Luedtke S A, Kuhn R J, McCaffrey F M
University of Kentucky Children's Hospital, Lexington, USA.
Ann Pharmacother. 1997 Nov;31(11):1347-59. doi: 10.1177/106002809703101113.
To review the literature regarding the use of antiarrhythmic agents in the management of atrial flutter (AF), atrial fibrillation (Afib), junctional ectopic tachycardia (JET), and atrial ectopic tachycardia (AET) in infants and children. To discuss the advantages and disadvantages of specific agents in each type of arrhythmia in an effort to develop treatment guidelines.
A MEDLINE search encompassing the years 1966-1996 was used to identify pertinent literature for discussion. Additional references were found in the articles, which were retrieved via MEDLINE.
Clinical trials that address the use of antiarrhythmic agents for the treatment of supraventricular tachycardia, AF, Afib, JET, and AET in children were selected. Literature pertaining to dosage, pharmacokinetics, efficacy, and toxicity of antiarrhythmic agents in children were considered for possible inclusion in the review; information judged to be pertinent by the authors was included in the discussion.
Although there are numerous reports of antiarrhythmic use in children, there are very few large studies designed that evaluate the use of specific antiarrhythmic agents in the treatment of AF, Afib, JET, or AET. Ideally, controlled clinical trials are used to develop clinical guidelines; however, in this situation, most data and information must be obtained from case series of children treated. Although the results from these types of studies may be useful in developing guidelines for the optimal use of these agents for the treatment of AF, Afib, JET, and AET, controlled trials are required for establishing standard treatment guidelines for all patients.
Despite limited scientific evaluation of conventional agents in the treatment of AF, Afib, JET, or AET in children, they continue to be the standards of care. Most information regarding the use of conventional agents in children has been extrapolated from the adult literature. Little justification for the use of the agents or dosing in children is available. Controlled trials regarding the use of newer antiarrhythmic agents (propafenone, amiodarone, flecainide) are available; however, the variance in dosing schemes, presence of structural heart disease, and patient age may confound the results.
Because of greater clinical experience, conventional antiarrhythmic agents generally remain as first-line therapy in the management of most supraventricular tachycardias in children. Atrial pacing or cardioversion to reestablish sinus rhythm is indicated for initial episodes of AF in infants, followed by chronic prophylactic therapy in those with significant structural heart disease or in infants in whom AF recurs. Attempts to eliminate AF in children outside the neonatal or infancy period should begin with trials of traditional agents such as digoxin or procainamide, and if unsuccessful, subsequent trials of amiodarone. Digoxin and beta-blockers remain the mainstay of therapy for children with Afib, followed by procainamide for treatment failures. Intravenous amiodarone, the newest addition to our antiarrhythmic armamentarium, is the most promising agent in the treatment of postoperative JET. This arrhythmia has been traditionally managed with corporal cooling and/or digoxin therapy; however, intravenous amiodarone may now be a valuable option. Although relatively unsuccessful in the management of congenital JET and AET, conventional agents are typically used prior to the initiation of long-term therapy with potentially more toxic agents such as amiodarone or propafenone. Additional well-designed, controlled trials are needed to further evaluate the comparative efficacy of agents such as flecainide, sotalol, moricizine, propafenone, and amiodarone in the management of AF, Afib, JET, and AET in children, as well as to evaluate the dosing and toxicity in various age groups.
回顾关于抗心律失常药物用于治疗婴幼儿和儿童房扑（AF）、房颤（Afib）、交界性异位性心动过速（JET）及房性异位性心动过速（AET）的文献。讨论特定药物在每种心律失常中的优缺点，以制定治疗指南。
使用涵盖1966年至1996年的MEDLINE搜索来识别相关文献以供讨论。通过MEDLINE检索的文章中还发现了其他参考文献。
选择了涉及抗心律失常药物用于治疗儿童室上性心动过速、AF、Afib、JET和AET的临床试验。考虑将有关抗心律失常药物在儿童中的剂量、药代动力学、疗效和毒性的文献纳入综述；作者认为相关的信息纳入讨论。
尽管有许多关于儿童使用抗心律失常药物的报道，但很少有大型研究设计来评估特定抗心律失常药物用于治疗AF、Afib、JET或AET。理想情况下，使用对照临床试验来制定临床指南；然而，在这种情况下，大多数数据和信息必须从接受治疗的儿童病例系列中获得。尽管这类研究的结果可能有助于制定这些药物用于治疗AF、Afib、JET和AET的最佳使用指南，但需要对照试验来为所有患者建立标准治疗指南。
尽管对传统药物治疗儿童AF、Afib、JET或AET的科学评估有限，但它们仍然是治疗标准。关于儿童使用传统药物的大多数信息是从成人文献中推断出来的。儿童使用这些药物或给药的理由很少。有关于使用新型抗心律失常药物（普罗帕酮、胺碘酮、氟卡尼）的对照试验；然而，给药方案的差异、结构性心脏病的存在和患者年龄可能会混淆结果。
由于临床经验更丰富，传统抗心律失常药物通常仍是治疗儿童大多数室上性心动过速的一线疗法。对于婴儿AF的初始发作，建议进行心房起搏或复律以恢复窦性心律，随后对有严重结构性心脏病的患儿或AF复发的婴儿进行长期预防性治疗。在新生儿期或婴儿期以外的儿童中尝试消除AF应首先试用传统药物如地高辛或普鲁卡因胺，如果不成功，随后试用胺碘酮。地高辛和β受体阻滞剂仍然是Afib患儿治疗的主要药物，治疗失败后用普鲁卡因胺。静脉注射胺碘酮是我们抗心律失常药物库中的最新成员，是治疗术后JET最有前景的药物。这种心律失常传统上采用体表降温及/或地高辛治疗；然而，静脉注射胺碘酮现在可能是一个有价值的选择。尽管在先天性JET和AET的治疗中相对不太成功，但在开始使用潜在毒性更大的药物如胺碘酮或普罗帕酮进行长期治疗之前，通常先使用传统药物。需要更多设计良好的对照试验来进一步评估氟卡尼、索他洛尔、莫雷西嗪、普罗帕酮和胺碘酮等药物在治疗儿童AF、Afib、JET和AET方面的相对疗效，以及评估不同年龄组的给药和毒性。
