Verapamil for Treatment of Supraventricular Tachyarrhythmias
1982; Elsevier BV; Volume: 81; Issue: 3 Linguagem: Inglês
10.1378/chest.81.3.267
ISSN1931-3543
Autores Tópico(s)Cardiac electrophysiology and arrhythmias
ResumoIntravenous (IV) verapamil has recently become available in the United States for treatment of supraventricular tachycardia. It will probably be available for oral administration in the near future. Verapamil, a coronary vasodilator, was originally introduced in Germany in 1962 as an anti-anginal agent, and has been used in Europe for more than 18 years for this purpose. More recently, studies from Europe and the United States have demonstrated that IV verapamil is an extremely effective agent for interruption of paroxysmal supraventricular tachycardia and for control of the ventricular rate during atrial fibrillation or flutter.1Sung RJ Elser B McAllister RG. Intravenous verapamil for termination of re-entrant supraventricular tachycardias: intracardiac studies correlated with plasma verapamil concentrations..Ann Intern Med. 1980; 93: 682Crossref PubMed Scopus (156) Google Scholar, 2Wellens HJJ Tan SL Bar FWH et al.Effect of verapamil studied by programmed electrical stimulation of the heart in patients with paroxysmal re-entrant supraventricular tachycardia..Br Heart J. 1977; 39: 1058-1066Crossref PubMed Scopus (116) Google Scholar, 3Waxman HL Myerburg RJ Appel R et al.Verapamil for control of ventricular rate in paroxysmal supraventricular tachycardia and atrial fibrillation or flutter: a double-blind randomized cross-over study..Ann Intern Med. 1981; 94: 1-6Crossref PubMed Scopus (168) Google Scholar, 4Rinkenberger RL Prystowsky EN Heger JJ et al.Effects of intravenous and chronic oral verapamil administration in patients with supraventricular tachyarrhythmias..Circulation. 1980; 62: 996-1010Crossref PubMed Scopus (215) Google Scholar, 5Aronow WS Landa D Plasencia G et al.Verapamil in atrial fibrillation and atrial flutter..Clin Pharmacol Ther. 1979; 26: 578-583Crossref PubMed Scopus (53) Google Scholar, 6Hagemeijer F. Verapamil in the management of supraventricular tachyarrhythmias occurring after a recent myocardial infarction..Circulation. 1978; 57: 751-755Crossref PubMed Scopus (46) Google Scholar, 7Soler-Soler J Sagristá-Sauleda J Cabrera A et al.Effect of verapamil in infants with paroxysmal supraventricular tachycardia..Circulation. 1979; 59: 876-879Crossref PubMed Scopus (60) Google Scholar Verapamil is a slow channel blocker.8Zipes DP Fischer JC. Effects of agents which inhibit the slow channel on sinus node automaticity and atrioventricular conduction in the dog..Circ Res. 1974; 34: 184-192Crossref PubMed Scopus (224) Google Scholar The slow channel is responsible for the electrophysiologic properties of the sinus node and the A-V node and is mainly, although not entirely, calcium dependent. Consequently, verapamil is most effective for termination of tachycardias that incorporate the sinus node or A-V node within the tachycardia circuit.1Sung RJ Elser B McAllister RG. Intravenous verapamil for termination of re-entrant supraventricular tachycardias: intracardiac studies correlated with plasma verapamil concentrations..Ann Intern Med. 1980; 93: 682Crossref PubMed Scopus (156) Google Scholar The ECG, the effect of physiologic maneuvers on the tachycardia, and if necessary intracardiac electrophysiologic studies can be used to define supraventricular tachycardia as: sinus node reentrant, atrial (automatic or reentrant), A-V nodal reentrant, and A-V reciprocating (tachycardia circuit usually incorporating the A-V node antegrade and a bypass tract retrograde). Intravenous verapamil will rapidly terminate 70 to 80 percent of episodes of sinus node reentrant, A-V node reentrant, and A-V reciprocating tachycardias.1Sung RJ Elser B McAllister RG. Intravenous verapamil for termination of re-entrant supraventricular tachycardias: intracardiac studies correlated with plasma verapamil concentrations..Ann Intern Med. 1980; 93: 682Crossref PubMed Scopus (156) Google Scholar, 2Wellens HJJ Tan SL Bar FWH et al.Effect of verapamil studied by programmed electrical stimulation of the heart in patients with paroxysmal re-entrant supraventricular tachycardia..Br Heart J. 1977; 39: 1058-1066Crossref PubMed Scopus (116) Google Scholar, 3Waxman HL Myerburg RJ Appel R et al.Verapamil for control of ventricular rate in paroxysmal supraventricular tachycardia and atrial fibrillation or flutter: a double-blind randomized cross-over study..Ann Intern Med. 1981; 94: 1-6Crossref PubMed Scopus (168) Google Scholar, 4Rinkenberger RL Prystowsky EN Heger JJ et al.Effects of intravenous and chronic oral verapamil administration in patients with supraventricular tachyarrhythmias..Circulation. 