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
