Amiodarone or Procainamide for the Termination of Sustained Stable Ventricular Tachycardia: An Historical Multicenter Comparison

Authors

  • Keith A. Marill MD,

    1. From the Department of Emergency Medicine (KAM, ELS), Cardiac Arrhythmia Service (JNR, PTE), Massachusetts General Hospital, Boston, MA; the Department of Emergency Medicine, SUNY Downstate Medical Center (IAD, DKN), Brooklyn, NY; the Department of Emergency Medicine, Mt. Auburn Hospital (GSS), Cambridge, MA; and the Department of Emergency Medicine, Brigham and Women’s Hospital (TOS), Boston, MA. Dr. Nishijima is currently with the Department of Emergency Medicine, U.C. Davis Medical Center, Sacramento, CA.
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  • Ian S. DeSouza MD,

    1. From the Department of Emergency Medicine (KAM, ELS), Cardiac Arrhythmia Service (JNR, PTE), Massachusetts General Hospital, Boston, MA; the Department of Emergency Medicine, SUNY Downstate Medical Center (IAD, DKN), Brooklyn, NY; the Department of Emergency Medicine, Mt. Auburn Hospital (GSS), Cambridge, MA; and the Department of Emergency Medicine, Brigham and Women’s Hospital (TOS), Boston, MA. Dr. Nishijima is currently with the Department of Emergency Medicine, U.C. Davis Medical Center, Sacramento, CA.
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  • Daniel K. Nishijima MD,

    1. From the Department of Emergency Medicine (KAM, ELS), Cardiac Arrhythmia Service (JNR, PTE), Massachusetts General Hospital, Boston, MA; the Department of Emergency Medicine, SUNY Downstate Medical Center (IAD, DKN), Brooklyn, NY; the Department of Emergency Medicine, Mt. Auburn Hospital (GSS), Cambridge, MA; and the Department of Emergency Medicine, Brigham and Women’s Hospital (TOS), Boston, MA. Dr. Nishijima is currently with the Department of Emergency Medicine, U.C. Davis Medical Center, Sacramento, CA.
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  • Emily L. Senecal MD,

    1. From the Department of Emergency Medicine (KAM, ELS), Cardiac Arrhythmia Service (JNR, PTE), Massachusetts General Hospital, Boston, MA; the Department of Emergency Medicine, SUNY Downstate Medical Center (IAD, DKN), Brooklyn, NY; the Department of Emergency Medicine, Mt. Auburn Hospital (GSS), Cambridge, MA; and the Department of Emergency Medicine, Brigham and Women’s Hospital (TOS), Boston, MA. Dr. Nishijima is currently with the Department of Emergency Medicine, U.C. Davis Medical Center, Sacramento, CA.
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  • Gary S. Setnik MD,

    1. From the Department of Emergency Medicine (KAM, ELS), Cardiac Arrhythmia Service (JNR, PTE), Massachusetts General Hospital, Boston, MA; the Department of Emergency Medicine, SUNY Downstate Medical Center (IAD, DKN), Brooklyn, NY; the Department of Emergency Medicine, Mt. Auburn Hospital (GSS), Cambridge, MA; and the Department of Emergency Medicine, Brigham and Women’s Hospital (TOS), Boston, MA. Dr. Nishijima is currently with the Department of Emergency Medicine, U.C. Davis Medical Center, Sacramento, CA.
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  • Thomas O. Stair MD,

    1. From the Department of Emergency Medicine (KAM, ELS), Cardiac Arrhythmia Service (JNR, PTE), Massachusetts General Hospital, Boston, MA; the Department of Emergency Medicine, SUNY Downstate Medical Center (IAD, DKN), Brooklyn, NY; the Department of Emergency Medicine, Mt. Auburn Hospital (GSS), Cambridge, MA; and the Department of Emergency Medicine, Brigham and Women’s Hospital (TOS), Boston, MA. Dr. Nishijima is currently with the Department of Emergency Medicine, U.C. Davis Medical Center, Sacramento, CA.
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  • Jeremy N. Ruskin MD,

