Management of Cardiac Arrhythmias

Part of the Contemporary Cardiology book series (CONCARD)


The rational basis of antiarrhythmic therapy ideally requires a knowledge of
  1. 1.
    The mechanism of the arrhythmia:
    • Disturbances in impulse generation (enhanced automaticity or ectopic tachyarrhythmia).

    • Disturbances of impulse conduction (reentrant arrhythmias). Most of the evidence suggests that reentry is the mechanism for sustained ventricular tachycardia (VT).

    • he site or sites where such disturbances are present.

  2. 2.

    The mode of action of the drug with which control of the arrhythmia is to be attempted.

  3. 3.
    The clinical situation:
    • Acute, persistent or paroxysmal.

    • Associated with a low blood pressure < 90 mmHg, congestive heart failure (CHF), or distressing symptoms.

    • Associated with cardiac pathology, accessory pathway or secondary to hypoxemia, acute blood loss, electrolyte or acid-base imbalance, extracardiac conditions as diverse as thyrotoxicosis, chronic obstructive pulmonary disease, or acute conditions such as pyrexial illness, pneumothorax, or even rupture of the esophagus.



Ventricular Tachycardia Sinus Rhythm Ventricular Arrhythmia Atrial Flutter Antiarrhythmic Agent 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Vaughan Williams EM. Classification of antiarrhythmic drugs. In: Sandhoe E, Flensted-Jensen E, Olesen KH (eds). Symposium on Cardiac Arrhythmias. Sodertalje, Sweden, AB Astra, 1970, p 449.Google Scholar
  2. 2.
    Task Force of the Working Group on Arrhythmias of the European Society of Cardiology. The Sicilian Gambit. A new approach to the classification of antiarrhythmic drugs based on their actions on arrhythmogenic mechanisms. Circulation 1991;4:1831.Google Scholar
  3. 3.
    Khan M Gabriel. Arrhythmias. In: Heart Disease, Diagnosis and Therapy. Totowa, NJ, Humana Press, 2005.Google Scholar
  4. 4.
    Steurer G, Gursoi S, Frey B, et al. Differential diagnosis on the electrocardiogram between ventricular tachycardia and preexcited tachycardia. Clin Cardiol 1994;17:306.PubMedGoogle Scholar
  5. 5.
    DiMarco JP, Miles W, Akhtar M. Adenosine for paroxysmal supraventricular tachycardia: Dose ranging and comparison with verapamil. Assessment in placebo-controlled, multicenter trials. Ann Intern Med 1990;113:104.PubMedGoogle Scholar
  6. 6.
    Rankin AC, McGovern B A. Adenosine or verapamil for the acute treatment of supraventricular tachycardia? Ann Intern Med 1991;114:513.PubMedGoogle Scholar
  7. 7.
    Delacretaz E. Supraventricular tachycardia. N Engl J Med 2006;354:1039–1051.PubMedCrossRefGoogle Scholar
  8. 8.
    Jaeggi E, Chiu C, Hamilton R, et al. Adenosine induced atrial pro arrhythmia in children. Can J Cardiol 1999;15:169.PubMedGoogle Scholar
  9. 9.
    Alboni P, Tomasi C, Menozzi C, et al. Efficacy and safety of out-of-hospital self-administered singledose oral drug treatment in the management of infrequent, well-tolerated paroxysmal supraventricular tachycardia. J Am Coll Cardiol 2001;37:548–553.PubMedCrossRefGoogle Scholar
  10. 10.
    Murray KT. Ibutilide. Circulation 1998;97:493.PubMedGoogle Scholar
  11. 11.
    Opolski G, Torbicki A, Kosior DA, et al. Rate control vs rhythm control in patients with nonvalvular persistent atrial fibrillation: the results of the Polish How to Treat Chronic Atrial Fibrillation (HOT CAFE) Study. Chest 2004;126:476–486.PubMedCrossRefGoogle Scholar
  12. 12.
    Wyse DG, Waldo AL, DiMarco JP, et al. Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002;347:1825–1833.PubMedCrossRefGoogle Scholar
  13. 13.
    Ruskin JN. The cardiac arrhythmia suppression trial (CAST). N Engl J Med 1989;321:385.CrossRefGoogle Scholar
  14. 14.
