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Class IC antiarrhythmic agents in structural heart disease: Is nothing CAST in stone?

  • Christopher Madias
    Affiliations
    New England Cardiac Arrhythmia Center, The Cardiovascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
    Search for articles by this author
  • N.A. Mark Estes III
    Correspondence
    Address reprint requests and correspondence: Dr. N.A. Mark Estes III, Tufts Medical Center, 800 Washington St, Boston, MA 02111.
    Affiliations
    New England Cardiac Arrhythmia Center, The Cardiovascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
    Search for articles by this author
      The development or worsening of cardiomyopathy due to frequent premature ventricular contractions (PVCs) is a well-recognized clinical entity.
      • Baman T.S.
      • Lange D.C.
      • Ilg K.J.
      • et al.
      Relationship between burden of premature ventricular complexes and left ventricular function.
      Suppression of PVCs with radiofrequency ablation or drug therapy can improve or even normalize ventricular dysfunction in patients with this form of cardiomyopathy.
      • Duffee D.F.
      • Shen W.K.
      • Smith H.C.
      Suppression of frequent premature ventricular contractions and improvement of left ventricular function in patients with presumed idiopathic dilated cardiomyopathy.
      • 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.
      • 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.
      • 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.
      Suppression of PVCs with pharmacologic therapy becomes the logical therapeutic option in patients initially taking a noninvasive approach. Because drug selection is principally guided by safety concerns, a trial of beta-blockers is a logical and commonly used treatment strategy. Ablation is also a reasonable initial option and is effective for the long-term management of PVCs in many, but not all, patients.
      • 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.
      Antiarrhythmic drug therapy becomes a therapeutic option for those who are not candidates for or who fail ablation and beta-blocker treatment. Antiarrhythmic agents can have serious adverse effects, including worsening of heart failure and proarrhythmia. In addition, they can have intolerable side effects and toxicities in some patients. Patients with underlying structural heart disease have more restricted treatment options because of absolute or relative contraindications to certain drugs.
      • January C.T.
      • Wann L.S.
      • Alpert J.S.
      • et al.
      2014 AHA/ACC 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. American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
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