Procainamide for Wide Complex Tachycardia

Procainamide for Wide Complex Tachycardia

Pharmacy Friday Pearl – Pharmacy & Acute Care University

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Introduction

  • Ventricular tachycardia (VT) is an uncommon but dangerous medical condition with an extremely variable clinical presentation.
  • Intravenous procainamide is guideline recommended and is the drug of choice for hemodynamically stable VT with a class IIa recommendation.
  • Procainamide is an old drug with new evidence supporting its use, but dosing strategies and administration techniques make it difficult to use at the bedside.

Procainamide

Parameter Details
Bolus Dose 10–17 mg/kg over 20–60 minutes (Max dose 1g, max rate 20–50 mg/min) OR 100 mg every 5 minutes (max rate 50 mg/min) up to 1g
Renal Adjustments eCrCl 10–50 ml/min: reduce dose by 25–50%
eCrCl <10 ml/min: reduce dose by 50–75%
Maintenance Infusion 1–6 mg/min
Mechanism Class 1A anti-arrhythmic; blocks fast sodium channels, prolongs action potential, reduces impulse conduction speed
PK/PD IV Onset: <2 min; IM: 10–30 min
IV Peak: 25–60 min; IM: 15–60 min
Duration: 3–4 hrs
Metabolism: Hepatic to active NAPA
Half-life: 2.5–4.7 hrs (NAPA: 7 hrs)
Excretion: 40–70% renally unchanged
Adverse Effects Hypotension, hepatotoxicity, lupus-like syndrome, positive ANA, anaphylaxis (sulfite), MG exacerbation, angioedema
Drug Interactions Interacts with diazepam, diltiazem, milrinone, phenytoin, hydralazine
Compatibility Compatible: 0.9% NaCl, 0.45% NaCl
Incompatible: D5 (variable), LR, D5NS

Clinical Pearl: Define institutional dosing and administration policies due to variable strategies in the literature and risk of adverse events.

Overview of Key Evidence

Author/Year Design (n) Key Findings
Ortiz, 2017 RCT (n=62) Procainamide: 67% VT termination; 9% major cardiac adverse
Amiodarone: 38% VT termination; 41% adverse
Marill, 2010 Multicenter cohort (n=187) VT termination: Amio 25%, Procainamide 30%
Komura, 2010 Retrospective (n=90) Procainamide terminated 75.7% VT vs. Lidocaine 35%
Marill, 2006 Case series (n=33) Amio VT termination: 29%; 6% needed cardioversion
Gorgels, 1996 Randomized (n=79) Procainamide terminated 79% VT vs. Lidocaine 19% (p<0.001)
Callans, 1992 Observational (n=15) VT termination rate 93% with median 600 mg procainamide

Clinical Conclusions

  • Procainamide is guideline-supported for stable VT (Class IIa).
  • Use empiric 10–17 mg/kg bolus dosing up to 1g.
  • Consider renal function for bolus dose reductions.
  • Initiate maintenance infusion at 1–6 mg/min after bolus.
  • Clearly define hospital protocols to avoid variability.

Full Reference List

  1. Procainamide. Micromedex [Electronic version]. Greenwood Village, CO: Truven Health Analytics. Retrieved July 6, 2020, from http://www.micromedexsolutions.com/
  2. Long B, Koyfman A. Best Clinical Practice: Emergency Medicine Management of Stable Monomorphic Ventricular Tachycardia. J Emerg Med. 2017;52:484-492.
  3. Ortiz M, Martín A, Arribas F, et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2017;38(17):1329-1335.
  4. Marill KA, deSouza IS, Nishijima DK, et al. Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison. Acad Emerg Med. 2010;17(3):297-306.
  5. Komura S, Chinushi M, Furushima H, et al. Efficacy of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia. Circ J. 2010;74(5):864-869.
  6. Marill KA, deSouza IS, Nishijima DK, et al. Amiodarone is poorly effective for the acute termination of ventricular tachycardia. Ann Emerg Med. 2006;47(3):217-224.
  7. Gorgels AP, van den Dool A, Hofs A, et al. Comparison of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia. Am J Cardiol. 1996;78(1):43-46.
  8. Callans DJ, Marchlinski FE. Dissociation of termination and prevention of inducibility of sustained ventricular tachycardia with infusion of procainamide: evidence for distinct mechanisms. J Am Coll Cardiol. 1992;19(1):111-117.
  9. Wellens HJ, Bär FW, Lie KI, et al. Effect of procainamide, propranolol and verapamil on mechanism of tachycardia in patients with chronic recurrent ventricular tachycardia. Am J Cardiol. 1977;40(4):579-585.
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