    Bigger JT. Definition of benign versus malignant ventricular arrhythmias: Targets for treatment. Am J Cardiol 1983;52:47C.PubMedCrossRefGoogle Scholar
  15. 15.
    Green HL, for the CASCADE Investigators. The CASCADE study: Randomized antiarrhythmic drug therapy in survivors of cardiac arrest in Seattle. Am J Cardiol 1993;72:70F.CrossRefGoogle Scholar
  16. 16.
    Nora M, Zipes DP. Empiric use of amiodarone and sotalol. Am J Cardiol 1993;72:62F.PubMedCrossRefGoogle Scholar
  17. 17.
    Buxton AE, Marchlinski FE, Flores BT, et al. Non-sustained ventricular tachycardia in patients with coronary artery disease: Role of electro-physiological study. Circulation 1986;75:1178.Google Scholar
  18. 18.
    Josephson ME. Treatment of ventricular arrhythmias after myocardial infarction. Circulation 1986;74: 653.PubMedGoogle Scholar
  19. 19.
    Smith WM, Gallagher JJ. “Les torsades de pointes”: An unusual ventricular arrhythmia. Ann Intern Med 1980;93:578.PubMedGoogle Scholar
  20. 20.
    Stratmann HG, Kennedy HL. Torsades de pointes associated with drugs and toxins: Recognition and management. Am Heart J 1987;113:1470.PubMedCrossRefGoogle Scholar
  21. 21.
    Lazzara R. Amiodarone and torsades de pointes. Ann Intern Med 1989;111:549.Google Scholar
  22. 22.
    Mattioni TA, Zheutlin TA, Sarmiento JJ, et al. Amiodarone in patients with previous drug-mediated torsade de pointes. Ann Intern Med 1989;111:574.PubMedGoogle Scholar
  23. 23.
    Rankin AC, Pringle SD, Cobe SM. Acute treatment of torsades de pointes with amiodarone: Proarrhythmic and antiarrhythmic association of QT prolongation. Am Heart J 1990;19:185.CrossRefGoogle Scholar
  24. 24.
    Tzivoni D, Banai S, Schuger C, et al. Magnesium sulfate therapy for sustained monomorphic ventricular tachycardia. Circulation 1988;77:392.PubMedGoogle Scholar
  25. 25.
    Allen BJ, Brodsky MA, Capparelli EV, et al. Magnesium sulfate therapy for sustained monomorphic ventricular tachycardia. Am J Cardiol 1989;64:1202.PubMedCrossRefGoogle Scholar
  26. 26.
    Ben-David J, Zipes DP. Torsades de pointes and proarrhythmia. Lancet 1993;341:1578.PubMedCrossRefGoogle Scholar
  27. 27.
    Leenhardt A, Glasser E, Burguera M, et al. Short-coupled variant of torsade depointes: A new electrocardiographic entity in the spectrum of idiopathic ventricular tachyarrhythmias. Circulation 1994;89: 206.PubMedGoogle Scholar
  28. 28.
    Cohn IS, Jick H, Cohen SI. Adverse reactions to quinidine in hospitalized patients: Findings based on data from the Boston Collaborative Drug Surveillance Program. Prog Cardiovasc Dis 1977;20:151.CrossRefGoogle Scholar
  29. 29.
    Grace AA, Camm AJ. Drug therapy. Quinidine. N Engl J Med 1998;338:35.PubMedCrossRefGoogle Scholar
  30. 30.
    Bauman JL, Beuerfeind RA, Hoff JV, et al. Torsades de pointes due to quinidine: Observations in 31 patients. Am Heart J 1984;107:425.PubMedCrossRefGoogle Scholar
  31. 31.
    Ruskin JN, McGovern B, Garan H, et al. Antiarrhythmic drugs: A possible cause of out-of-hospital cardiac arrest. N Engl J Med 1983;309:1302.PubMedCrossRefGoogle Scholar
  32. 32.
    Huang SK, Marcus FI. Antiarrhythmic drug therapy of ventricular arrhythmias. Curr Prob Cardiol 1986; 11:179.CrossRefGoogle Scholar
  33. 33.
    Ellrodt AG, Murata GH, Riedinger MS, et al. Severe neutropenia associated with sustained release procainamide. Ann Intern Med 1984;100:197.PubMedGoogle Scholar
  34. 34.
    MacMahon S, Collins, R, Peto R, et al. Effects of prophylactic lidocaine in suspected acute myocardial infarction. JAMA 1988;260:1910.PubMedCrossRefGoogle Scholar
  35. 35.
    Koster RW, Dunning AJ. Intramuscular lidocaine for prevention of lethal arrhythmias in the prehospitalization phase of acute myocardial infarction. N Engl J Med 1985;313:1105.PubMedCrossRefGoogle Scholar
