Skip to main content
SpringerLink
Log in

Amiodaron zur Therapie perioperativer kardialer Rhythmusstörungen

Ein Breitspektrumantiarrhythmikum?

Amiodaron for treatment of perioperative cardiac arrythmia

A broad spectrum antiarrythmetic agent?

  • Klinische Pharmakologie
  • Published:
Der Anaesthesist Aims and scope Submit manuscript

Zusammenfassung

Kardiale Arrhythmien stellen eine häufige Komplikation in der perioperativen Phase dar. Die in der Literatur zu findende Inzidenz schwankt stark und ist vom untersuchten Patientenkollektiv und der zugrunde gelegten Definition abhängig. Insgesamt überwiegen deutlich die supraventrikulären Rhythmusstörungen, angeführt durch das Vorhofflimmern. Aufgrund seines breiten Wirkspektrums ist Amiodaron ein weit verbreitetes Medikament zur Behandlung lebensbedrohlicher supraventrikulärer und ventrikulärer Tachyarrhythmien. Der Einsatz von Amiodaron wird durch schwere kardiale und extrakardiale Nebenwirkungen (lebensbedrohliche Bradykardien, schwere pulmonale und thyreotoxische Komplikationen) limitiert. Aufgrund dieses ungünstigen Nebenwirkungsprofils sollte die Indikation für die Amiodarongabe immer sorgfältig überprüft werden. Als Orientierung können offizielle Empfehlungen wie die Leitlinien der American Heart Association (AHA) zur Therapie des Vorhofflimmerns und die Leitlinien des European Resuscitation Council (ERC) zur kardiopulmonalen Reanimation herangezogen werden. Bei perioperativem Vorhofflimmern sollte aufgrund des unsicheren Nutzens einer medikamentösen Rhythmuskonversion, der hohen spontanen Konversionsrate und der gefährlichen Proarrhythmogenität von Antiarrhythmika zunächst eine frequenzkontrollierende Therapie mit β-Blockern oder Kalziumantagonisten angestrebt werden. Bei der Therapie hämodynamisch stabiler ventrikulärer Tachykardien sollte gemäß den ERC-Leitlinien Amiodaron eingesetzt werden. Alternativ kann hier aber auch Ajmalin verabreicht werden. Im Rahmen der kardiopulmonalen Reanimation bei ventrikulärer Tachykardie oder Kammerflimmern sollte Amiodaron nach 3 erfolglosen Defibrillationen zum Einsatz kommen. In klinischer Erprobung befinden sich zur Zeit Dronedaron, ein Derivat von Amiodaron mit ähnlichem Wirkungsprofil, jedoch günstigerem Nebenwirkungsprofil, und vorhofspezifische Kaliumkanalblocker (AZD7009, Vernakalant). In Zukunft muss die Rolle von Statinen sowie Angiotensinkonversionsenzym- (ACE-)Hemmern und Angiotensinrezeptorenblockern in der Prophylaxe perioperativer Rhythmusstörungen weiter evaluiert werden.

Abstract

Cardiac arrhythmias are a common problem in the perioperative period. The incidence found in the current literature varies depending on the population studied and the definition of arrhythmia used. Overall supraventricular arrhythmias, namely atrial fibrillation, are the most common form. Because of its broad spectrum amiodarone is often used to suppress supraventricular and ventricular arrhythmias. It is believed to be safe for treating patients with severe cardiac disease and it has less proarrhyhmogenic potential than many other antiarrhythmic drugs. However, the use of amiodarone is limited by its cardiac and non-cardiac adverse effects, such as life-threatening bradycardia, pulmonary fibrosis or thyrotoxicosis. According to the guidelines of the American Heart Association, amiodarone can be used to treat atrial fibrillation. Because spontaneous conversion rates in the perioperative setting are high and the advantage of a rhythm control strategy over rate control is questionable, a rate control strategy using less toxic drugs like beta blockers or calcium channel blockers should be preferred in hemodynamically stable patients. The current guidelines of the European Resuscitation Council (ERC) recommend amiodarone to treat hemodynamically stable ventricular tachycardia and in this setting ajmaline is also highly effective. Amiodarone should be administered to patients with cardiac arrest if ventricular tachycardia or ventricular fibrillation persists after three attempts at defibrillation. Dronedarone is a derivate of amiodarone with a similar mechanism of action but with less non-cardiac side effects and is currently being tested in clinical trials. The use of the atrial-specific potassium channel blockers AZD7009 and vernakalant are also being investigated. Furthermore, the role of statins, ACE inhibitors and angiotensin receptor blockers in the prevention of atrial fibrillation has to be evaluated.

