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 the treatment of hemodynamically stable VT with a class IIa recommendation. Procainamide is an old drug with new evidence that supports it’s use but dosing strategies and administration techniques makes it difficult to use at the bedside.
Key Points
- Ventricular tachycardia (VT) is uncommon but dangerous, with a highly variable clinical presentation.
- IV procainamide is guideline-recommended (Class IIa) and a drug of choice for hemodynamically stable VT.
- In the PROCAMIO trial (Ortiz 2017) procainamide terminated VT more often than the comparator, and it outperformed lidocaine in supporting studies.
- It is an old drug with renewed evidence, but complex dosing and administration make bedside use challenging.
Clinical Detail
| Procainamide | Detail |
|---|---|
| Dose and administration | Bolus Dosing • 10–17 mg/kg over 20–60 minutes (Max dose suggest 1g and max rate of 20–50 mg/min) or • 100 mg every 5 minutes at max rate of 50 mg/min to max dose 1g Renal Adjustments • eCrCl 10–50 ml/min: Reduce initial dosing by 25–50 % • eCrCL < 10 ml/min: Reduce initial dosing by 50–75% Maintenance Infusion Dosing • 1–6 mg/min |
| Mechanism of Action | • Class 1A anti-arrhythmic that binds to fast sodium channels inhibiting recovery after repolarization. It also prolongs the action potential and reduces the speed of impulse conduction |
| PK/PD | • Onset: IV <2 minutes; IM 10–30 minutes • Time to Peak: IV 25–60 minute; IM 15–60 minutes • Duration: IV/IM: 3–4 hours • Metabolism: Converted by the liver to N-acetylprocainamide (NAPA), an active compound • Half-life: 2.5–4.7 hr (NAPA–7 hr); increased in renal impairment • Excretion: 40–70% excreted unchanged by the kidneys |
| Adverse Effects | • Hypotension • Hepatotoxicity • Positive ANA titer • Lupus-like syndrome • Anaphylaxis caused by sulfite salt • Myasthenia gravis exacerbation • Angioedema |
| Drug Interactions and warnings | • Interacts with diazepam, diltiazem, milrinone, phenytoin, and hydralazine |
| Compatibility | • Compatible in ◦ 0.9 % Sodium Chloride and 0.45% sodium chloride, • Incompatible with ◦ D5 (depending on procainamide concentration), LR, and D5NS |
| Comments | • Define hospital’s dosing and administration policy as there is a risk for adverse event’s due to multiple dosing strategies in the literature |
Evidence
| Author, year | Design / sample size | Intervention & Comparison | Outcome |
|---|---|---|---|
| Ortiz, 2017 | Randomized controlled trial n= 62 | • IV procainamide 10 mg/kg over 20 min • IV amiodarone 5mg/kg over 20 min | • Major cardiac adverse occurred in 3 of 33 (9%) procainamide and 12 of 29 (41%) amiodarone patients. • Tachycardia terminated within 40 min in 22 (67%) procainamide and 11 (38%) amiodarone patients. |
| Maril, 2010 | Multicenter cohort study n= 187 | • IV Amiodarone 2 mg/kg infusion at a rate of at least 10 mg/min • IV Procainamide 10 mg/kg infusion at a rate of at least 15 mg/min | • The rates of VT termination were 25% (13/53) and 30% (9/30) for amiodarone and procainamide, respectively. |
| Komura, 2010 | Retrospective analysis n= 90 | • IV Procainamide 100 mg over 1–2 min • IV Lidocaine bolus of 50 mg | • Procainamide and lidocaine terminated VTs in 53/70 (75.7%) and in 7/20 (35.0%) respectively. |
| Maril, 2006 | Retrospective case series n= 33 | • IV Amiodarone 150 mg over 15 minutes | • Amiodarone rate of successful ventricular tachycardia termination was 8 of 28 (29%). • Two of 33 patients (6%) required direct current cardioversion for presyncope or hypotension temporally associated with amiodarone treatment. |
| Gorgels, 1996 | Randomized parallel study n= 79 | • IV Procainamide 10 mg/kg • IV Lidocaine 1.5 mg/kg | • Lidocaine terminated 6 of 31 VTs and procainamide 38 of 48 (p <0.001). • A comparison of the QRS width and QT interval before and at the end of the injection revealed significant lengthening of these values after procainamide but no change after lidocaine. |
| Callans, 1992 | Observational study n= 15 | • IV Procainamide rate of 50 mg/min until the arrhythmia terminated or a total dose of 15 mg/kg | • Procainamide was well tolerated and resulted in termination of ventricular tachycardia in 93% of patients after administration of 100 to 1,080 mg (median dose 600 mg). |
Conclusions
- Intravenous procainamide is guideline-recommended (Class IIa) and is a drug of choice for hemodynamically stable wide complex / monomorphic ventricular tachycardia.
- In the randomized PROCAMIO trial (Ortiz 2017), procainamide terminated tachycardia more often and caused fewer major cardiac adverse events than amiodarone in stable wide QRS tachycardia.
- Across the supporting studies, procainamide outperformed lidocaine for VT termination (Gorgels 1996, Komura 2010) and was well tolerated, while amiodarone was poorly effective for acute termination (Marill 2006, Marill 2010).
- Procainamide is an old drug with renewed evidence, but multiple dosing and administration strategies make bedside use complex — define a hospital-specific dosing and administration policy to limit adverse events.
References
Procainamide. Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved July 6, 2020, from http://www.micromedexsolutions.com/
Long B, Koyfman A. Best Clinical Practice: Emergency Medicine Management of Stable Monomorphic Ventricular Tachycardia. J Emerg Med 2017;52:484-492.
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. doi:10.1093/eurheartj/ehw230
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. doi:10.1111/j.1553-2712.2010.00680.x
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. doi:10.1253/circj.cj-09-0932
Marill KA, deSouza IS, Nishijima DK, Stair TO, Setnik GS, Ruskin JN. Amiodarone is poorly effective for the acute termination of ventricular tachycardia. Ann Emerg Med. 2006;47(3):217-224. doi:10.1016/j.annemergmed.2005.08.022
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. doi:10.1016/s0002-9149(96)00224-x
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. doi:10.1016/0735-1097(92)90060-z
Wellens HJ, Bär FW, Lie KI, Düren DR, Dohmen HJ. 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. doi:10.1016/0002-9149(77)90074-1
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