Pharmacologic therapy in survivors of sudden cardiac arrest
- Philip J Podrid, MD, FACC
Philip J Podrid, MD, FACC
- Professor of Medicine, Professor of Pharmacology and Experimental Therapeutics
- Boston University School of Medicine
- Lecturer, Harvard Medical School
- Section Editors
- Scott Manaker, MD, PhD
Scott Manaker, MD, PhD
- Section Editor — Critical Care
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Samuel Lévy, MD
Samuel Lévy, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Cardiology
- University of Marseille, France
Sudden cardiac arrest (SCA) and sudden cardiac death (SCD) refer to the sudden cessation of cardiac activity with hemodynamic collapse, typically due to sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). The event is referred to as SCA (or aborted SCD) if an intervention (eg, defibrillation) or spontaneous reversion restores circulation, while the SCD terminology is employed if the patient dies. However, the use of SCD to describe both fatal and nonfatal cardiac arrest often persists by convention. (See "Overview of sudden cardiac arrest and sudden cardiac death", section on 'Definitions'.)
The treatment of SCA consists of acute resuscitation using standardized advanced cardiac life-support protocols, followed by therapy to prevent recurrent arrhythmias and SCD. Patients who survive SCA caused by VT/VF not due to a reversible cause generally receive an implantable cardioverter-defibrillator (ICD). Antiarrhythmic drugs are used in select patients as adjunctive therapy, or as primary therapy when an ICD is not indicated or refused by the patient. This approach, endorsed by numerous professional societies, is based on the significant survival benefit of patients receiving an ICD compared with antiarrhythmic drugs alone or no therapy.
This topic will review the role of pharmacologic therapy in survivors of SCA, with an emphasis on the role of antiarrhythmic drugs. Issues related to the acute management of SCA, the evaluation of survivors, and the utility of an ICD, arrhythmic surgery, or radiofrequency ablation are discussed separately. (See "Advanced cardiac life support (ACLS) in adults" and "Evaluation of the survivor of sudden cardiac arrest" and "Secondary prevention of sudden cardiac death in heart failure and cardiomyopathy".)
INDICATIONS FOR PHARMACOLOGIC THERAPY
Nearly all survivors of sudden cardiac arrest (SCA) without a reversible cause should be evaluated for placement of an implantable cardioverter-defibrillator (ICD). Because an ICD treats, but does not prevent, arrhythmias, patients who have arrhythmias with symptoms or device discharges may require adjunctive antiarrhythmic therapy.
In addition to ICD therapy for survivors of SCA, there are three main indications for concomitant antiarrhythmic drug therapy [1-3]:
Subscribers log in hereLiterature review current through: Jul 2017. | This topic last updated: Jul 27, 2017.References
- Knilans TK, Prystowsky EN. Antiarrhythmic drug therapy in the management of cardiac arrest survivors. Circulation 1992; 85:I118.
- Manz M, Jung W, Lüderitz B. Interactions between drugs and devices: experimental and clinical studies. Am Heart J 1994; 127:978.
- Steinberg JS, Martins J, Sadanandan S, et al. Antiarrhythmic drug use in the implantable defibrillator arm of the Antiarrhythmics Versus Implantable Defibrillators (AVID) Study. Am Heart J 2001; 142:520.
- Nanthakumar K, Paquette M, Newman D, et al. Inappropriate therapy from atrial fibrillation and sinus tachycardia in automated implantable cardioverter defibrillators. Am Heart J 2000; 139:797.
- Pacifico A, Hohnloser SH, Williams JH, et al. Prevention of implantable-defibrillator shocks by treatment with sotalol. d,l-Sotalol Implantable Cardioverter-Defibrillator Study Group. N Engl J Med 1999; 340:1855.
- Kim SG. The management of patients with life-threatening ventricular tachyarrhythmias: programmed stimulation or Holter monitoring (either or both)? Circulation 1987; 76:1.
- Wilber DJ, Garan H, Finkelstein D, et al. Out-of-hospital cardiac arrest. Use of electrophysiologic testing in the prediction of long-term outcome. N Engl J Med 1988; 318:19.