  36. 36.
    Rotmensch HH, Elkayam U, Frishman W. Antiarrhythmic drug therapy during pregnancy. Ann Intern Med 1983;98:487.PubMedGoogle Scholar
  37. 37.
    Palileo EV, Welsch W, Hoff J, et al. Lack of effectiveness of oral mexiletine in patients with drug-refractory paroxysmal sustained ventricular tachycardia. Am J Cardiol 1982;50:1075.PubMedCrossRefGoogle Scholar
  38. 38.
    Poole JE, Werner JA, Brady GH, et al. Intolerance and ineffectiveness of mexiletine in patients with serious ventricular arrhythmias. Am Heart J 1986;112:322.PubMedCrossRefGoogle Scholar
  39. 39.
    Campbell RWF. Medical intelligence: drug therapy, mexiletine. N Engl J Med 1987;316:29.PubMedCrossRefGoogle Scholar
  40. 40.
    Roden DM, Woosley RL. Drug therapy: Flecainide. N Engl J Med 1986;315:36.PubMedCrossRefGoogle Scholar
  41. 41.
    Anderson JL, Jolivette DM, Fredell PA. Summary of efficacy and safety of flecainide for supraventricular arrhythmias. Am J Cardiol 1988;62:62D.PubMedCrossRefGoogle Scholar
  42. 42.
    Benditt DG, Dunnigan A, Buetikofer J, et al. Flecainide acetate for long-term prevention of PSVT. Circulation 1991;83:345.PubMedGoogle Scholar
  43. 43.
    Siddoway LA, Roden DM, Woosley RL. Clinical pharmacology of propafenone. Pharmacokinetics, metabolism and concentration-response relations. Am J Cardiol 1984;54:9D.PubMedCrossRefGoogle Scholar
  44. 44.
    Siddoway LA, Thompson KA, McAllister BC, et al. Polymorphism of propafenone metabolism and disposition in man: Clinical and pharmacokinetic consequences. Circulation 1987;75:785.PubMedGoogle Scholar
  45. 45.
    Prystowsky EN, Heger JJ, Chilson DA, et al. Antiarrhythmic and electrophysiologic effects of oral propafenone. Am J Cardiol 1984;54:26D.PubMedCrossRefGoogle Scholar
  46. 46.
    NaccarellaF, BracchettiD, Palmieri M, etal. Propafenone for refractory ventricular arrhythmias: Correlation with drug plasma levels during long-term treatment. Am J Cardiol 1984;54:1008.CrossRefGoogle Scholar
  47. 47.
    Conmel P, Leclercq J, Assayag P. European experience with the antiarrhythmic efficacy of propafenone for supraventricular and ventricular arrhythmias. Am J Cardiol 1984;54:60D.CrossRefGoogle Scholar
  48. 48.
    Heger JJ, Hubbard J, Zipes D, et al. Propafenone treatment of recurrent ventricular tachycardia: Comparison of continuous electrocardiographic recording and electrophysiologic study in predicting drug efficacy. Am J Cardiol 1984;54:40D.PubMedCrossRefGoogle Scholar
  49. 49.
    Chilson DA, Heger JJ, Zipes DP, et al. Electrophysiologic effects and clinical efficacy of oral propafenone therapy in patients with ventricular tachycardia. J Am Coll Cardiol 1985;5:1407.PubMedGoogle Scholar
  50. 50.
    Podrid JP, Lown B. Propafenone: A new agent for ventricular arrhythmia. J Am Coll Cardiol 1984;4:117.PubMedGoogle Scholar
  51. 51.
    Naccarella F, Bracchetti D, Palmieri M, et al. Comparison of propafenone and disopyramide for treatment of chronic ventricular arrhythmias: Placebo-controlled, double-blind randomized crossover study. Am Heart J 1985;109:833.CrossRefGoogle Scholar
  52. 52.
    Breithardt G, Borggrefe M, Wiebringhaus E, et al. Effects of propafenone in the Wolff-Parkinson-White syndrome: Electrophysiologic findings and long-term follow-up. Am J Cardiol 1984;54:29D.PubMedCrossRefGoogle Scholar
  53. 53.
    Ludmer PL, McGowan NE, Antman EM, et al. Efficacy of propafenone in Wolff-Parkinson-White syndrome: Electrophysiologic findings and long term follow-up. J Am Coll Cardiol 1987;9:1357.PubMedGoogle Scholar
  54. 54.
    Nathan AW, Bexton RS, Hellestrand KG, Camm AJ. Fatal ventricular tachycardia in association with propafenone, a new class IC antiarrhythmic agent. Postgrad Med J 1984;60:155.PubMedCrossRefGoogle Scholar
  55. 55.
