Skip to main content
SpringerLink
Log in

Approach to antiarrhythmic therapy in patients with ICDs and frequent activations

  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Patients with an implantable defibrillator may require concomitant antiarrhythmic drug therapy to reduce therapy from the device, especially shocks from the device. New evidence suggests that amiodarone, in combination with β-blockade, is the most effective treatment to reduce the frequency of defibrillator therapies, but sotalol and azimilide have also been shown to be effective. Electrical storm is a serious condition that occurs in 20% of patients living with a defibrillator, and its management requires a complex approach to the patient.

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 and Recommended Reading

  1. Connolly SJ, Hallstrom AP, Cappato R, et al.: Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Eur Heart J 2000, 21:2071–2078.

    Article  PubMed  CAS  Google Scholar 

  2. Lee KL, Hafley G, Fisher JD, et al.: Effect of implantable defibrillators on arrhythmic events and mortality in the multicenter unsustained tachycardia trial. Circulation 2002, 106:233–238.

    Article  PubMed  Google Scholar 

  3. Bardy GH, Lee KL, Mark DB, et al.: Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005, 352:225–237. The SCD-HeFT trial showed a mortality benefit from ICD therapy but not from amiodarone therapy in patients with heart failure and low ejection fraction.

    Article  PubMed  CAS  Google Scholar 

  4. Moss AJ, Zareba W, Hall WJ, et al.: Prophylactic implantation of a deflbrillator in patients with myocardial infarction and reduced ejection fraction. For the multicenter automatic deflbrillator implantation trial II investigators. N Engl J Med 2002, 346:877–883. The MADIT II study showed a mortality benefit from ICD therapy on top of optimal medical management in patients with ischemic cardiomyopathy and low ejection fraction.

    Article  PubMed  Google Scholar 

  5. Steinberg IS, Martins I, Sadanandan S, et al.: Antiarrhythmic drug use in the implantable deflbrillator arm of the Antiarrhythmics Versus Implantable Defibrillators (AVID) Study. Am Heart J 2001, 142:520–529.

    Article  PubMed  CAS  Google Scholar 

  6. Rajawat YS, Patel VV, Gerstenfeld EP, et al.: Advantages and pitfalls of combining device-based and pharmacologic therapies for the treatment of ventricular arrhythmias: observations from a tertiary referral center. PACE 2004, 27:1670–1681.

    PubMed  Google Scholar 

  7. Gradaus R, Block M, Brachmann I, et al.: Mortality, morbidity and complications in 3344 patients with implantable cardioverter-defibrillators: Results from the Germany ICD registry EURID. PACE 2003, 26:1511–1518.

    PubMed  Google Scholar 

  8. Freedberg NA, Hill JN, Fogel RI, Prystowsky EN: Recurrence of symptomatic ventricular arrhythmias in patients with implantable cardioverter defibrillator after the first device therapy. J Am Coll Cardiol 2001, 37:1910–1915. Recurrence of ventricular arrhythmia requiring treatment from the ICD is frequent following the first ICD therapy. Secondary prophylactic antiarrhythmic drug treatment should be considered.

    Article  PubMed  CAS  Google Scholar 

  9. Klein RC, Raitt MH, Wilkoff BL, et al.: Analysis of implantable cardioverter defibrillator therapy in the Antiarrhythmics Versus Implantable Defibrillators (AVID) Trial. J Cardiovasc Electrophysiol 2003, 14:940–948.

    Article  PubMed  Google Scholar 

  10. Credner SC, Klingenheben T, Mauss O, et al.: Electrical storm in patients with transvenous implantable cardioverter-defibrillators: incidence, management and prognostic implications. J Am Coll Cardiol 1998, 32:1909–1915.

    Article  PubMed  CAS  Google Scholar 

  11. Exner DV, Pinski SL, Wyse DG, et al.: Electrical storm presages nonsudden death: the antiarrhythmics versus implantable defibrillators (AVID) trial. Circulation 2001, 103:2066–2071. Important insights regarding electrical storm from a large, secondary prophylaxis ICD study.

