Predictors of atrial flutter with 1:1 conduction in patients treated with class I antiarrhythmic drugs for atrial tachyarrhythmias

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Abstract

Objectives: The purpose of the study was to look for the predictor factors of atrial proarrhythmic effects of class I antiarrhythmic drugs. Background: Class I antiarrhythmic drugs may induce or exacerbate cardiac arrhythmias. The predictors of ventricular proarrhythmia are known. The predictors of atrial flutter with 1:1 conduction are unknown. Methods: Clinical history, EGG, signal-averaged EGG (SAECG) and electrophysiologic study were analysed in 24 cases of 1:1 atrial flutter with class I AA drugs and in 100 control patients without history of 1:1 atrial flutter with class I AA drugs. Results: The ages of patients varied from 46 to 78 years. Underlying heart disease was present in nine patients. The surface EGG revealed the presence of a short PR interval (PR<0.13 ms), visible in leads V5, V6 in eight (35%) patients with normal P wave duration; in other patients with prolonged P wave duration, PR seemed normaL On SAECG recording, there was a pseudofusion between P wave and QRS complex. The electrophysiologic study revealed some signs indicating a rapid AV nodal conduction (short AH interval or rate of 2nd degree AV block at atrial pacing >200 beats/mm) in 19 of the 23 studied patients. All patients, except one, had at least one sign indicating a rapid AV nodal conduction (short PR and/or P wave-QRS complex continuity on SAECG). In the control group, seven patients (7%) had a short PR interval (P<0.01) and 11 (11%) had a pseudofusion between P wave and QRS complex on SAECG (P<0.001). The P wave-QRS complex pseudofusion on SAECG had a sensitivity of 100% and a specificity of 89% for the prediction of an atrial proarrhythmic effect with class I antiarrhythmic drug. Conclusion: We recommend avoiding class I AA drugs in patients with a short PR interval on surface EGG and to record SAECG in those with apparently normal PR interval to detect a continuity between P wave and QRS complex, which could indicate a rapid AV nodal conduction, predisposing to 1:1 atrial flutter with the drug.

Introduction

Class I antiarrhythmic agents are the drugs most frequently prescribed to suppress recurrences of atrial arrhythmias. They are known to be effective for the treatment of these arrhythmias. However, with the increasing use of such agents, it has become apparent that they may also induce or exacerbate cardiac arrhythmias.

The predictors of ventricular proarrhythmia are actually known, and in particular, existing organic heart disease augments the risk [1], [2], [3], [4], [5]. The risk factors promoting atrial proarrhythmias are unknown; a young patient without cardiac heart disease can be at risk of this accident. However, the risk of atrial flutter with 1:1 conduction during treatment with class I antiarrhythmic drugs has been reported since 1956 [6] with quinidine and later, successively, with all class I antiarrhythmic drugs [7], [8], [9], [10], [11].

Therefore, the purpose of the study was to identify the possible risk factors of atrial proarrhythmic effects related to class I antiarrhythmic drug by the analysis of 24 atrial flutters with 1:1 conduction in patients treated with class I antiarrhythmic drug.

Section snippets

Study population

Twenty-four patients, eighteen males and six females, aged 31–78 years (mean 62±11) presented with atrial flutter and 1:1 conduction: patients were admitted for a regular tachycardia at a rate between 180 and 220 beats/min, mimicking a ventricular tachycardia in twenty-two patients (Fig. 1). Two remaining patients had a rapid and fine QRS complex tachycardia.

The diagnosis of the tachycardia nature was established by recording of the atrial electrogram with 1:1 ventricular response either by

Methods

Alter restoration of sinus rhythm and interruption of all antiarrhythmic drugs for five half-lives, systematic noninvasive and invasive studies were prospectively collected

  • 1.

    History and clinical data

  • 2.

    Recording of the 12-lead surface ECG; the duration of PR interval was automatically measured; the value of PR interval in each lead was also manually measured

  • 3.

    Two-dimensional echocardiogram

  • 4.

    Electrophysiological study including the study of AV conduction and programmed atrial and ventricular stimulation:

Clinical and technical data of the study population

An underlying heart disease was present in nine patients (37.5%), but the left ventricular ejection fraction was preserved in all these patients (>50%); three patients had a minor mitral or aortic insufficiency; two patients had hypertension; three patients had a coronary heart disease, without myocardial infarction and had a normal left ventricular function; another patient had a hypertrophic cardiomyopathy.

Left atrial anteroposterior diameter varied from 25 to 60 mm (38±11).

The automatic

Discussion

In the present study, the age and the presence of an underlying heart disease did not predict the occurrence of atrial flutter with 1:1 conduction. One sign was found to be associated with the risk of atrial proarrhythmia: all patients but one had either a short PR interval on leads V5, V6 of their surface ECG without other signs of preexcitation or the recording of SAECG demonstrated that the apparently normal PR interval was related to an increased P wave duration. The short AV nodal

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