Dr. Mitsuaki Isobe,
Sudden Cardiac death is one of the most serious outcomes of heart failure patients. Despite the widespread use of intracardiac defibrillators, many heart failure patients die of arrhythmias. Sometimes sudden cardiac death is brought about by antiarrhythmic agents. In this symposium the issue of sudden cardiac death especially due to proarrhythmia are discussed by four experts. Dr. Ata (Oslo, Norway) talked about general aspects of proarrhythmias associated with heart failure treatment. He pointed out that arrhthymic death is common in heart failure patients even with mild symptoms. The CAST trial published 20 years ago showed that treatment with encainide or flecainide increases mortality after MI. Based on this trial, class III drugs including amiodarone (EMIAT and CAMIAR) and sotalol (SWARD), dronedarone (ANDROMEDA) were tested, but the results were not favourable. He also introduced antiarrhythmic treatment for atrial fibrillation. In his conclusion, he does not recommend appropriate antiarrhythmic drugs for advanced heart failure. Dr. Fenelon (San Paulo, Brazil) presented the issue of polypharmacy. Prescription of unnecessary and inappropriate medications is usually harmful especially in elderly persons. Drug–induced long QT syndrome that leads to torsade de pointes is not rare and caused by a variety of drug categories. He mentioned factors predisposing to torsade de pointes. They include female gender, elderly, bradycardia, renal and hepatic dysfunction, hypokalemia, heart failure, etc. He emphasised the importance of the risk of polypharmacy, subsequent proarrhythima and sudden cardiac death.
Dr. Ravens (Dresden Germany) talked about new types of antiarrhythmic drugs which can be used for patients with ICD implantation. As previous speakers presented, currently available antiarrhythimic drugs for ventricular arrhythmias are not satisfactory. She introduced new clinical data on ranolazine which blocks INa, late channel selectively. She showed several new targets of new antiarrhythmic drugs for prevention of EAD. She concluded that we need new antiarrhythmic drugs with novel mechanism with less toxicity. Dr. Vaclavik (Olomouc, Czech Republic) emphasized the role of aldosterone antagonists for the prevention of sudden cardiac death especially in patients with heart failure. Aldosterone causes excessive sodium retention and potassium loss, left ventricular hypertrophy, and myocardial fibrosis. Aldosterone also deteriorates endothelial function. All of these factors promote sudden cardiac death. He introduced randomized clinical trials, including RALE, EPHESUS, EMPHASIS-HF and SPIRIT. These clinical data suggest a beneficial effect of aldosterone blockade for the prevention of sudden cardiac death. Based on these results, several new clinical studies are started. In conclusion, proarrhythmia is a critical issue in the management of heart failure. We should be aware of the potential side effects of antiarrhythmic drugs to do no harm to patients. New types of effective drugs with less toxicity are strongly desired.
Influencing sudden cardiac death by pharmacotherapy
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