Class IC antiarrhythmic drugs for suspected premature ventricular contraction–induced cardiomyopathy

      Background

      Class IC antiarrhythmic drugs (IC-AADs) can effectively suppress premature ventricular contractions (PVCs). However, IC-AADs increase mortality in patients with PVCs and left ventricular dysfunction after myocardial infarction. Whether IC-AADs can be safely used to treat premature ventricular contraction–induced cardiomyopathy (PVC-CM) remains to be established.

      Objective

      The purpose of this study was to determine the safety and efficacy of IC-AADs in patients suspected of having PVC-CM.

      Methods

      The electronic medical records at the Hospital of the University of Pennsylvania were screened to identify all patients suspected of having PVC-CM treated with flecainide or propafenone. Clinical, electrocardiographic, and imaging studies were reviewed.

      Results

      Twenty patients suspected of having PVC-CM were treated with IC-AADs. Patients had undergone an average of 1.3 ± 0.2 previous unsuccessful ablations. Six had an implantable or wearable defibrillator. With IC-AAD treatment, mean PVC burden decreased from 36.2% ± 3.5% to 10.0% ± 2.4% (P <.001). Mean left ventricular ejection fraction (LVEF) increased from 37.4% ± 2.0% to 49.0% ± 1.9% (P <.001). Seven patients with myocardial delayed enhancement on cardiac magnetic resonance imaging (all <5% of the total myocardium) experienced similar improvement in LVEF (from 36.8% ± 4.3% before IC-AAD to 51.7% ± 3.7% afterward; P <.01). Over an average 3.8 ± 0.9 treatment-years, no sustained ventricular arrhythmias or sudden cardiac deaths occurred.

      Conclusion

      In patients suspected of having PVC-CM, IC-AADs effectively suppressed PVCs, leading to LVEF recovery in the majority. No adverse events occurred in this small cohort.