    PubMed  CAS  Google Scholar 

  12. Greene M, Newman D, Geist M, et al.: Is electrical storm in ICD patients a sign of a dying heart? Outcome of patients with clusters of ventricular tachyarrhythmias. Europace 2000, 2:263–269.

    Article  PubMed  CAS  Google Scholar 

  13. Nanthakumar K, Dorian P, Paquette M, et al.: Is inappropriate implantable defibrillator shock therapy predictable? J Interv Card Electrophysiol 2003, 8:215–220.

    Article  PubMed  Google Scholar 

  14. Whang W, Mittleman MA, Rich DQ, et al.: Heart failure and the risk of shocks in patients with implantable cardioverter defibrillators: results from the Triggers Of Ventricular Arrhythmia (TOVA) study. Circulation 2004, 109:1386–1391. Heart failure is implied as an independent risk factor for recurrent ICD discharge.

    Article  PubMed  Google Scholar 

  15. Irvine J, Dorian P, Baker B, et al.: Quality of life in the Canadian Implantable Defibrillator Study (CIDS). Am Heart J 2002, 144:282–289.

    PubMed  Google Scholar 

  16. Schron EB, Exner DV, Yao Q, et al.: Quality of life in the antiarrhythmics versus implantable defibrillators trial.: impact of therapy and influence of adverse symptoms and defibrillator shocks. Circulation 2002, 105:589–594.

    Article  PubMed  Google Scholar 

  17. Yusuf S, Peto R, Lewis J, et al.: Beta blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis 1985, 27:335–371.

    Article  PubMed  CAS  Google Scholar 

  18. CIBIS-II Investigators and Committees: The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet 1999, 353:9–13.

    Article  Google Scholar 

  19. Levine JH, Mellits D, Baumgardner RA, et al.: Predictors of first discharge and subsequent survival in patients with automatic implantable cardioverter-defibrillators. Circulation 1991, 84:558–566.

    PubMed  CAS  Google Scholar 

  20. Kettering K, Mewis C, Dornberger V, et al.: Efficacy of metoprolol and sotalol in the prevention of recurrences of sustained ventricular tachyarrhythmias in patients with an implantable defibrillator. PACE 2002, 11:1571–1576.

    Google Scholar 

  21. Kuhlkamp V, Mewis C, Mermi J, et al.: Suppression of sustained ventricular tachyarrhythmias: a comparison of d,l-sotalol with no antiarrhythmic drug treatment. J Am Coll Cardiol 1999, 33:46–52.

    Article  PubMed  CAS  Google Scholar 

  22. Pacifico A, Hohnloser SH, Williams JH, et al.: Prevention of implantable-defibrillator shocks by pretreatment with sotalol. N Engl J Med 1999, 340:1855–1862. Prophylactic use of sotalol prolonged the time to first shock from ICD or death.

    Article  PubMed  CAS  Google Scholar 

  23. Singer I, Al-Khalidi H, Niazi I, et al.: Azimilide decreases recurrent ventricular tachyarrhythmias in patients with implantable cardioverter-defibrillators. J Am Coll Cardiol 2004, 43:39–43.

    Article  PubMed  CAS  Google Scholar 

  24. Dorian P, Borggrefe M, Al-Khalidi HR, et al.: Placebo-controlled, randomized clinical trial of azimilide for prevention of ventricular tachyarrhythmias in patients with an implantable cardioverter defibrillator. Circulation 2004, 110:3646–3654. This randomized trial showed, that azimilide, compared to placebo, reduced the burden of symptomatic ventricular tachyarrhythmia in ICD patients.

    Article  PubMed  CAS  Google Scholar 

  25. Kowey P, Levine J, Herre J, et al.: Randomized, double-blind comparison of intravenous amiodarone and bretylium in the treatment of patients with recurrent, hemodynamically destabilizing ventricular tachycardia or fibrillation. Circulation 1995, 92:3255–3263.

