[ARVD-FORUM] Answers by Drs. Sandeep Joshi and Dr. Jonathan S.
Steinberg.
ARVD Symposium
info at arvd-symposium.org
Sat Apr 16 09:05:06 ART 2005
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English - Spanish
Why in this disease, sotalol seems to be more efficient as an antiarrhythmic
agent than amiodarone?
Studies have shown that increased heart rate with shortening of the coupling
intervals of the first cycles preceding the tachycardia may be due to a
change in the autonomic balance, i.e. an increased sympathetic tone in ARVD.
Some reports suggest therapeutic efficacy rates of sotalol in the range of
68%-83%, at least as judged by noninducibility in the electrophysiology (EP)
laboratory. Required doses are often high and necessary to achieve beta
blockade. Greater success compared to amiodarone is not based on randomized
comparisons, but may be due to better tolerance.
- Sen-Chowdhry S, Lowe MD, Sporton SC, et al. Arrhythmogenic right
ventricular cardiomyopathy: Clinical presentation, diagnosis, and management.
Am J Med 2004; 117:685-695.
- Wichter T, Borggrefe M, Haverkamp W, et al. Efficacy of antiarrhythmic
drugs in patients with arrhythmogenic right ventricular disease. Results in
patients with inducible and noninducible ventricular tachycardia. Circulation
1992; 86:29-37.
- Marcus FI, Fontaine GH, Frank R, et al. Long term follow up in patients
with arrhythmogenic right ventricular disease. Eur Heart J 1989; 10 (suppl
D):68-73.
What criteria would you follow to consider an asymptomatic patient with ARVD
as in high risk for developing sudden death (SCD) and therefore, for the
implantation of an ICD?
Risk factors for SCD in the asymptomatic patient with ARVD are poorly
described. Presentation with syncope and a severely depressed RV function
have been reported as risk factors for SCD. Complicating the challenges of
risk stratification is the fact that ARVD is a progressive disease and the
patient’s risk of SCD may increase with time. Improved risk stratification
will clarify the indications for ICD therapy in the asymptomatic patient.
- Corrado D, Basso C, Nava A, et al. Arrhythmogenic right ventricular
cardiomyopathy: Current diagnostic and management strategies. Cardiology In
Review 2001; 9(5):259-265.
- Marcus FI, Fontaine G, Guiraudon G, et al. Right ventricular dysplasia: A
report of 24 adult cases. Circulation 1982;65:384-398
- Corrado D, Basso C, Thiene G, et al. Spectrum of clinicopathological
manifestations of arrhythmogenic right ventricular cardiomyopathy/dysplasia:
A multicenter study. J Am Coll Cardiology 1997;30:1512-1520.
- Corrado D, Leoni L, Link MS, et al. Implantable cardioverter-defibrillator
therapy for prevention of sudden death in patients with arrhythmogenic right
ventricular cardiomyopathy/dysplasia. Circulation 2003;108:3084-3091.
- Link MS, Wang PJ, Haugh CJ, et al. Arrhythmogenic right ventricular
dysplasia: Clinical results with implantable cardioverter defibrillators. J
Intervent Card Electrophysiol 1997;1:41-48.
A cardioverter defibrillator should be implanted in patients with ARVD and
sustained VT?
ICD therapy confers protection against SCD and is indicated in cardiac arrest
survivors, those who present with syncope thought to be due to VT, or VT
refractory to drug therapy. Some centers use pharmacological therapy as
first line treatment in patients without any of the aforementioned conditions
for sustained VT. However depending on the clinical circumstances and prior
history, ICD therapy may be warranted in the vast majority of high risk
patients.
- Sen-Chowdhry S, Lowe MD, Sporton SC, et al. Arrhythmogenic right
ventricular cardiomyopathy: Clinical presentation, diagnosis, and management.
Am J Med 2004; 117:685-695.
- Corrado D, Basso C, Nava A, et al. Arrhythmogenic right ventricular
cardiomyopathy: Current diagnostic and management strategies. Cardiology In
Review 2001; 9(5):259-265.
- R Tavernier, S Gevaert, J De Sutter, et al. Long term results of
cardioverter-defibrillator implantation in patients with right ventricular
dysplasia and malignant ventricular tachyarrhythmias. Heart 2001;85(1):53-6.
- Roguin A, Bomma CS, Nasir K, et al. Implantable cardioverter-defibrillators
in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy.
J Am Coll Cardiol 2004;43:1843-52.
In the cases in which ICD is indicated, is it convenient to associate an
antiarrhythmic drug? If so, which one?
Among patients with an ICD for ARVD sustained VT is often terminated via
antitachycardia pacing without the need for cardioversion, therefore allowing
the reduction of pharmacological therapy in patients with debilitating
adverse drug effects. Insertion of an ICD may allow withdrawal or complete
discontinuation of drug therapy. However, when necessary after device
placement to reduce the likelihood of discharge, pharmacological drug therapy
may be instituted. Sotalol has been effective in this patient population due
to its combination of beta-adrenergic receptor blockade properties and class
III antiarrhythmic activities. Antiarrhythmic drugs are not routinely
required.
Sandeep Joshi and Dr. Jonathan S. Steinberg.
-------------------------
Por que en esta enfermedad, el sotalol parece ser mas eficiente como agente
antiarritmico que la amiodarona?
Los estudios han demostrado que una frecuencia cardiaca aumentada con
acortamiento de los intervalos de acoplamiento de los primeros ciclos que
preceden la taquicardia pueden deberse a un cambio en el balance autonomico,
es decir, un tono simpatico aumentado en la DAVD.