    Hodges M, Salerno D, Granrud G. Double-blind placebo-controlled evaluation of propafenone in suppressing ventricular ectopic activity. Am J Cardiol 1984;54:45D.PubMedCrossRefGoogle Scholar
  56. 56.
    Guindo J, De La Serna AR, Borja J, et al. Propafenone and a syndrome of lupus erythematosus type. Ann Intern Med 1986;104:589.PubMedGoogle Scholar
  57. 57.
    Podrid PH, Cytryn R, Lown B. Propafenone noninvasive evaluation of efficacy. Am J Cardiol 1984; 54:53.CrossRefGoogle Scholar
  58. 58.
    Norris RM, Barnaby PF, Brown MA, et al. Prevention of ventricular fibrillation during acute myocardial infarction by intravenous propranolol. Lancet 1984;2:883.PubMedCrossRefGoogle Scholar
  59. 59.
    Fenster PE, Reynolds D, Horowitz LD, et al. Atenolol for ventricular ectopy: A dose response study. Clin Pharmacol Ther 1987;41:118.PubMedCrossRefGoogle Scholar
  60. 60.
    Kubac G, Klinke WP, Grace M. Randomized double blind trial comparing sotalol and propranolol in chronic ventricular arrhythmia. Can J Cardiol 1988;4:355.PubMedGoogle Scholar
  61. 61.
    Singh SN, Cohen A, Chen Y, et al. Sotalol for refractory sustained ventricular tachycardia and nonfatal cardiac arrest. Am J Cardiol 1988;62:399.PubMedCrossRefGoogle Scholar
  62. 62.
    Amiodarone vs. Sotalol Study Group. Multi-centre randomized trial of sotalol vs. amiodarone for chronic malignant ventricular tachyarrhythmias. Eur Heart J 1989;10:685.Google Scholar
  63. 63.
    Mason JW, on behalf of the ESVEM investigators. A comparison of 7 anti-arrhythmic drugs in patients with ventricular tachyarrhythmia. N Engl J Med 1993;329:452.PubMedCrossRefGoogle Scholar
  64. 64.
    Singh SN, Lazin A, Cohen A, et al. Sotalol-induced torsades de pointes successfully treated with hemodialysis after failure of conventional therapy. Am Heart J 1991;121:601.PubMedCrossRefGoogle Scholar
  65. 65.
    Soyka LF, Wirtz C, Spangenberg RB. Clinical safety profile of sotalol in patients with arrhythmias. Am J Cardiol 1990;65(Suppl):74A.PubMedCrossRefGoogle Scholar
  66. 66.
    Somberg JC. Antiarrhythmic drags: Making sense of the deluge. Am Heart J 1987;113:408.PubMedCrossRefGoogle Scholar
  67. 67.
    Kerin NZ, Blevins RD, Frumin H, et al. Intravenous and oral loading versus oral loading alone with amiodarone for chronic refractory ventricular arrhythmias. Am J Cardiol 1985;55:89.PubMedCrossRefGoogle Scholar
  68. 68.
    Nademanee K, Singh BN, Hendrickson J, et al. Amiodarone in refractory life-threatening ventricular arrhythmias. Ann Intern Med 1983;98:577.PubMedGoogle Scholar
  69. 69.
    Horowitz LN, Greenspan AM, Spielman SR, et al. Usefulness of electrophysiologic testing in evaluation of amiodarone therapy for sustained ventricular tachyarrhythmias associated with coronary heart disease. Am J Cardiol 1985;55:367.PubMedCrossRefGoogle Scholar
  70. 70.
    Naccarelli GV, Fineberg NS, Zipes DP, et al. Amiodarone: Risk factors for recurrence of symptomatic ventricular tachycardia identified at electrophysiologic study. J Am Coll Cardiol 1985;6:814.PubMedGoogle Scholar
  71. 71.
    McGovern B, Hasan G, Malacoff RF, et al. Long-term clinical outcome of ventricular tachycardia or fibrillation treated with amiodarone. Am J Cardiol 1984;53:1558.PubMedCrossRefGoogle Scholar
  72. 72.
    Kaski JC, Girotti LA, Messuti H, et al. Long-term management of sustained, recurrent, symptomatic ventricular tachycardia with amiodarone. Circulation 1981;64:273.PubMedGoogle Scholar
  73. 73.
    Mason JW. Drug therapy: Amiodarone. N Engl J Med 1987;316:455.PubMedCrossRefGoogle Scholar
  74. 74.
    Rosenbaum MB, Chiale PA, Halpern MS, et al. Clinical efficacy of amiodarone as an antiarrhythmic agent. Am J Cardiol 1976;38:934.PubMedCrossRefGoogle Scholar
  75. 75.