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

Abb. 1
Abb. 2

Literatur

  1. Amar D (2007) Postthoracotomy atrial fibrillation. Curr Opin Anaesthesiol 20: 43–47

    Article  PubMed  Google Scholar 

  2. Anand K, Mooss AN, Hee TT, Mohiuddin SM (2006) Meta-analysis: inhibition of renin-angiotensin system prevents new-onset atrial fibrillation. Am Heart J 152: 217–222

    Article  PubMed  CAS  Google Scholar 

  3. Argyriou M, Hountis P, Antonopoulos N, Mathioudaki M (2007) Acute fatal post-CABG low dose amiodarone lung toxicity. Asian Cardiovasc Thorac Ann 15(6): e66–e68

    PubMed  Google Scholar 

  4. Atlee JL (1997) Perioperative cardiac dysrhythmias. Anesthesiology 86: 1397–1424

    Article  PubMed  CAS  Google Scholar 

  5. Balser JR, Martinez EA, Winters BD et al. (1998) Beta-adrenergic blockade accelerates conversion of postoperative supraventricular tachyarrhythmias. Anesthesiology 89(5): 1047–1049

    Article  Google Scholar 

  6. Bianconi L, Castro A, Dinelli M et al. (2000) Comparison of intravenously administered dofetilide versus amiodarone in the acute termination of atrial fibrillation and flutter. A multicentre, randomized, double-blind, placebo-controlled study. Eur Heart J 21(15): 1265–1273

    Article  PubMed  CAS  Google Scholar 

  7. Boriani G, Diemberger I, Biffi M et al. (2004) Pharmacological cardioversion of atrial fibrillation: current management and treatment options. Drugs 64: 2741–2762

    Article  PubMed  CAS  Google Scholar 

  8. Brendorp B, Pedersen OD, Torp-Pedersen C et al. (2002) A benefit-risk assessment of class III antiarrhythmic agents. Drug Saf 25(12): 847–865

    Article  PubMed  CAS  Google Scholar 

  9. Chen X, Borggrefe M, Martinez-Rubio A et al. (1994) Efficacy of ajmaline and propafenone in patients with accessory pathways: a prospective randomized study. J Cardiovasc Pharmacol 24(4): 664–669

    Article  PubMed  CAS  Google Scholar 

  10. Chevalier P, Durand-Dubief A, Burri H et al. (2003) Amiodarone versus placebo and class Ic drugs for cardioversion of recent-onset atrial fibrillation: a meta-analysis. J Am Coll Cardiol 41(2): 255–262

    Article  PubMed  CAS  Google Scholar 

  11. Deedwania PC, Singh BN, Ellenbogen K et al. (1998) Spontaneous conversion and maintenance of sinus rhythm by amiodarone in patients with heart failure and atrial fibrillation: observations from the veterans affairs congestive heart failure survival trial of antiarrhythmic therapy (CHF-STAT). Circulation 98(23): 2574–2579

    PubMed  CAS  Google Scholar 

  12. Delle Karth G, Geppert A, Neunteufl T et al. (2001) Amiodarone versus diltiazem for rate control in critically ill patients with atrial tachyarrhythmias. Crit Care Med 29(6): 1149–1153

    Article  Google Scholar 

  13. Dietz R, Rauch B (2003) Leitlinie zur Diagnose und Behandlung der chronischen Herzerkrankung der Deutschen Gesellschaft für Kardiologie- Herz- und Kreislaufforschung (DGK). Z Kardiol 92(6): 501–521

    PubMed  CAS  Google Scholar 

  14. Dorian P, Cass D, Schwartz B et al. (2002) Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation. N Engl J Med 346: 884–890

    Article  PubMed  CAS  Google Scholar 

  15. Echt DS, Liebson PR, Mitchell LB et al. (1991) Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The cardiac arrhythmia suppression trial. N Engl J Med 324(12): 781–788

    PubMed  CAS  Google Scholar 

  16. Ehrlich JR, Nattel S, Hohnloser SH (2002) Atrial fibrillation and congestive heart failure: specific considerations at the intersection of two common and important cardiac disease sets. J Cardiovasc Electrophysiol 13(4): 399–405

    Article  PubMed  Google Scholar 

  17. Fauchier L, Pierre B, Labriolle A de et al. (2008) Antiarrhythmic effect of statin therapy and atrial fibrillation a meta-analysis of randomized controlled trials. J Am Coll Cardiol 51(8): 828–835

    Article  PubMed  CAS  Google Scholar 

  18. Fideler FJ, Dieterich HJ, Schroeder TH (2008) Fatal outcome during anaesthesia induction in a patient with amiodarone-induced thyrotoxicosis. Eur J Anaesthesiol 25(4): 337–339