      Keywords

      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kennedy H.L.
        • Whitlock J.A.
        • Sprague M.K.
        • Kennedy L.J.
        • Buckingham T.A.
        • Goldberg R.J.
        Long-term follow-up of asymptomatic healthy subjects with frequent and complex ventricular ectopy.
        N Engl J Med. 1985; 312: 193-197
        • Baman T.S.
        • Lange D.C.
        • Ilg K.J.
        • et al.
        Relationship between burden of premature ventricular complexes and left ventricular function.
        Heart Rhythm. 2010; 7: 865-869
        • Mountantonakis S.E.
        • Frankel D.S.
        • Gerstenfeld E.P.
        • et al.
        Reversal of outflow tract ventricular premature depolarization-induced cardiomyopathy with ablation: effect of residual arrhythmia burden and preexisting cardiomyopathy on outcome.
        Heart Rhythm. 2011; 8: 1608-1614
        • Campos B.
        • Jauregui M.E.
        • Park K.M.
        • et al.
        New unipolar electrogram criteria to identify irreversibility of nonischemic left ventricular cardiomyopathy.
        J Am Coll Cardiol. 2012; 60: 2194-2204
        • Capucci A.
        • Di Pasquale G.
        • Boriani G.
        • Carini G.
        • Balducelli M.
        • Frabetti L.
        • Carozzi A.
        • Finzi A.
        • Pinelli G.
        • Magnani B.
        A double-blind crossover comparison of flecainide and slow-release mexiletine in the treatment of stable premature ventricular complexes.
        Int J Clin Pharmacol Res. 1991; 11: 23-33
        • Zhong L.
        • Lee Y.H.
        • Huang X.M.
        • Asirvatham S.J.
        • Shen W.K.
        • Friedman P.A.
        • Hodge D.O.
        • Slusser J.P.
        • Song Z.Y.
        • Packer D.L.
        • Cha Y.M.
        Relative efficacy of catheter ablation vs antiarrhythmic drugs in treating premature ventricular contractions: a single-center retrospective study.
        Heart Rhythm. 2014; 11: 187-193
        • Echt D.S.
        • Liebson P.R.
        • Mitchell L.B.
        • et al.
        Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The cardiac arrhythmia suppression trial.
        N Engl J Med. 1991; 324: 781-788
        • Cardiac Arrhythmia Suppression Trial II Investigators
        Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction.
        N Engl J Med. 1992; 327: 227-233
        • Epstein A.E.
        • Hallstrom A.P.
        • Rogers W.J.
        • Liebson P.R.
        • Seals A.A.
        • Anderson J.L.
        • Cohen J.D.
        • Capone R.J.
        • Wyse D.G.
        Mortality following ventricular arrhythmia suppression by encainide, flecainide, and moricizine after myocardial infarction. The original design concept of the Cardiac Arrhythmia Suppression Trial (CAST).
        JAMA. 1993; 270: 2451-2455
        • Ruskin J.N.
        The Cardiac Arrhythmia Suppression Trial (CAST).
        N Engl J Med. 1989; 321: 386-388
        • Ermakov S.
        • Gerstenfeld E.P.
        • Svetlichnaya Y.
        • Scheinman M.M.
        Use of flecainide in combination antiarrhythmic therapy in patients with arrhythmogenic right ventricular cardiomyopathy.
        Heart Rhythm. 2017; 14: 564-569
        • Rashid S.
        • Rapacchi S.
        • Vaseghi M.
        • Tung R.
        • Shivkumar K.
        • Finn J.P.
        • Hu P.
        Improved late gadolinium enhancement MR imaging for patients with implanted cardiac devices.
        Radiology. 2014; 270: 269-274
        • Lang R.M.
        • Badano L.P.
        • Mor-Avi V.
        • et al.
        Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
        J Am Soc Echocardiogr. 2015; 28: 1-39.e14
        • Prystowsky E.N.
        • Padanilam B.J.
        • Fogel R.I.
        Treatment of atrial fibrillation.
        JAMA. 2015; 314: 278-288
        • Ling Z.
        • Liu Z.
        • Su L.
        • et al.
        Radiofrequency ablation versus antiarrhythmic medication for treatment of ventricular premature beats from the right ventricular outflow tract: prospective randomized study.
        Circ Arrhythm Electrophysiol. 2014; 7: 237-243
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • et al.
        2014 AHA/AC/HRS guideline 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 Heart Rhythm Society.
        J Am Coll Cardiol. 2014; 64: e1-e76
        • Mueller K.A.L.
        • Heinzmann D.
        • Klingel K.
        • et al.
        Histopathological and immunological characteristics of tachycardia-induced cardiomyopathy.
        J Am Coll Cardiol. 2017; 69: 2160-2172
        • Faber T.S.
        • Zehender M.
        • Krahnefeld O.
        • Daisenberger K.
        • Meinertz T.
        • Just H.
        Propafenone during acute myocardial ischemia in patients: a double-blind, randomized, placebo-controlled study.
        J Am Coll Cardiol. 1997; 29: 561-567
        • Akiyama T.
        • Pawitan Y.
        • Greenberg H.
        • Kuo C.S.
        • Reynolds-Haertle R.A.
        Increased risk of death and cardiac arrest from encainide and flecainide in patients after non-q-wave acute myocardial infarction in the cardiac arrhythmia suppression trial. Cast investigators.
        Am J Cardiol. 1991; 68: 1551-1555
        • Anderson J.L.
        • Platia E.V.
        • Hallstrom A.
        • Henthorn R.W.
        • Buckingham T.A.
        • Carlson M.D.
        • Carson P.E.
        Interaction of baseline characteristics with the hazard of encainide, flecainide, and moricizine therapy in patients with myocardial infarction. A possible explanation for increased mortality in the Cardiac Arrhythmia Suppression Trial (CAST).
        Circulation. 1994; 90: 2843-2852
        • Meinertz T.
        • Lip G.Y.
        • Lombardi F.
        • Sadowski Z.P.
        • Kalsch B.
        • Camez A.
        • Hewkin A.
        • Eberle S.
        Efficacy and safety of propafenone sustained release in the prophylaxis of symptomatic paroxysmal atrial fibrillation (the European Rythmol/Rytmonorm Atrial Fibrillation Trial [ERAFT] study).
        Am J Cardiol. 2002; 90: 1300-1306
        • Penela D.
        • Van Huls Van Taxis C.
        • Aguinaga L.
        • et al.
        Neurohormonal, structural, and functional recovery pattern after premature ventricular complex ablation is independent of structural heart disease status in patients with depressed left ventricular ejection fraction: a prospective multicenter study.
        J Am Coll Cardiol. 2013; 62: 1195-1202
        • El Kadri M.
        • Yokokawa M.
        • Labounty T.
        • et al.
        Effect of ablation of frequent premature ventricular complexes on left ventricular function in patients with nonischemic cardiomyopathy.
        Heart Rhythm. 2015; 12: 706-713
        • Halliday B.P.
        • Gulati A.
        • Ali A.
        • et al.
        Association between midwall late gadolinium enhancement and sudden cardiac death in patients with dilated cardiomyopathy and mild and moderate left ventricular systolic dysfunction.
        Circulation. 2017; 135: 2106-2115

      Linked Article