Feature Article
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Therapy of Older Persons With Ventricular Arrhythmias Ventricular arrhythmias (VA) in asymptomatic older persons without heart disease should not be treated with antiarrhythmic drugs. Class I antiarrhythmic drugs should not be used to treat VA in older persons with heart disease. Beta blockers should be used to treat complex VA in older persons with ischemic or nonischemic heart disease without contraindications to beta blockers. Angiotensin-converting enzyme inhibitors should be used to treat older persons with heart failure, an anterior myocardial infarction, or a left ventricular ejection fraction of 40% or less after myocardial infarction. Amiodarone should be reserved for treating life-threatening ventricular tachyarrhythmias in older persons who cannot tolerate or who do not respond to beta blockers. If older persons have life-threatening recurrent ventricular tachycardia or ventricular fibrillation resistant to antiarrhythmic drug therapy, invasive intervention should be performed. The automatic implantable cardioverter-defibrillator is the most effective treatment for older persons with life-threatening ventricular tachycardia or ventricular fibrillation. (Annals of Long-Term Care: Clinical Care and Aging 2000;8[8]:35-44)
The presence of three or more consecutive ventricular premature complexes (VPCs) on an electrocardiogram is diagnosed as ventricular tachycardia (VT).1,2 VT is considered sustained if it lasts 30 seconds or more and nonsustained if it lasts less than 30 seconds.2 Complex ventricular arrhythmias (VA) include VT or paired, multiform, or frequent VPCs. This author considers frequent VPCs an average of 30 or more per hour on a 24-hour ambulatory electrocardiogram (AECG) or six or more per minute on a one-minute rhythm strip of an electrocardiogram.2,3 Simple VA include infrequent VPCs and no complex forms.
The prevalence of nonsustained VT detected by 24-hour AECGs in older populations without cardiovascular disease was 4%,1,4,5 2%,6 and 4% in 729 older women and 13% in 643 older men in the Cardiovascular Health Study.7 The prevalence of nonsustained VT detected by 24-hour AECGs was 9% in older persons with hypertension, valvular heart disease, or cardiomyopathies and 16% in older persons with coronary artery disease (CAD).5
The prevalence of complex VA in older persons without cardiovascular disease detected by 24-hour AECGs was 50%,1 31%,4 30%,5 20%,6 and 16% in women,7 28% in men,7 and 33%.3 The prevalence of complex VA detected by 24-hour AECGs was 55% in older persons with hypertension, valvular heart disease, or cardiomyopathies,5 68% in older persons with CAD,5 and 55% in 843 older persons with heart disease.3 Complex VA were present on a one-minute strip of an electrocardiogram in 2% of 104 older persons without cardiovascular disease and 4% of 843 older persons with cardiovascular disease.3 In older persons with cardiovascular disease, there is a higher prevalence of VT and of complex VA in persons who have an abnormal left ventricular (LV) ejection fraction,8 echocardiographic LV hypertrophy,9 or silent myocardial ischemia.10
Prognosis of Ventricular Arrhythmias Prognosis for people without heart disease and with heart disease will be discussed separately.
No Heart Disease Nonsustained VT or complex VA diagnosed by 24-hour AECGs5,11,12 or by 12-lead electrocardiograms with one-minute rhythm strips3 in older persons with no clinical evidence of heart disease was not associated with an increased incidence of new coronary events. Exercise-induced nonsustained VT13 or complex VA14 in older persons with no clinical evidence of heart disease also was not associated with an increased incidence of new coronary events. Therefore, asymptomatic nonsustained VA or complex VA in older persons without heart disease should not be treated with antiarrhythmic drugs.