    PubMed  CAS  Google Scholar 

  26. Scheinman MM, Levine JH, Cannom DS, et al.: Dose-ranging study of intravenous amiodarone in patients with life threatening ventricular tachyarrhythmias. Circulation 1995, 92:3264–3272.

    PubMed  CAS  Google Scholar 

  27. Connolly SJ, Hohnloser S, Dorian P, et al.: Optimal Pharmacological Therapy in Implantable Cardioverter Defibrillator Patients (OPTIC) trial. Presented at the American College of Cardiology Annual Scientific Sessions. Late Breaking Clinical Trials I. Orlando, FL; March 6–9, 2005.

  28. Anderson JL, Karagounis LA, Roskelley M, et al.: Effect of prophylactic antiarrhythmic therapy on time to implantable cardioverter-defibrillator discharge in patients with ventricular tachyarrhythmias. Am J Cardiol 1994, 73:683–687.

    Article  PubMed  CAS  Google Scholar 

  29. Manolis A, Katsivas A, Vassilopoulos C, et al.: Electrical storm in an ICD-recipient with 429 delivered appropriate shocks: therapeutic management with antiarrhythmic drug combination. J Interven Card Electrophysiol 2002, 6:91–94.

    Article  Google Scholar 

  30. Waleffe A, Mary-Rabine L, Legrand V, et al.: Combined mexiletine and amiodarone treatment of refractory recurrent ventricular tachycardia. Am Heart J 1980, 100(6 Pt 1):788–793.

    Article  PubMed  CAS  Google Scholar 

  31. Boriani G, Lubinski A, Capucci A et al.: A multicentre, double-blind randomized crossover comparative study on the efficacy and safety of dofetilide vs sotalol in patients with inducible sustained ventricular tachycardia and ischemic heart disease. Eur Heart J 2001, 22:2180–2191.

    Article  PubMed  CAS  Google Scholar 

  32. O’Toole M, O’Neill G, Kluger J, et al.: Efficacy and safety of oral dofetilide in patients with an implantable defibrillator: A multicenter study [abstract]. Circulation 1999, 100:1–794.

    Google Scholar 

  33. Bokhari F, Newman D, Greene M, et al.: Long-term comparison of the implantable cardioverter defibrillator versus amiodarone: eleven-year follow-up of a subset of patients in the Canadian Implantable Defibrillator Study (CIDS). Circulation 2004, 110:112–116.

    Article  PubMed  CAS  Google Scholar 

  34. Pinter A, Dorian P: Interactions between implantable devices and antiarrhythmic drugs. Card Electrophysiol Rev 2000, 4:222–226.

    Article  Google Scholar 

  35. Dorian P: Amiodarone and defibrillation thresholds: a clinical conundrum. J Cardiovasc Electrophysiol 2000, 11:741–743.

    Article  PubMed  CAS  Google Scholar 

  36. Dorian P, Newman D: Effect of sotalol on ventricular fibrillation and defibrillation in humans. Am J Cardiol 1993, 72:72A-79A.

    Article  PubMed  CAS  Google Scholar 

  37. Lee SD, Newman D, Ham M, Dorian P: Electrophysiologic mechanisms of antiarrhythmic efficacy of a sotalol and class Ia drug combination: elimination of reverse use dependence. J Am Coll Cardiol 1997, 29:100–105.

    Article  PubMed  CAS  Google Scholar 

  38. Dorian P, Cass D: An overview of the management of electrical storm. Can J Cardiol 1997, 13(Suppl A):13A-17A.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Cardiology, St. Michael’s Hospital, 30 Bond Street, M5B IW8, Toronto, ON, Canada

    Paul Dorian MD, MSc

Authors
  1. Arnold Pinter MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Paul Dorian MD, MSc
    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

Pinter, A., Dorian, P. Approach to antiarrhythmic therapy in patients with ICDs and frequent activations. Curr Cardiol Rep 7, 376–381 (2005). https://doi.org/10.1007/s11886-005-0092-5

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11886-005-0092-5

Keywords

Search

Navigation