Antiarrhythmic drug therapy in patients with renal failure, liver failure, and congestive heart failure

Commonly prescribed antiarrhythmic agents--and several recently developed agents--are reviewed with respect to their use in patients with renal failure, hepatic failure, and congestive heart failure. Because removal of electrophysiologically active agents from the systemic circulation in most cases depends on either renal elimination, hepatic metabolism, or both, patients with preexisting kidney or liver disease may be at increased risk of treatment-related drug toxicity, including proarrhythmia. These susceptibilities should be anticipated, with drug selection and/or dosage modified accordingly. Patients with left ventricular dysfunction and heart failure also are at increased risk of treatment-related complications, including proarrhythmia and hemodynamic intolerance. In addition, the metabolism of antiarrhythmic drugs may be impaired in these patients. Preference should be given to drugs with a proven safety profile, such as amiodarone, in patients with heart failure.