1980; 62: 996-1010Crossref PubMed Scopus (215) Google Scholar It is less likely to terminate atrial tachycardia but may result in a decrease in the ventricular response due to its A-V nodal blocking properties. Similarly, verapamil is associated with only a 10 to 15 percent incidence of termination of atrial fibrillation or flutter but usually results in a significant decrease in the ventricular rate due to A-V nodal blockade.3Waxman HL Myerburg RJ Appel R et al.Verapamil for control of ventricular rate in paroxysmal supraventricular tachycardia and atrial fibrillation or flutter: a double-blind randomized cross-over study..Ann Intern Med. 1981; 94: 1-6Crossref PubMed Scopus (168) Google Scholar, 4Rinkenberger RL Prystowsky EN Heger JJ et al.Effects of intravenous and chronic oral verapamil administration in patients with supraventricular tachyarrhythmias..Circulation. 1980; 62: 996-1010Crossref PubMed Scopus (215) Google Scholar, 5Aronow WS Landa D Plasencia G et al.Verapamil in atrial fibrillation and atrial flutter..Clin Pharmacol Ther. 1979; 26: 578-583Crossref PubMed Scopus (53) Google Scholar Verapamil is particularly attractive and may be useful for the treatment of supraventricular tachycardia in patients with chronic obstructive pulmonary disease since, unlike the β -blockers, it does not seem to worsen bronchospasm.9Ringquist T. Effect of verapamil in obstructive airways disease..Eur J Clin Pharmacol. 1974; 7: 61-64Crossref Scopus (15) Google Scholar Intravenous verapamil has also been safely used for the treatment of supraventricular tachycardia in the early postinfarction setting6Hagemeijer F. Verapamil in the management of supraventricular tachyarrhythmias occurring after a recent myocardial infarction..Circulation. 1978; 57: 751-755Crossref PubMed Scopus (46) Google Scholar and in infants.7Soler-Soler J Sagristá-Sauleda J Cabrera A et al.Effect of verapamil in infants with paroxysmal supraventricular tachycardia..Circulation. 1979; 59: 876-879Crossref PubMed Scopus (60) Google Scholar Although many studies have evaluated IV verapamil, few have carefully evaluated the effectiveness of oral verapamil for prevention of recurrent paroxysmal supraventricular tachycardia or recurrent paroxysmal atrial fibrillation or flutter. In this issue of Chest (p 308), Stern et al examine the effectiveness of oral verapamil in a small number of patients with chronic or paroxysmal atrial fibrillation. They found oral verapamil effective for control of the ventricular response in chronic atrial fibrillation; however, as expected, verapamil did not alter the frequency of attacks of paroxysmal atrial fibrillation in 4/4 patients. Furthermore, in spite of adequate control of the ventricular rate, it did not alleviate the symptoms in 2/4 patients during episodes of paroxysmal atrial fibrillation. Several questions remain unanswered concerning the use of verapamil. Preliminary data suggest that digoxin levels may increase in patients taking oral verapamil.10Lang R Klein HO Weiss E et al.Effect of verapamil on blood level and renal clearance of digoxin..Circulation. 1980; 62: 83Google Scholar The clinical importance of this observation will have to be defined. The hemodynamic and electrophysiologic interactions of verapamil with β -blockers will have to be more carefully delineated, although preliminary data suggest that this will not be a major problem.11Kieval J Kirsten EB Kessler KM et al.Effects of intravenous verapamil on hemodynamic status of patients receiving propranolol (abstr)..Circulation. 1980; 62: 87Google Scholar Its use in patients with mild to moderate congestive heart failure is probably safe, particularly if a component of the congestive heart failure is related to a rapid ventricular rate. Nevertheless, verapamil may cause further hemodynamic embarrassment in patients with severe congestive heart failure because of its negative inotropic effects, and its use should be avoided in these patients. Finally, the use of verapamil in patients with the Wolff-Parkinson-White syndrome and a history of atrial fibrillation will have to be more fully evaluated before its use can be recommended without electrophysiologic study, since it has been observed that verapamil, like digoxin, may result in an increase in ventricular rate during atrial fibrillation or flutter in these patients.3Waxman HL Myerburg RJ Appel R et al.Verapamil for control of ventricular rate in paroxysmal supraventricular tachycardia and atrial fibrillation or flutter: a double-blind randomized cross-over study..Ann Intern Med. 1981; 94: 1-6Crossref PubMed Scopus (168) Google Scholar,4Rinkenberger RL Prystowsky EN Heger JJ et al.Effects of intravenous and chronic oral verapamil administration in patients with supraventricular tachyarrhythmias..Circulation. 1980; 62: 996-1010Crossref PubMed Scopus (215) Google Scholar Intravenous verapamil will undoubtedly become the first-line medication for short-term treatment of paroxysmal supraventricular tachycardia after simple vagal maneuvers fail. It will also be very useful for rapid control of the ventricular rate in patients with atrial tachycardia, atrial fibrillation, or atrial flutter by increasing A-V nodal blockade. This temporizing measure will allow time for digitalization or institution of other measures to provide more prolonged control. In contrast to the dramatic effect of IV verapamil on supraventricular tachyarrhythmias, the role of oral verapamil as long-term therapy for these arrhythmias is not as clear.
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