Vol. 10, No 2, 2003 pp. 69 - 75
UC 616.12-008.46+616.12-008.311]:616-085 
AN ACCOUNT OF A SEVEN YEAR EXPERIENCE WITH CARVEDILOL AND AMIODARONE IN SEVERE CONGESTIVE HEART FAILURE PATIENTS
WITH SINUS TACHYCARDIA
Goran P. Koraćević, Mirko Burazor, Miloje Tomašević,
Zoran Perišić, Svetlana Apostolović, Aleksandar Mihajlović
Department of Cardiovascular Diseases, Clinical Center Niš, Serbia

Summary. The aim is to report on a rationale for amiodarone and carvedilol combination in severe congestive heart failure with sinus tachycardia, because there are very few reports on this topic in available medical literature. We analyzed 112 patients with NYHA III/IV congestive heart failure, with coronary artery disease in two thirds. There were 59 males and 53 females, aged 64 +/- 9 years, from March 1996. The average initial dose of Amiodarone was 860 +/- 95 mg, and maintenance dose was 285 +/- 140 mg. Carvedilol was introduced in dosage of 6.25 mg, and kept at 28 +/- 13 mg. Patients were followed from 2 months to 6.5 years (average 1.7 years).
Results: The heart rate was reduced with amiodarone either intravenously or sublingually from 130.2 +/- 4.9 to 94.0 +/- 7.4 /min. (P<0.0001) in 2 days. Following recompensation in 5-10 days carvedilol was added and the heart rate diminished further, from 94.0 +/- 7.4/min. to 81.0 +/- 3.6 /min. (P<0.0001). The decrease in the rehospitalization rate was obvious. In our 1st patient (and among the first ones in the country), the left ventricle end-diastolic diameter = 80 mm and ejection fraction = 30% remained unchanged for 5 years. Side effects attributed to amiodarone and carvedilol combination: mild hypothyroidism (9 patients), AV block I O (16 patients), QTc prolongation without torsade (34 patients) and INR control problems (32 patients).
Conclusions: 1) There is a rationale for combining amiodarone and carvedilol in severe congestive heart failure and sinus tachycardia: to diminish oxygen consumption by decreasing the heart rate and afterload, to prolong diastole (and thus both left ventricle filling and coronary artery filling), with consequent ischemia suppression and reverse remodeling; to prevent both atrial fibrillation and ventricular tachycardia / fibrillation. 2) Amiodarone can be applied immediately and carvedilol following recompensation. 3) The risk / benefit ratio of amiodarone and carvedilol combination is quite acceptable.
Key words: Amiodarone, carvedilol, congestive heart failure, sinus tachycardia

SEDMOGODIŠNJA PRIMENA KARVEDILOLA I AMIODARONA
U TEŠKOJ INSUFICIJENCIJI SRCA SA SINUSNOM TAHIKARDIJOM: OBRAZLOŽENJE I BEZBEDNOST
Kratak sadržaj: Cilj rada je da pruži obrazloženje za kombinaciju amiodarona i karvedilola u teškoj srčanoj insuficijenciji sa sinusnom tahikardijom, jer o tome ima vrlo malo izveštaja u raspoloživoj medicinskoj literaturi. Analizovano je 112 bolesnika sa sinusnom tahikardijom i srčanom insuficijencijom (NYHA III-IV), 74 sa koronarnom bolešću, 59 muškaraca i 53 žene, 64 +/- 9 god, od marta 1996.
Rezultati: amiodaronom sublingvalno ili intravenski smo smanjili SF sa 130,2 +/- 4,9 na 94,0 +/- 7,4 /min. (P<0,0001) za 2 dana. Dodatkom karvedilola po rekompenzaciji je srčana frekvenca nakon 5-10 dana dodatno redukovana sa 94,0 +/- 7,4 /min. na 81,0 +/- 3,6 /min. (P<0,0001). Očigledno je smanjen broj rehospitalizacija. Našem prvom pacijentu su enddijastolni dijametar leve komore = 80 mm i ejekciona frakcija = 30% ostali nepromenjeni 5 godina. Nuzefekti: blag hipotireoidizam (9 pacijenta), AV blok IO (16), produženje QTc bez torzade (34) i otežana kontrola INR-a (32 pacijnta).
Zaključci: 1) Kombinacija amiodarona i karvedilola u teškoj SI, u sinusnoj tahikardiji je opravdana - da se smanji opterećenje srca frekvencom, a time i ishemija, da se produži dijastola, a time i punjenje kako leve komore, tako i koronarnih arterija, sa smanjenjem ishemije i reverznim remodelovanjem, te da se preveniraju / bolje kontrolišu atrijalna fibrilacija i ventrikularna tahikardija. 2) Amiodaronom se ubrzava rekompenzacija, a onda uvodi karvedilol. 3) Bezbednost kombinacije je vrlo prihvatljiva u odnosu na korist.
Ključne reči: Amiodaron, karvedilol, kongestivna srčana insuficijencija, sinusna tahikardija