    Article  PubMed  CAS  Google Scholar 

  19. Fuster V, Rydén LE, Cannom DS et al. (2006) ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing committee to revise the 2001 guidelines for the management of patients with atrial fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114(7): e257–e354

    Article  PubMed  Google Scholar 

  20. Groeben H, Böttiger BW, Heine J (2003) Grundlagen und Management des perioperativen Vorhofflimmerns. Anasthesiol Intensivmed Notfallmed Schmerzther 38(9): 600–604

    Article  PubMed  CAS  Google Scholar 

  21. Gulizia M, Mangiameli S, Orazi S et al. (2008) A randomized comparison of amiodarone and class IC antiarrhythmic drugs to treat atrial fibrillation in patients paced for sinus node disease: the prevention investigation and treatment: a group for observation and research on atrial arrhythmias (PITAGORA) trial. Am Heart J 155(1): 100–107

    Article  PubMed  CAS  Google Scholar 

  22. Herold G (2008) Herzrhythmusstörungen. In: Herold G (Hrsg) Innere Medizin. Eine vorlesungsorientierte Darstellung. Eigenverlag, Köln, S 241–275

  23. Hohnloser SH, Connolly SJ, Crijns HJ et al. (2008) Rationale and design of ATHENA: a placebo-controlled, double-blind, parallel arm trial to assess the efficacy of dronedarone 400 mg bid for the prevention of cardiovascular hospitalization or death from any cause in patients with atrial fibrillation/atrial flutter. J Cardiovasc Electrophysiol 19(1): 69–73

    Article  PubMed  Google Scholar 

  24. Hoppe UC, Böhm M, Dietz R et al. (2005) Leitlinien zur Therapie der chronischen Herzinsuffizienz. Z Kardiol 94(8): 488–509

    Article  PubMed  CAS  Google Scholar 

  25. Julian DG, Camm AJ, Frangin G et al. (1997) Randomised trial of effect of amiodarone on mortality in patients with left-ventricular dysfunction after recent myocardial infarction: EMIAT. European Myocardial Infarct Amiodarone Trial Investigators. Lancet 349(9053): 667–674

    Article  PubMed  CAS  Google Scholar 

  26. Kober L, Bloch Thomsen PE, Moller M et al. (2000) Effect of dofetilide in patients with recent myocardial infarction and left-ventricular dysfunction: a randomised trial. Lancet 356(9247): 2052–2058

    Article  PubMed  CAS  Google Scholar 

  27. Kochiadakis GE, Igoumenidis NE, Hamilos ME et al. (2007) A comparative study of the efficacy and safety of procainamide versus propafenone versus amiodarone for the conversion of recent-onset atrial fibrillation. Am J Cardiol 99: 1721–1725

    Article  PubMed  CAS  Google Scholar 

  28. Kudenchuk PJ, Cobb LA, Copass MK et al. (1999) Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med 341: 871–878

    Article  PubMed  CAS  Google Scholar 

  29. Liakopoulos OJ, Choi YH, Haldenwang PL et al. (2008) Impact of preoperative statin therapy on adverse postoperative outcomes in patients undergoing cardiac surgery: a meta-analysis of over 30,000 patients. Eur Heart J 29(12): 1548–1559

    Article  PubMed  Google Scholar 

  30. Manz M, Mletzko R, Jung W, Lüderitz B (1992) Electrophysiological and haemodynamic effects of lidocaine and ajmaline in the management of sustained ventricular tachycardia. Eur Heart J 13: 1123–1128

    PubMed  CAS  Google Scholar 

  31. McBride BF, Min B, Kluger J et al. (2006) An evaluation of the impact of oral magnesium lactate on the corrected QT interval of patients receiving sotalol or dofetilide to prevent atrial or ventricular tachyarrhythmia recurrence. Ann Noninvasive Electrocardiol 11(2): 163–169

    Article  PubMed  Google Scholar 

  32. Mittal S, Ayati S, Stein KM et al. (2000) Transthoracic cardioversion of atrial fibrillation: comparison of rectilinear biphasic versus damped sine wave monophasic shocks. Circulation 101(11): 1282–1287

    PubMed  CAS  Google Scholar 

  33. Morrow JP, Cannon CP, Reiffel JA (2007) New antiarrhythmic drugs for establishing sinus rhythm in atrial fibrillation: what are our therapies likely to be by 2010 and beyond? Am Heart J 154(5): 824–829

    Article  PubMed  CAS  Google Scholar 

  34. Nolan JP, Deakin CD, Soar J et al. (2005) European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support. Resuscitation 67 [Suppl 1]: 39–86

