Division of Cardiology, Cardiovascular and Heart Rhythm Consultants, New York City, New York, USA.
Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA.
J Cardiovasc Electrophysiol. 2024 Mar;35(3):574-582. doi: 10.1111/jce.16055. Epub 2023 Sep 7.
Premature ventricular complexes (PVCs) are the most common ventricular arrhythmia that are encountered in the clinical practice. Recent data suggests that high PVC burden may lead to the development of PVC-induced cardiomyopathy (PVC-CM) even in patients without structural heart disease. Treatment for effective suppression of PVCs, can reverse PVC-CM. Both antiarrhythmic drugs (AADs) and catheter ablation (CA) are recognized treatment modalities for any cardiac arrhythmias. However, with increasing preference of CA, the role of AADs needs further defining regarding their efficacy, safety, indications and patient selection to treat PVC-CM.
To ascertain the role of AADs to treat PVC-CM; whether they are indicated to treat PVC-CM, and if so, when, we interrogated PubMed and other search engines for English language publications with key words premature ventricular complexes (PVCs), cardiomyopathy, anti-arrhythmic drugs, catheter ablation, and pharmacological agents. All publications were carefully reviewed and scrutinized by the authors for their inclusion in the review paper. For illustration of cases, ethical standard was observed as per the 1975 Declaration of Helsinki, and the patient was treated as per the prevailing standard of care. Informed consent was obtained from the patient for conducting the ablation procedure.
Our literature search specifically the pharmacological treatment of PVC-CM with AADs revealed significant paradigm shift in treatment approach for PVCs and PVC-induced cardiomyopathy. No major large, randomized control trials of AADs versus CA for PVC-CM were found. We found that beta-blockers and calcium channel blockers are particularly effective in the treatment of PVCs originating from right ventricular outflow tract. For Class Ic AADs - flecainide and propafenone, small clinical studies showed Class Ic AADs to be effective in PVC suppression, but their usage was not recommended in patients with significant coronary artery disease. Mexiletine was found to have modest effect on PVC suppression. Studies showed sotalol to significantly reduce PVCs frequency in patients receiving both low and high doses. Studies also showed amiodarone to have higher successful PVC suppression, but not recommended as a first-line treatment for patients with idiopathic PVCs in the absence of symptoms and left ventricular dysfunction. For dronedarone, no major clinical data were available.
Based on the available data in the literature, we conclude that AADs play important role in the treatment of PVC-induced cardiomyopathy. However, appropriate patient selection criteria are vitally important, and in general terms AADs are indicated or polymorphic PVCs, epicardial PVCs; and when CA procedure is contraindicated, or not feasible or failed.
室性期前收缩（PVCs）是临床实践中最常见的室性心律失常。最近的数据表明，即使在没有结构性心脏病的患者中，高 PVC 负荷也可能导致 PVC 诱导的心肌病（PVC-CM）的发展。有效抑制 PVCs 的治疗方法可以逆转 PVC-CM。抗心律失常药物（AADs）和导管消融（CA）都是治疗任何心律失常的公认方法。然而，随着 CA 的日益普及，AAD 的作用需要进一步明确，包括其疗效、安全性、适应证和患者选择，以治疗 PVC-CM。
为了确定 AAD 治疗 PVC-CM 的作用；它们是否适用于治疗 PVC-CM，如果是，何时适用，我们使用关键词“过早的心室复合（PVCs）”、“心肌病”、“抗心律失常药物”、“导管消融”和“药理学制剂”在 PubMed 和其他搜索引擎上搜索英文出版物。作者仔细审查并仔细审查了所有出版物，以将其纳入审查论文。为了说明病例，我们按照 1975 年《赫尔辛基宣言》的标准进行了伦理审查，并按照现行的护理标准对患者进行了治疗。在进行消融手术之前，已获得患者的知情同意。
我们的文献检索特别针对 AAD 治疗 PVC-CM 的药理学治疗方法显示，治疗 PVC 和 PVC 诱导性心肌病的方法发生了重大转变。没有发现针对 PVC-CM 的 AAD 与 CA 进行的大型、随机对照试验。我们发现，β受体阻滞剂和钙通道阻滞剂在治疗起源于右心室流出道的 PVC 方面特别有效。对于 Ic 类 AADs-氟卡尼和普罗帕酮，小型临床研究表明 Ic 类 AADs 可有效抑制 PVC，但不建议在有明显冠状动脉疾病的患者中使用。美西律对 PVC 抑制有适度作用。研究表明，索他洛尔可显著降低低剂量和高剂量患者的 PVC 频率。研究还表明，胺碘酮在无症状和左心室功能障碍的特发性 PVC 患者中具有更高的 PVC 抑制成功率，但不建议作为首选治疗方法。对于多非利特，没有主要的临床数据。
根据文献中的现有数据，我们得出结论，AAD 在治疗 PVC 诱导性心肌病中发挥重要作用。然而，适当的患者选择标准至关重要，一般来说，AAD 适用于或多形性 PVC、心外膜 PVC；并且在 CA 程序禁忌、不可行或失败时。