Algunos informes sugieren frecuencias de eficacia terapeutica de sotalol en el
rango del 68%-83%, por lo menos considerando la no inducibilidad en el
laboratorio electrofisiologico. Las dosis requeridas a menudo son altas y
necesarias para alcanzar el beta-bloqueo. El mayor exito comparado con la
amiodarona no se basa en comparaciones randomizadas, pero pueden deberse a
una mejor tolerancia.
- Sen-Chowdhry S, Lowe MD, Sporton SC, et al. Arrhythmogenic right
ventricular cardiomyopathy: Clinical presentation, diagnosis, and management.
Am J Med 2004; 117:685-695.
- Wichter T, Borggrefe M, Haverkamp W, et al. Efficacy of antiarrhythmic
drugs in patients with arrhythmogenic right ventricular disease. Results in
patients with inducible and noninducible ventricular tachycardia.
Circulation 1992; 86:29-37.
- Marcus FI, Fontaine GH, Frank R, et al. Long term follow up in patients
with arrhythmogenic right ventricular disease. Eur Heart J 1989; 10 (suppl
D):68-73.
Que criterios seguiria para considerar que un paciente asintomatico con DAVD
esta en alto riesgo de desarrollar muerte subita (MS) y por lo tanto, para el
implante de un CDI?
Los factores de riesgo para la MS en el paciente asintomatico con DAVD se
describen pobremente. Se ha informado sobre la presentacion con sincope y
funcion del VD gravemente deprimida como factores de riesgo para la MS. El
hecho de que la DAVD es una enfermedad progresiva y que el riesgo del
paciente de tener MS puede aumentar con el tiempo, complica los desafios de
la estratificacion de riesgo. Una estratificacion de riesgo mejorada aclarara
las indicaciones para la terapia con CDI en el paciente asintomatico.
- Corrado D, Basso C, Nava A, et al. Arrhythmogenic right ventricular
cardiomyopathy: Current diagnostic and management strategies. Cardiology In
Review 2001; 9(5):259-265.
- Marcus FI, Fontaine G, Guiraudon G, et al. Right ventricular dysplasia: A
report of 24 adult cases. Circulation 1982;65:384-398
- Corrado D, Basso C, Thiene G, et al. Spectrum of clinicopathological
manifestations of arrhythmogenic right ventricular cardiomyopathy/dysplasia:
A multicenter study. J Am Coll Cardiology 1997;30:1512-1520.
- Corrado D, Leoni L, Link MS, et al. Implantable cardioverter-defibrillator
therapy for prevention of sudden death in patients with arrhythmogenic right
ventricular cardiomyopathy/dysplasia. Circulation 2003;108:3084-3091.
- Link MS, Wang PJ, Haugh CJ, et al. Arrhythmogenic right ventricular
dysplasia: Clinical results with implantable cardioverter defibrillators. J
Intervent Card Electrophysiol 1997;1:41-48.
Un cardiodesfibrilador deberia ser implantado en pacientes con DAVD y TV
sostenida?
La terapia con CDI confiere proteccion contra la MS y se indica en los
sobrevivientes de paro cardiaco, aquellos que se presentan con sincope que se
piensa que se debe a TV o TV refractaria a la terapia con drogas. Algunos
centros usan terapia farmacologica como tratamiento de primera linea en
pacientes sin ninguna de las afecciones antes mencionadas para la TV
sostenida. Sin embargo, dependiendo de las circunstancias clinicas y la
historia previa, la terapia con CDI puede ser la unica opcion en la vasta
mayoria de los pacientes con alto riesgo.
- Sen-Chowdhry S, Lowe MD, Sporton SC, et al. Arrhythmogenic right
ventricular cardiomyopathy: Clinical presentation, diagnosis, and management.
Am J Med 2004; 117:685-695.
- Corrado D, Basso C, Nava A, et al. Arrhythmogenic right ventricular
cardiomyopathy: Current diagnostic and management strategies. Cardiology In
Review 2001; 9(5):259-265.
- R Tavernier, S Gevaert, J De Sutter, et al. Long term results of
cardioverter-defibrillator implantation in patients with right ventricular
dysplasia and malignant ventricular tachyarrhythmias. Heart 2001;85(1):53-6.
- Roguin A, Bomma CS, Nasir K, et al. Implantable cardioverter-defibrillators
in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy. J
Am Coll Cardiol 2004;43:1843-52.
En los casos en que se indique CDI, es conveniente asociar una droga
antiarritmica? Si es asi, cual?
Entre los pacientes con CDI por DAVD, la TV sostenida con frecuencia es
terminada mediante estimulacion antitaquicardica sin necesidad de
cardioversion, permitiendo por lo tanto, la reduccion de la terapia
farmacologica en pacientes con efectos adversos y debilitantes por las
drogas. El implante de un CDI puede permitir la interrupcion o la
discontinuacion completa de la terapia con drogas. Sin embargo, se puede
iniciar terapia con drogas cuando sea necesario despues de la colocacion del
dispositivo para reducir la posibilidad de descarga. El sotalol ha sido
efectivo en esta poblacion de pacientes por su combinacion de propiedades de
bloqueo de receptores beta-adrenergicos y actividades antiarritmicas clase
III. Las drogas antiarritmicas no son necesarias en forma rutinaria.
Sandeep Joshi and Dr. Jonathan S. Steinberg.
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