  35. October TW, Schleien CL, Berg RA et al. (2008) Increasing amiodarone use in cardiopulmonary resuscitation: an analysis of the national registry of cardiopulmonary resuscitation. Crit Care Med 36: 126–130

    PubMed  CAS  Google Scholar 

  36. Onalan O, Crystal E, Daoulah A et al. (2007) Meta-analysis of magnesium therapy for the acute management of rapid atrial fibrillation. Am J Cardiol 99(12): 1726–1732

    Article  PubMed  CAS  Google Scholar 

  37. Polanczyk CA, Goldman L, Marcantonio ER et al. (1998) Supraventricular arrhythmia in patients having noncardiac surgery: clinical correlates and effect on length of stay. Ann Intern Med 129: 279–285

    PubMed  CAS  Google Scholar 

  38. Schmieder RE, Kjeldsen SE, Julius S et al. (2008) Reduced incidence of new-onset atrial fibrillation with angiotensin II receptor blockade: the VALUE trial. J Hypertens 26: 403–411

    PubMed  CAS  Google Scholar 

  39. Shah SA, Kluger J, White CM (2007) Monotherapy versus combination therapy with class III antiarrhythmic agents to attenuate transmural dispersion of repolarization: a potential risk factor for torsade de pointes. Pharmacotherapy 27(9): 1297–1305

    Article  PubMed  CAS  Google Scholar 

  40. Sideris AM, Galiatsu E, Filippatos GS et al. (1996) Effects of magnesium and potassium on Wolff-Parkinson-White syndrome. J Electrocardiol 29(1): 11–15

    Article  PubMed  CAS  Google Scholar 

  41. Strom C, Brömsen J, Kilger E (2008) Therapie perioperativer Arrhythmien. Anasthesiol Intensivmed 49: 195–216

    Google Scholar 

  42. Thomas KL, Al-Khatib SM, Lokhnygina Y et al. (2008) Amiodarone use after acute myocardial infarction complicated by heart failure and/or left ventricular dysfunction may be associated with excess mortality. Am Heart J 155(1): 87–93

    Article  PubMed  CAS  Google Scholar 

  43. Thompson A, Balser JR (2004) Perioperative cardiac arrhythmias. Br J Anaesth 93: 86–94

    Article  PubMed  CAS  Google Scholar 

  44. Tijunelis MA, Herbert ME (2005) Myth: intravenous amiodarone is safe in patients with atrial fibrillation and Wolff-Parkinson-White syndrome in the emergency department. CJEM 7(4): 262–265

    PubMed  Google Scholar 

  45. Trujillo TC, Nolan PE (2000) Antiarrhythmic agents: drug interactions of clinical significance. Drug Saf 23(6): 509–532

    Article  PubMed  CAS  Google Scholar 

  46. Torp-Pedersen C, Moller M, Bloch-Thomsen PE et al. (1999) Dofetilide in patients with congestive heart failure and left ventricular dysfunction. Danish investigations of arrhythmia and mortality on dofetilide study group. N Engl J Med 341(12): 857–865

    Article  PubMed  CAS  Google Scholar 

  47. Vasallo P, Trohman RG (2007) Prescribing amiodarone: an evidence-based review of clinical indications. JAMA 298(11): 1312–1322

    Article  Google Scholar 

  48. Vaughan Williams EM (1984) A classification of antiarrhythmic actions reassessed after a decade of new drugs. J Clin Pharmacol 24: 129–147

    Google Scholar 

  49. Walsh SR, Tang T, Wijewardena C et al. (2007) Postoperative arrhythmias in general surgical patients. Ann R Coll Surg Engl 89: 91–95

    Article  PubMed  Google Scholar 

  50. Wyse DG, Waldo AL, DiMarco JP et al. (2002) A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 347: 1825–1833

    PubMed  CAS  Google Scholar 

Download references

Interessenkonflikt

Es besteht kein Interessenkonflikt. Der korrespondierende Autor versichert, dass keine Verbindungen mit einer Firma, deren Produkt in dem Artikel genannt wird, oder einer Firma, die ein Konkurrenzprodukt vertreibt, bestehen. Die Präsentation des Themas ist unabhängig und die Darstellung der Inhalte produktneutral.

Author information

Authors and Affiliations

  1. Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum der Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland

    N. Butte, B.W. Böttiger & P. Teschendorf

Authors
  1. N. Butte
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. B.W. Böttiger
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. P. Teschendorf
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to N. Butte.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Butte, N., Böttiger, B. & Teschendorf, P. Amiodaron zur Therapie perioperativer kardialer Rhythmusstörungen. Anaesthesist 57, 1183–1192 (2008). https://doi.org/10.1007/s00101-008-1432-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00101-008-1432-9

Schlüsselwörter

Keywords

Search

Navigation