Procainamide for Wide Complex Tachycardia

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.

Clinical Detail

Procainamide

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)

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

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 ⁄

and 30% (9 ⁄ 30) for amiodarone and

procainamide, respectively.

Komura,

2010

Retrospective analysis

n= 90

Conclusions

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

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