- Graboys TB, Lown B, Podrid PJ, DeSilva R. Long-term survival of patients with malignant ventricular arrhythmia treated with antiarrhythmic drugs. Am J Cardiol 1982; 50:437.
- Lampert S, Lown B, Graboys TB, et al. Determinants of survival in patients with malignant ventricular arrhythmia associated with coronary artery disease. Am J Cardiol 1988; 61:791.
- Vlay SC, Kallman CH, Reid PR. Prognostic assessment of survivors of ventricular tachycardia and ventricular fibrillation with ambulatory monitoring. Am J Cardiol 1984; 54:87.
- Mason JW. A comparison of electrophysiologic testing with Holter monitoring to predict antiarrhythmic-drug efficacy for ventricular tachyarrhythmias. Electrophysiologic Study versus Electrocardiographic Monitoring Investigators. N Engl J Med 1993; 329:445.
- Mason JW. A comparison of seven antiarrhythmic drugs in patients with ventricular tachyarrhythmias. Electrophysiologic Study versus Electrocardiographic Monitoring Investigators. N Engl J Med 1993; 329:452.
- Swerdlow CD, Winkle RA, Mason JW. Determinants of survival in patients with ventricular tachyarrhythmias. N Engl J Med 1983; 308:1436.
- Exner DV, Reiffel JA, Epstein AE, et al. Beta-blocker use and survival in patients with ventricular fibrillation or symptomatic ventricular tachycardia: the Antiarrhythmics Versus Implantable Defibrillators (AVID) trial. J Am Coll Cardiol 1999; 34:325.
- Weinberg BA, Miles WM, Klein LS, et al. Five-year follow-up of 589 patients treated with amiodarone. Am Heart J 1993; 125:109.
- Connolly SJ, Dorian P, Roberts RS, et al. Comparison of beta-blockers, amiodarone plus beta-blockers, or sotalol for prevention of shocks from implantable cardioverter defibrillators: the OPTIC Study: a randomized trial. JAMA 2006; 295:165.
- 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.
- 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.
- Kühlkamp 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.
- Ferreira-González I, Dos-Subirá L, Guyatt GH. Adjunctive antiarrhythmic drug therapy in patients with implantable cardioverter defibrillators: a systematic review. Eur Heart J 2007; 28:469.
- Randomized antiarrhythmic drug therapy in survivors of cardiac arrest (the CASCADE Study). The CASCADE Investigators. Am J Cardiol 1993; 72:280.
- Ha AH, Ham I, Nair GM, et al. Implantable cardioverter-defibrillator shock prevention does not reduce mortality: a systemic review. Heart Rhythm 2012; 9:2068.
- Zhou L, Chen BP, Kluger J, et al. Effects of amiodarone and its active metabolite desethylamiodarone on the ventricular defibrillation threshold. J Am Coll Cardiol 1998; 31:1672.
- Pelosi F Jr, Oral H, Kim MH, et al. Effect of chronic amiodarone therapy on defibrillation energy requirements in humans. J Cardiovasc Electrophysiol 2000; 11:736.
- Nielsen TD, Hamdan MH, Kowal RC, et al. Effect of acute amiodarone loading on energy requirements for biphasic ventricular defibrillation. Am J Cardiol 2001; 88:446.
- Brunn J, Böcker D, Weber M, et al. Is there a need for routine testing of ICD defibrillation capacity? Results from more than 1000 studies. Eur Heart J 2000; 21:162.
- Hohnloser SH, Dorian P, Roberts R, et al. Effect of amiodarone and sotalol on ventricular defibrillation threshold: the optimal pharmacological therapy in cardioverter defibrillator patients (OPTIC) trial. Circulation 2006; 114:104.
- INDICATIONS FOR PHARMACOLOGIC THERAPY
- CHOICE OF PHARMACOLOGIC THERAPY
- Empiric versus guided pharmacologic therapy
- Beta blockers
- Antiarrhythmic drugs
- - Efficacy
- - Administration
- Treatment of breakthrough arrhythmias
- IMPACT ON ICD THERAPIES
- Alterations in DFTs
- VT rate slowing
- SUMMARY AND RECOMMENDATIONS