Heart Disease In older persons with heart disease, nonsustained VT5,10,12 or complex VA3,5,10,12 significantly increased the incidence of new coronary events. At two-year follow-up of 391 older persons with heart disease, the incidence of new coronary events was significantly increased 6.8 times in older persons with VT plus an abnormal LV ejection fraction and 7.6 times in older persons with complex VA plus an abnormal LV ejection fraction.5
At 27-month follow-up of 468 older persons with heart disease, the incidence of primary ventricular fibrillation or sudden cardiac death was significantly increased 7.1 times in older persons with VT plus echocardiographic LV hypertrophy and 7.3 times in persons with complex VA plus echocardiographic LV hypertrophy.12 At 37-month follow-up of 404 older persons with heart disease, the incidence of new coronary events was significantly increased 2.5 times in older persons with VT plus silent ischemia and 4.0 times in older persons with complex VA plus silent ischemia.10
General Therapeutic Measures Underlying causes of complex VA should be treated, if possible. Therapy of digitalis toxicity, congestive heart failure (CHF), LV dysfunction, hypokalemia, hypomagnesemia, myocardial ischemia (by anti-ischemic drugs such as beta blockers or by coronary revascularization), hypertension, LV hypertrophy, hypoxia, and other conditions may abolish or decrease complex VA. The person should not smoke or drink alcohol and should avoid drugs that may cause or increase complex VA.
All older persons with CAD should be treated with aspirin15-17 and with beta blockers17-21 unless there are contraindications to these drugs. Older persons who, after myocardial infarction, have CHF, an anterior myocardial infarction, or an LV ejection fraction of 40% or less should be treated with angiotensin-converting enzyme (ACE) inhibitors unless there are contraindications to these drugs.17,22-25 Older persons with CAD with serum low-density lipoprotein cholesterol levels of 125 mg/dL or more should be treated with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors.17,26-28
Age-related physiologic changes may affect absorption, distribution, metabolism, and excretion of cardiovascular drugs.29 Numerous physiologic changes occur with aging that affect pharmacodynamics, resulting in changes in end-organ responsiveness to cardiovascular drugs.29 Drug interactions between antiarrhythmic drugs and other cardiovascular drugs are common, especially in older persons.29 Important drug-disease interactions also occur in older persons.29 Class I antiarrhythmic drugs are more proarrhythmic than Class III antiarrhythmic drugs. Except for beta blockers, all antiarrhythmic drugs can cause torsades des pointes VT (polymorphous appearance associated with prolonged QT interval).
Class I Antiarrhythmic Drugs Class I antiarrhythmic drugs are sodium channel blockers. Class Ia antiarrhythmic drugs have intermediate channel kinetics and prolong repolarization. These drugs include quinidine, disopyramide, and procainamide. Class Ib antiarrhythmic drugs have rapid channel kinetics and shorten repolarization slightly. These drugs include lidocaine, tocainide, mexiletine, and phenytoin. Class Ic antiarrhythmic drugs have slow channel kinetics and have little effect on repolarization. These drugs include encainide, flecainide, moricizine, lorcainide, and propafenone. None of the Class I antiarrhythmic drugs have been shown in controlled, clinical trials to reduce sudden cardiac death, total cardiac death, or total mortality.
Table I shows the effect of Class I antiarrhythmic drugs on mortality in persons with heart disease and complex VA.30-36 A meta-analysis of six double-blind studies of persons with chronic atrial fibrillation who underwent direct-current cardioversion to sinus rhythm demonstrated that the mortality at one year was significantly higher in persons treated with quinidine (2.9%) than in persons treated with placebo (0.8%).37
Of 1330 persons in the Stroke Prevention in Atrial Fibrillation Study,38 127 were treated with quinidine, 57 with procainamide, 34 with flecainide, 20 with encainide, and seven with amiodarone. The adjusted relative risk of cardiac mortality was 1.8 times higher and the adjusted relative risk of arrhythmic death was 2.1 times higher in persons receiving antiarrhythmic drugs versus those receiving no antiarrhythmic drugs.38 In persons with a history of CHF, the adjusted relative risk of cardiac death was 3.3 times higher and the adjusted relative risk of arrhythmic death was 5.8 times higher in persons receiving antiarrhythmic drugs versus those receiving no antiarrhythmic drugs.38
An analysis was made of 59 randomized, controlled clinical trials comprising 23,229 patients that investigated the use of Class I antiarrhythmic drugs after myocardial infarction.39 The Class I antiarrhythmic drugs investigated included encainide, flecainide, quinidine, procainamide, disopyramide, imipramine, moricizine, tocainide, lidocaine, mexiletine, aprindine, and phenytoin. Mortality was significantly higher in persons receiving Class I antiarrhythmic drugs than in persons receiving no antiarrhythmic drugs (odds ratio, 1.14).39 None of the 59 studies found that the use of a Class I antiarrhythmic drug reduced mortality in persons after myocardial infarction. On the basis of the available data, the author would not use any of the Class I antiarrhythmic drugs for the treatment of VT or complex VA in either older or younger persons with heart disease.
