Therapy is not required for all forms of ES.
Depending on the type of ES, symptomatic therapy may consist of:
- Checking potassium and magnesium balance with possible substitution up to high-normal serum levels (Herold 2022).
- Avoidance of certain triggers such as alcohol, nicotine, coffee, overtiredness, emotional arousal, cocaine (Herold 2022 / Haas 2011).
- If necessary, correction of drug levels (especially with digitalis [Wolff 2012]).
Medicinally, antiarrhythmic drugs may be considered under certain conditions.
Indications may be:
- Increased risk of sudden cardiac death due to e.g. ventricular fibrillation.
- complex ES in patients with restriction of left ventricular pump function or severe underlying myocardial disease (Herold 2022)
- symptomatic (idiopathic) ES (Muser 2021 / Heaton 2022)
- frequently occurring ES
- echocardiographic evidence of left ventricular dysfunction
- Occurrence of warning arrhythmias, ie:
- Occurrence of volley-like VES with limitations in exercise capacity.
- occurrence of syncope (Braun 2022)
For more details see VES and SVES.
Dosage and choice of antiarrhythmic drug:
- Beta blocker
Antiarrhythmics of 1st choice are beta blockers without intrinsic sympathomimetic activity for patients with impaired pumping capacity and Z. n. myocardial infarction (Herold 2022).
- Calcium channel blockers
If beta-blockers do not produce the desired outcome, therapy with non-dihydropyridine calcium channel blockers is indicated. The lowest effective dose should be used, except in patients with recent myocardial infarction or existing heart failure. Here, the maximum tolerated dose should be titrated (Muser 2021).
- Sodium channel blockers.
If therapeutic success cannot be achieved with both beta blockers and calcium channel blockers, therapy with sodium channel blockers such as flecainide or propafenone is recommended. However, sodium channel blockers are contraindicated in the presence of existing coronary artery disease, heart failure, or severe left ventricular hypertrophy (Muser 2021).
- Amiodarone
In patients with VES-induced cardiomyopathy, amiodarone has been shown to improve symptoms and left ventricular function (Muser 2021)
In patients with structural heart disease such as heart failure, CHD, class I antiarrhythmic drugs are contraindicated because they may worsen prognosis in them. Similarly, amiodarone and sotalol show no prognostic advantage, even leading to worsening of prognosis in patients with NYHA III . In all these cases, an implantable cardioverter- defibrillator (ICD) is recommended (Herold 2022).
In patients with cardiomyopathy, heart failure, atrial fibrillation, etc. associated with ES, further interventional therapy is indicated. These include atrial pacing, catheter ablation (Heaton 2022), radiofrequency catheter ablation (Muser 2021), thoracoscopic ablation (Heaton 2022), implantation of a defibrillator (Braun 2022).
For more details see VES and SVES.