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A comparison of seven antiarrhythmic drugs in patients with ventricular tachyarrhythmias . Electrophysiologic Study versus Electrocardiographic Monitoring Investigators . BACKGROUND The relative efficacies of various antiarrhythmic drugs in the treatment of ventricular tachyarrhythmias are not well known . This study examined the effectiveness of imipramine , mexiletine , pirmenol , procainamide , propafenone , quinidine , and sotalol in patients with ventricular tachyarrhythmias who were enrolled in the Electrophysiologic Study versus Electrocardiographic Monitoring trial . METHODS Patients were randomly assigned to undergo serial testing of the efficacy of the seven antiarrhythmic drugs by one of two strategies : electrophysiologic study or Holter monitoring together with exercise testing . The seven drugs were then tested for efficacy in random order in patients who were eligible to receive them . The frequencies of predictions of drug efficacy and of adverse drug effects during the initial drug titration were tabulated for all 486 randomized subjects . Patients received long-term treatment with the first antiarrhythmic drug that was predicted to be effective on the basis of drug testing . Recurrences of arrhythmia , deaths , and adverse drug effects during long-term follow-up were recorded for the 296 patients in whom an antiarrhythmic drug was predicted to be effective . RESULTS In the electrophysiologic-study group , the percentage of patients who had predictions of drug efficacy was higher with sotalol ( 35 percent ) than with the other drugs ( 16 percent , P < 0.001 ) . There was no significant difference among the drugs in the Holter-monitoring group . The percentage of patients with adverse drug effects was lowest among those receiving sotalol . The actuarial probability of a recurrence of arrhythmia after a prediction of drug efficacy by either strategy was significantly lower for patients treated with sotalol than for patients treated with the other drugs ( risk ratio , 0.43 ; 95 percent confidence interval , 0.29 to 0.62 ; P < 0.001 ) . With sotalol , as compared with the other drugs combined , there were lower risks of death from any cause ( risk ratio , 0.50 ; 95 percent confidence interval , 0.30 to 0.80 ; P = 0.004 ) , death from cardiac causes , ( 0.50 ; P = 0.02 ) , and death from arrhythmia ( 0.50 ; P = 0.04 ) . The cumulative percentage of patients in whom a drug was predicted to be effective and in whom it remained effective and tolerated was higher for sotalol than for the other drugs ( P < 0.001 ) . CONCLUSIONS Sotalol was more effective than the other six antiarrhythmic drugs in preventing death and recurrences of arrhythmia . In patients similar to those in this study , if antiarrhythmic-drug therapy is to be used to prevent recurrences of ventricular tachyarrhythmias , treatment with sotalol and assessment of its potential efficacy by Holter monitoring are a reasonable initial strategy .
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Intervention_Pharmacological
antiarrhythmic drugs
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Intervention_Pharmacological
imipramine
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Intervention_Pharmacological
mexiletine
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Intervention_Pharmacological
pirmenol
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Intervention_Pharmacological
procainamide
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Intervention_Pharmacological
propafenone
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Intervention_Pharmacological
quinidine
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Intervention_Pharmacological
sotalol
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Intervention_Physical
electrophysiologic study or Holter monitoring together with exercise testing
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Outcome_Physical
drug efficacy
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Outcome_Mental
higher
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Outcome_Mental
no significant difference
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Outcome_Mental
patients with adverse drug effects
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Outcome_Mental
lowest
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Outcome_Mental
actuarial probability of a recurrence of arrhythmia
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Outcome_Mental
significantly lower
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Outcome_Mental
lower risks of death
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Outcome_Mental
death from arrhythmia
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Participant_Condition
ventricular tachyarrhythmias
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Participant_Condition
ventricular tachyarrhythmias
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Participant_Sample-size
486
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Participant_Sample-size
296