    1. From the Department of Emergency Medicine (KAM, ELS), Cardiac Arrhythmia Service (JNR, PTE), Massachusetts General Hospital, Boston, MA; the Department of Emergency Medicine, SUNY Downstate Medical Center (IAD, DKN), Brooklyn, NY; the Department of Emergency Medicine, Mt. Auburn Hospital (GSS), Cambridge, MA; and the Department of Emergency Medicine, Brigham and Women’s Hospital (TOS), Boston, MA. Dr. Nishijima is currently with the Department of Emergency Medicine, U.C. Davis Medical Center, Sacramento, CA.
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  • Patrick T. Ellinor MD, PhD

    1. From the Department of Emergency Medicine (KAM, ELS), Cardiac Arrhythmia Service (JNR, PTE), Massachusetts General Hospital, Boston, MA; the Department of Emergency Medicine, SUNY Downstate Medical Center (IAD, DKN), Brooklyn, NY; the Department of Emergency Medicine, Mt. Auburn Hospital (GSS), Cambridge, MA; and the Department of Emergency Medicine, Brigham and Women’s Hospital (TOS), Boston, MA. Dr. Nishijima is currently with the Department of Emergency Medicine, U.C. Davis Medical Center, Sacramento, CA.
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  • This work was presented at the Society for Academic Emergency Medicine annual meeting, Chicago, IL, May 2007.

  • This work was supported by the Eleanor and Miles Shore Scholars in Medicine Fellowship, Harvard Medical School, Boston, MA.

  • Dr. Ellinor is a paid consultant to Sanofi-Aventis regarding the antiarrhythmic agent dronedarone. No other authors report financial interests, relationships, or affiliations relevant to the subject matter.

Address for correspondence: Keith A. Marill, MD; e-mail: kmarill@partners.org. Reprints will not be available.

Abstract

Objectives:  The objective was to compare the effectiveness of intravenous (IV) procainamide and amiodarone for the termination of spontaneous stable sustained ventricular tachycardia (VT).

Methods:  A historical cohort study of consecutive adult patients with stable sustained VT treated with IV amiodarone or procainamide was performed at four urban hospitals. Patients were identified for enrollment by admissions for VT and treatment with the study agents in the emergency department (ED) from 1993 to 2008. The primary measured outcome was VT termination within 20 minutes of onset of study medicine infusion. A secondary effectiveness outcome was the ultimate need for electrical therapy to terminate the VT episode. Major adverse effects were tabulated, and blood pressure responses to medication infusions were compared.

Results:  There were 97 infusions of amiodarone or procainamide in 90 patients with VT, but the primary outcome was unknown after 14 infusions due to administration of another antidysrhythmic during the 20-minute observation period. The rates of VT termination were 25% (13/53) and 30% (9/30) for amiodarone and procainamide, respectively. The adjusted odds of termination with procainamide compared to amiodarone was 1.2 (95% confidence interval [CI] = 0.4 to 3.9). Ultimately, 35/66 amiodarone patients (53%, 95% CI = 40 to 65%) and 13/31 procainamide patients (42%, 95% CI = 25 to 61%) required electrical therapy for VT termination. Hypotension led to cessation of medicine infusion or immediate direct current cardioversion (DCCV) in 4/66 (6%, 95% CI = 2 to 15%) and 6/31 (19%, 95% CI = 7 to 37%) patients who received amiodarone and procainamide, respectively.

Conclusions:  Procainamide was not more effective than amiodarone for the termination of sustained VT, but the ability to detect a significant difference was limited by the study design and potential confounding. As used in practice, both agents were relatively ineffective and associated with clinically important proportions of patients with decreased blood pressure.

ACADEMIC EMERGENCY MEDICINE 2010; 17:297–306 © 2010 by the Society for Academic Emergency Medicine

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