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Structural heart disease: its importance in association with antiarrhythmic drug therapy
1Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York.
Insights
Before prescribing antiarrhythmic drugs, screening for structural heart disease is crucial. This assessment helps prevent potentially fatal proarrhythmia, especially in patients with underlying cardiac conditions.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Structural heart disease (SHD) influences antiarrhythmic drug efficacy and safety.
- Class I and III antiarrhythmic agents carry proarrhythmic risks, particularly in patients with SHD.
Purpose of the Study:
- To outline a prudent approach for screening patients for SHD before initiating antiarrhythmic drug therapy.
- To identify key diagnostic tools and patient factors influencing screening decisions.
Main Methods:
- Comprehensive patient evaluation including history, physical exam, and electrocardiogram (ECG).
- Echocardiography recommended for all patients.
- Further testing like exercise tests, Holter monitoring, signal-averaged ECG, chest x-ray, and invasive procedures considered for selected patients.
- Physician's strategy, patient-specific risk, arrhythmia type, drug class, and cost-effectiveness guide test selection.
Main Results:
- A multi-step screening approach is proposed, ranging from universal tests to selected investigations.
- Individualized assessment is necessary to balance the risk of proarrhythmia against the cost and yield of testing.
Conclusions:
- Pre-drug assessment for SHD is prudent despite low proarrhythmia incidence, due to the potentially lethal consequences.
- Screening decisions should be tailored to the individual patient and clinical context.
Abstract:
The presence or absence of structural heart disease is an important factor to consider prior to initiating antiarrhythmic drug therapy with a class I or class III antiarrhythmic agent. An appropriate screen for structural heart disease and other associated proarrhythmic risk factors should include a complete history, physical examination, electrocardiogram (ECG), and echocardiogram in all patients; exercise test and Holter monitoring in many/most selected patients; and a signal-averaged ECG, chest x-ray, and invasive procedures only in selected/occasional patients. Whether and when to obtain the tests that are not indicated for all patients must be determined by each individual physician's practice strategy and philosophy, while keeping in mind the likelihood of finding an abnormality in a particular patient, the arrhythmia being treated, the nature of the drug to be used, and cost-effectiveness issues. Given the low incidence of proarrhythmia under most circumstances, screening for clinically unrecognized structural heart disease may appear difficult to justify in the current era of cost containment. However, due to the potential lethality of proarrhythmia, particularly in patients with structural heart disease, pre-drug assessment is prudent.