Calcium Channel Blockers Calcium channel blockers are not useful in the treatment of complex VA. Although verapamil can terminate a left septal VT, hemodynamic collapse can occur if intravenous verapamil is administered to persons with the more common forms of VT. An analysis was made of randomized, controlled clinical trials comprising 20,342 patients that investigated the use of calcium channel blockers after myocardial infarction.39 Mortality was insignificantly higher in persons receiving calcium channel blockers than in persons receiving no antiarrhythmic drugs (odds ratio, 1.04).39 On the basis of the available data, the author would not use any of the calcium channel blockers in the treatment of VT or complex VA in either older or younger persons with heart disease.
Beta Blockers An analysis of 55 randomized, controlled clinical trials comprising 53,268 patients that investigated the use of beta blockers after myocardial infarction demonstrated that mortality was significantly reduced in patients receiving beta blockers versus placebo (odds ratio, 0.81).39 Beta sblockers caused a greater reduction in mortality in older persons than in younger persons.18-21,40 Table II shows the effect of beta blockers on mortality in persons with heart disease and complex VA.36,40-45
The reduction in mortality by beta blockers in older persons with heart disease and complex VA is due more to an anti-ischemic effect than to an antiarrhythmic effect.46 Beta blockers also abolish the circadian distribution of sudden cardiac death or fatal myocardial infarction,47 markedly reduce the circadian variation of complex VA,48 and abolish the circadian variation of myocardial ischemia.49 On the basis of the available data, the author recommends the use of beta blockers in the treatment of both older and younger persons with heart disease and complex VA if there are no contraindications to the use of beta blockers.
Angiotensin-Converting Enzyme Inhibitors ACE inhibitors have been found to reduce sudden cardiac death in some studies of patients with CHF.25,50 ACE inhibitors should be administered to decrease total mortality to older and younger persons with CHF,23,25,50,51 an anterior myocardial infarction,24 and an LV ejection fraction of 40% or less after myocardial infarction.22,25 ACE inhibitors should be used to treat both older and younger persons with CHF with abnormal LV ejection fraction23,25,50,51 or with normal LV ejection fraction.52,53
On the basis of the available data, the author also recommends the use of ACE inhibitors in treating both older and younger persons with VT or complex VA associated with CHF, an anterior myocardial infarction, or an LV ejection fraction of 40% or less after myocardial infarction if there are no contraindications to the use of ACE inhibitors. Beta blockers should be used in addition to ACE inhibitors in treating these persons.
Class III Antiarrhythmic Drugs Class III antiarrhythmic drugs are potassium channel blockers that prolong repolarization, manifested by an increase in QT interval on the electrocardiogram. These drugs are effective in suppressing complex VA, including nonsustained VT, by increasing the refractory period. However, antiarrhythmic aggravation can occur, especially torsades des pointes.
Table III shows the effect of Class III antiarrhythmic drugs on mortality in persons with heart disease.54-58 None of the Class III antiarrhythmic drugs has been demonstrated in a double-blind, randomized, placebo-controlled clinical trial to reduce mortality in persons with heart disease and complex VA.
