Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Sotalol terminated ventricular tachycardia better than lignocaine

ACP J Club. 1995 Jan-Feb;122:12. doi:10.7326/ACPJC-1995-122-1-012


Source Citation

Ho DS, Zecchin RP, Richards DA, Uther JB, Ross DL. Double-blind trial of lignocaine versus sotalol for acute termination of spontaneous sustained ventricular tachycardia. Lancet. 1994 Jul 2;344:18-23.


Abstract

Objective

To compare intravenous lignocaine with sotalol for acute termination of spontaneous sustained ventricular tachycardia in conscious adults.

Design

Randomized, double-blind, crossover trial.

Setting

Wards and emergency departments of 3 hospitals in Australia.

Patients

33 conscious patients (mean age, 65 y; 26 men) with sustained broad complex ventricular tachycardia on the basis of clinical history and a 12-lead electrocardiogram (ECG). Exclusion criteria were receipt of the study drugs within the previous 24 hours, poor hemodynamic status, torsade de pointes, or ventricular tachycardia interrupted by runs of sinus rhythm. Ventricular tachycardia was reconfirmed by ECG. Coronary angiography and left ventriculography were done to establish underlying heart disease.

Intervention

17 patients were allocated to lignocaine first and 16 patients to sotalol first. Both drugs were given intravenously over 5 minutes in 100-mg doses. Patients were monitored by ECG; 15 minutes after injection, patients were given the alternate drug if ventricular tachycardia persisted. Direct-current countershocks were given as needed.

Main Outcome Measures

Termination of ventricular tachycardia, hemodynamic collapse requiring cardioversion, and persistence of ventricular tachycardia 30 minutes after administration of both drugs. Secondary outcomes were mortality and adverse effects.

Main Results

Ventricular tachycardia termination was 51% higher in patients who received sotalol first than in those who received lignocaine first (69% vs, 18%; 95% CI for the 51% absolute risk reduction, 22% to 80%; relative risk reduction, 74%; number needed to treat, 2; CI, 1 to 5). 14 patients who received lignocaine first subsequently required treatment with sotalol compared with 4 patients who received sotalol first. Ventricular tachycardia ceased in 7 patients (50%) who crossed over to sotalol and in 1 patient (25%) who crossed over to lignocaine. The groups did not differ in need for countershocks (1 patient in each group after first treatment), mortality (1 patient died after lignocaine as first treatment, 1 patient after sotalol as first treatment, and 1 patient after treatment with both drugs), or adverse effects.

Conclusion

Intravenous sotalol was more effective than lignocaine in terminating spontaneous sustained ventricular tachycardia not causing cardiac arrest.

Sources of funding: National Health and Medical Research Council of Australia and Astra Pharmaceuticals (both drugs).

For article reprint: Professor D.L. Ross, Department of Cardiology, Westmead Hospital, Sydney, NSW, 2145 Australia. FAX 61-2-687-2331.


Commentary

Lignocaine has remained the drug of choice for the termination of ventricular tachycardia despite a limited efficacy of approximately 19%. Early recurrence of ventricular tachycardia and the ineffectiveness of repeat lignocaine therapy has heightened this paradox (1). Furthermore, a meta-analysis of results of lignocaine treatment after myocardial infarction indicated a trend toward increased mortality, apparently caused by asystole (2).

This randomized, double-blind study of lignocaine and sotalol, a β-blocking agent with type 3 antiarrhythmic effects, is welcome because of the superior efficacy of sotalol compared with class I agents (3). Sotalol was effective in 69% of this highly selected and small patient population with spontaneous, hemodynamically stable ventricular tachycardia, whereas lignocaine was effective in only 18%.

The efficacy and safety of sotalol in this setting must be confirmed before the drug can be used as the first-line therapy for sustained ventricular tachycardia.

I. Paul Gupta, MD
Paul W. Armstrong, MD University of Alberta Edmonton, Alberta