Guerra P G, Talajic M, Roy D, Dubuc M, Thibault B, Nattel S
Research Center, Montreal Heart Institute, Quebec, Canada.
Drugs. 1998 Nov;56(5):767-81. doi: 10.2165/00003495-199856050-00003.
Drug therapy has traditionally been the mainstay of treatment for both ventricular and supraventricular arrhythmias. However, increasing knowledge about the potentially significant adverse effects of these medications, together with the emergence of new, nonpharmacological approaches to the treatment of arrhythmias, has led some to question the future of antiarrhythmic drug therapy. Antiarrhythmic drugs are quite effective in terminating a variety of arrhythmias, including atrioventricular (AV) node re-entrant and AV tachycardias (particularly calcium antagonists and adenosine), atrial flutter (class III agents) and atrial fibrillation (class IA and IC drugs. The chronic use of antiarrhythmic drugs has been increasingly limited by a fear of adverse effects (especially proarrhythmia) and the availability of highly effective nonpharmacological alternatives (particularly ablation for re-entrant tachycardias involving the AV node and bypass tracts and cardiovertor/defibrillators for malignant ventricular arrhythmias. Atrial fibrillation (AF) continues to be a therapeutic challenge for which there is no safe and curative nonpharmacological therapy. Antiarrhythmic drugs of classes IA, IC and III show efficacy in preventing recurrence of AF but there are concerns about possible pro-arrhythmic complications. In the future, antiarrhythmic agents will continue to be used acutely to terminate a broad range of sustained arrhythmias. Chronic use is likely to depend on the development of safer and/or more effective compounds, as well as on improved ways of predicting which patients are likely to develop pro-arrhythmic reactions. The development of molecular electrophysiology will allow for the identification of agents with selected ion channel blocking profiles which may prove efficacious with a lower risk of complications. Finally, an improved understanding of arrhythmia substrates may permit the identification of therapy that prevents arrhythmias by acting on the underlying substrate, rather than simply trying to modify the electrical end product.
传统上，药物治疗一直是室性和室上性心律失常治疗的主要手段。然而，随着人们对这些药物潜在的重大不良反应的认识不断增加，以及心律失常治疗新的非药物方法的出现，一些人开始质疑抗心律失常药物治疗的未来。抗心律失常药物在终止各种心律失常方面相当有效，包括房室（AV）结折返性心动过速和房室性心动过速（特别是钙拮抗剂和腺苷）、心房扑动（III类药物）和心房颤动（IA类和IC类药物）。抗心律失常药物的长期使用越来越受到对不良反应（尤其是促心律失常作用）的担忧以及高效非药物替代方法的限制（特别是针对涉及房室结和旁路传导束的折返性心动过速的消融治疗，以及针对恶性室性心律失常的心脏复律除颤器）。心房颤动（AF）仍然是一个治疗挑战，目前尚无安全有效的非药物治疗方法。IA类、IC类和III类抗心律失常药物在预防房颤复发方面显示出疗效，但人们担心可能出现促心律失常并发症。未来，抗心律失常药物将继续用于急性终止各种持续性心律失常。长期使用可能取决于更安全和/或更有效的化合物的研发，以及改进预测哪些患者可能发生促心律失常反应的方法。分子电生理学的发展将有助于识别具有特定离子通道阻断特征的药物，这些药物可能在并发症风险较低的情况下证明有效。最后，对心律失常基质的更好理解可能有助于识别通过作用于潜在基质来预防心律失常的治疗方法，而不是仅仅试图改变电活动的最终结果。