In 481 persons with VT, d,l-sotalol caused torsades des pointes (12 persons) or an increase in VT episodes (11 persons) in 23 persons (5%).59 On the basis of the available data, the author prefers the use of beta blockers to the use of d,l-sotalol in treating older and younger persons with heart disease and VT or complex VA.
Amiodarone is very effective in suppressing VT and complex VA associated with heart disease.56,57,60 However, the incidence of adverse effects from amiodarone approaches 90% after five years of therapy.61 In the Cardiac Arrest in Seattle: Conventional versus Amiodarone Drug Evaluation study,60 the incidence of pulmonary toxicity was 10% at two years in persons receiving 158 mg of amiodarone daily. Amiodarone can also cause hyperthyroidism, hypothyroidism, and cardiac, gastrointestinal, hepatic, neurologic, dermatologic, and ophthalmologic adverse effects.
Because amiodarone has not been demonstrated to decrease mortality in either older or younger persons with VT or complex VA associated with prior myocardial infarction or CHF and has a very high incidence of toxicity, this author prefers to use beta blockers rather than amiodarone in treating these persons. There are also data suggesting that persons receiving amiodarone plus beta blockers had a better survival than persons receiving amiodarone alone.62
Invasive Intervention If persons have life-threatening VT or ventricular fibrillation that is resistant to antiarrhythmic drugs, invasive intervention should be performed. Persons with critical coronary artery stenosis and severe myocardial ischemia should undergo coronary artery bypass graft surgery to decrease mortality.63
Surgical ablation of the arrhythmogenic focus in persons with life-threatening ventricular tachyarrhythmias can be curative. This treatment includes aneurysmectomy or infarctectomy and endocardial resection with or without adjunctive cryoablation based on activation mapping in the operating room.64-66 However, the perioperative mortality rate is high. Endoaneurysmorrhaphy with a pericardial patch combined with mapping-guided subendocardial resection frequently cures recurrent VT with a low operative mortality and improvement of LV systolic function.67 Radiofrequency catheter ablation of VT has also been beneficial in the treatment of selected persons with arrhythmogenic foci of monomorphic VT.68,69
Automatic Implantable Cardioverter-Defibrillator The automatic implantable cardioverter-defibrillator (AICD) is the most effective treatment for persons with life-threatening VT or ventricular fibrillation. Table IV shows the effect of the AICD on mortality in persons with ventricular tachyarrhythmias.70-75 Tresch et al65,66 showed in retrospective studies that the AICD was very effective in treating life-threatening VT in older as well as in younger patients. The Canadian Implantable Defibrillator Study76 found that patients most likely to benefit from an AICD were those with two or more of the following factors: age 70 years or above, LV ejection fraction 35% or less, and New York Heart Association function class III or IV.
At 26-month follow-up, survival was 91% for persons treated with metoprolol plus an AICD versus 83% for persons treated with d,l-sotalol plus an AICD.77 These data favor using a beta blocker for persons with an AICD needing antiarrhythmic drug therapy.
The American College of Cardiology/American Heart Association guidelines recommend that Class I indications for treatment with an AICD are (1) cardiac arrest due to VT or ventricular fibrillation not caused by a transient or reversible cause; (2) spontaneous sustained VT; (3) syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or ventricular fibrillation induced at electrophysiologic study when drug therapy is ineffective, not tolerated, or not preferred; and (4) nonsustained VT with CAD, prior myocardial infarction, LV systolic dysfunction, and inducible ventricular fibrillation or sustained VT at electrophysiologic study that is not suppressed by a Class I antiarrhythmic drug.78 The author agrees with these recommendations.
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From the Hebrew Hospital Home, Bronx and Westchester County, NY, and the Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY. Address for correspondence: Wilbert S. Aronow, MD, CMD, Corporate Medical Director, Hebrew Hospital Home, 801 Co-op City Blvd, Bronx, NY 10475.
Annals of Long-Term Care - ISSN: 1524-7929 - Volume 8 - Issue 08 - August 2000 |