiarrhythmic drug therapy with beta-blocker therapy in patients with symptomatic, sustained ventricular arrhythmias. N Eng J Med 1992;327:987–992.

    Google Scholar 

  39. Bocker D, Block M, Isbrunch F, et al. Do patients with an implantable defibrillator live longer? J Am Coll Cardiol 1993;21:1638–1644.

    Google Scholar 

  40. Bocker D, Haverkamp W, Block M, et al. Comparison of d,l-sotalol with an implantable defibrillator in patients with coronary disease at high risk for ventricular arrhythmias. Circulation 1996;94:151–157.

    Google Scholar 

  41. Weves EFD, Hauer RNW, Van Capelle FJL, et al. Randomized study of implantable defibrillator as first choiche therapy versus conventional strategy in postinfarct sudden death survivors. Circulation 1995;91:2195–2203.

    Google Scholar 

  42. Moss A, Hall J, Cannom D, et al. for the MADIT Investigators. Improved survival with an implanted defibrillator in patients with coronary disease at high risk of ventricular arrhythmias, N Eng J Med 1996;335:1984–1985.

    Google Scholar 

  43. The AVID Investigators. A comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from near fatal ventricular arrhythmias. N Eng J Med 1997;337:1576–1583.

    Google Scholar 

  44. Bigger JT Jr, for the CABG Patch Trial Investigators. Prophylatic use of implanted cardiac defibrillators in patients at high risk for ventricular arrhythmias after coronary artery graft surgery. N Eng J Med 1997;337:1569–1575.

    Google Scholar 

  45. Connolly SJ, Gent M, Roberts RS. Canadian Implantable Defibrillator Study (CIDS): Perspective of the principal investigators. CEPR 1998;2:11–12.

    Google Scholar 

  46. Buxton AE. MUSTT: Results. In: Epstein AE, Schron EB (chairs): Clinical Trials (Mini course 10). 20th Annual Scientific Session of the North American Society of Pacing and Electrophysiology (NASPE), Toronto, Canada, 1999

Download references

Author information

Authors and Affiliations

  1. Divisione di Cardiologia, Ospedale Civile, via Taverna 49, 29100, Piacenza-, Italy

    Alessandro Capucci

  2. Divisione di Cardiologia, Ospedale Civile, via Taverna 49, 29100, Piacenza-, Italy

    Daniela Aschieri & Giovanni Quinto Villani

Authors
  1. Alessandro Capucci
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Daniela Aschieri
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Giovanni Quinto Villani
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Capucci, A., Aschieri, D. & Villani, G.Q. The Role of EP-Guided Therapy in Ventricular Arrhythmias: Beta-Blockers, Sotalol, and ICD's. J Interv Card Electrophysiol 4 (Suppl 1), 57–63 (2000). https://doi.org/10.1023/A:1009822313578

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1023/A:1009822313578

Search

Navigation