    Nademandee K, Hendrickson J A, Cannon DS, et al. Control of refractory life threatening ventricular tachyarrhythmias by amiodarone. Am Heart J 1981;101:759.CrossRefGoogle Scholar
  76. 76.
    Hohnloser SH, Meinertiz T, Dammbacher T, et al. Electrocardiographic and antiarrhythmic effects of intravenous amiodarone: Results of a prospective, placebo-controlled study. Am Heart J 1991;91:89.CrossRefGoogle Scholar
  77. 77.
    Ochi RP, Goldenberg IF, Airnquist A, et al. Intravenous amiodarone for the rapid treatment of life-threatening ventricular arrhythmias in critically illpatients with coronary artery disease. Am J Cardiol 1989;64: 599.PubMedCrossRefGoogle Scholar
  78. 78.
    Weiss JJ, Nademanee K, Stevenson WG, et al. Ventricular arrhythmias in ischemic heart disease. Ann Intern Med 1991;114:784.PubMedGoogle Scholar
  79. 79.
    Amiodarone Trials Meta-Analysis Investigators. Effect of prophylactic amiodarone on mortality after acute myocardial infarction and in congestive heart failure: Meta-analysis of individual data from 64500 patients in randomised trials. Lancet 1997;350:1417.CrossRefGoogle Scholar
  80. 80.
    Burkhart F, Pfisterer M, Kiowski W, et al. Effect of antiarrhythmic therapy on mortality in survivors of myocardial infarction with asymptomatic complex ventricular arrhythmias: B asel Antiarrhythmic Study of Infarct Survival (BASIS). J Am Coll Cardiol 1990;16:1711.Google Scholar
  81. 81.
    Julian DG, Camm AJ, Frangin G, et al. Randomised trial of effect of amiodarone on mortality in patients with left ventricular dysfunction after recent myocardial infarction: EMIAT. Lancet 1997;349:667.PubMedCrossRefGoogle Scholar
  82. 82.
    Rankin AC, Pringle SD, Cobbe SM. Acute treatment of torsades de pointes with amiodarone proarrhythmic and antiarrhythmic association of QT prolongation. Am Heart J 1990;119:185.PubMedCrossRefGoogle Scholar
  83. 83.
    Rankin AC, Pringle SD, Cobbe SM, et al. Amiodarone and torsades de pointes. Am Heart J 1990;120: 1482.CrossRefGoogle Scholar
  84. 84.
    Morady F, Sauve MJ, Malone P, et al. Long-term efficacy and toxicity of high-dose amiodarone therapy for ventricular tachycardia or ventricular fibrillation. Am J Cardiol 1983;52:975.PubMedCrossRefGoogle Scholar
  85. 85.
    Marchlinski FE, Gansher TS, Waxman HL, et al. Amiodarone pulmonary toxicity. Ann Intern Med 1982; 98:839.Google Scholar
  86. 86.
    Myers M, Peter T, Weiss D, et al. Benefit and risks of long-term amiodarone therapy for sustained ventricular tachycardia/fibrillation: Minimum of three-year follow-up in 145 patients. Am Heart J 1990; 119:8.PubMedCrossRefGoogle Scholar
  87. 87.
    Herre JM, Sauve MJ, Malone P, et al. Long-term results of amiodarone therapy in patients with recurrent sustained ventricular tachycardia or ventricular fibrillation. J Am Coll Cardiol 1989;13:442.PubMedGoogle Scholar
  88. 88.
    Guccione P, Paul T, Garson A. Long-term follow-up of amiodarone therapy in the young: Continued efficacy, unimpaired growth, moderate side effects. J Am Coll Cardiol 1990;15:1118.PubMedCrossRefGoogle Scholar
  89. 89.
    Hamer A, Peter T, Mandel WJ, et al. The potentiation of warfarin anti-coagulation by amiodarone. Circulation 1982;65:1025.PubMedGoogle Scholar
  90. 90.
    Smith WM, Lubbe WF, Whitlock RM, et al. Long-term tolerance of amiodarone treatment for cardiac arrhythmias. Am J Cardiol 1986;57:1288.PubMedCrossRefGoogle Scholar

Suggested Reading

  1. Alboni P, Tomasi C, Menozzi C, et al. Efficacy and safety of out-of-hospital self-administered single-dose oral drug treatment in the management of infrequent, well-tolerated paroxysmal supraventricular tachycardia. J Am Coll Cardiol 2001;37:548–553.PubMedCrossRefGoogle Scholar

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