The proarrhythmic effects of antiarrhythmic drugs.

Although antiarrhythmic drugs are effective for controlling cardiac arrhythmias, they may also induce or exacerbate them. Case reports have appeared implicating all classes of antiarrhythmic drugs. It is difficult to assess the size of the problem in practice, as it varies with different subgroups of patients, but rates of up to 13% have been found where proarrhythmic effects were actively sought. Their occurrence is affected both by the electrophysiologic characteristics of the drugs and by the arrhythmia substrate. Mechanisms of proarrhythmic effects may be classified according to the electrophysiologic and hemodynamic effects of the drugs. Detection of drug-induced arrhythmias depends on appreciation of the problem by physicians and, although there are few clear predictors, some form of monitoring of antiarrhythmic drug treatment is recommended. Management of such arrhythmias when they occur involves withdrawal of the offending agent, correcting contributory factors, and reassessing the initial arrhythmia and the strategy for its management.