Effects of bepridil on cardiac electrophysiologic properties

The current classification system for antiarrhythmic drugs has several shortcomings; for example, electrophysiologic effects are defined in normal tissue, whereas antiarrhythmic drugs are often used clinically in diseased or injured tissue. Consideration of the electrophysiologic effects of bepridil in humans emphasizes the drawbacks of the classification system. Bepridil is primarily a calcium antagonist with class IV action. However, because the drug has class IA action as well, it should not be considered a typical class I or class IV agent. Bepridil has been observed to prolong the QT interval in the majority of patients in whom it is used for treatment of angina. However, in US clinical trials, including open extensions, only 7 cases of torsades de pointes have been recorded. In France, where the drug is approved for treatment of angina, the incidence of torsades de pointes was 0.01% in 1989. No consensus currently exists regarding what degree of QT prolongation constitutes increased risk for a ventricular proarrhythmic event. Based on current information, bepridil should be used cautiously in patients with a propensity toward hypokalemia, which can exacerbate or induce a proarrhythmic state. The drug should not be used in patients with a prolonged QT interval at baseline, a history of torsades de pointes, or long QT interval syndrome. Bepridil also should be avoided in patients with sinus node dysfunction or second- or third-degree atrioventricular block.