Scanu P, Agostini D, Grollier G, Belin A, Valette B, Potier J C
Service de soins intensifs de cardiologie, hôpital Côte-de-Nacre, CHRU de Caen, France.
Rev Med Interne. 1995;16(8):602-7. doi: 10.1016/0248-8663(96)80759-4.
Antiarrhythmic medications are widely used either at the ventricular or supraventricular level. However, those drugs can induce severe side effects. Actually, antiarrhythmic drugs are paradoxically able to favour the occurrence of new arrhythmias or aggravate the preexisting arrhythmia for which they were indicated. These proarrhythmic effects have been found in 10 to 20% of patients, as evidenced by literature. Moreover, the CAST study showed a significant increase in mortality in patients with non sustained ventricular arrhythmias after myocardial infarction who were treated with either flecainide or encainide, compared to the placebo group. This overmortality seems to be due, in large, to the proarrhythmic effects of antiarrhythmic drugs. Several mechanisms have been evoked, related to the type of antiarrhythmic drug and to the presenting arrhythmia: early post-depolarization due to slow calcium and sodium inward currents in the case of torsades de pointes, facilitation of intraventricular reentries in the case of class 1c antiarrhythmic drugs, facilitation of the ventricular response of atrial arrhythmias. These deleterious effects, that can be very serious, are unpredictable, not toxicity-related and all antiarrhythmic drugs are involved. Their detection appears to be difficult and is based upon ECG, Holter monitoring, treadmill test and possibly electrophysiologic study. The use of antiarrhythmic drugs requires the knowledge of their proarrhythmic effects, the analysis of the benefit-risk ratio--particularly if left ventricular function is impaired--and careful monitoring.
抗心律失常药物广泛应用于心室或室上性心律失常。然而，这些药物可引起严重的副作用。实际上，抗心律失常药物自相矛盾地能够促使新的心律失常发生或加重其原本用于治疗的既有心律失常。文献表明，这些促心律失常作用在10%至20%的患者中被发现。此外，CAST研究显示，与安慰剂组相比，心肌梗死后非持续性室性心律失常患者使用氟卡尼或恩卡尼治疗后死亡率显著增加。这种过高的死亡率在很大程度上似乎归因于抗心律失常药物的促心律失常作用。已经提出了几种机制，与抗心律失常药物的类型和所出现的心律失常有关：在尖端扭转型室速的情况下，由于缓慢的钙和钠内向电流导致早期后去极化；在1c类抗心律失常药物的情况下，促进心室内折返；促进房性心律失常的心室反应。这些有害作用可能非常严重，是不可预测的，与毒性无关，所有抗心律失常药物都可能涉及。它们的检测似乎很困难，基于心电图、动态心电图监测、平板运动试验以及可能的电生理研究。抗心律失常药物的使用需要了解其促心律失常作用，分析获益风险比——特别是在左心室功能受损的情况下——并进行仔细监测。
