#1
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Ñîòàëîë
Ìîæåò ÿ ñòàðåþ? Èëè â Ìîñêâå ïîçàáûëè çà÷åì (öåëü?!) ëå÷àò àðèòìèè?
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Ñîòàëîë ïðÿìî òàèíñòâåííûé óíèâåðñàëüíûé àíòèàðèòìèê, íåñìîòðÿ íà òî, ÷òî ïðîàðèòìîãåíåí è íå âëèÿåò íà ïðîãíîç ïîëîæèòåëüíî...
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#2
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Äîêàçàòåëüíàÿ áàçà âðåäíîñòè ñîòàëîëà.
Cochrane Database Syst Rev. 2015 Mar 28;(3):CD005049. doi: 10.1002/14651858.CD005049.pub4. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Lafuente-Lafuente C1, Valembois L, Bergmann JF, Belmin J. CONCLUSIONS: Several class IA, IC and III drugs, as well as class II drugs (beta-blockers), are moderately effective in maintaining sinus rhythm after conversion of atrial fibrillation. However, they increase adverse events, including pro-arrhythmia, and some of them (disopyramide, quinidine and sotalol) may increase mortality. Possible benefits on clinically relevant outcomes (stroke, embolism, heart failure) remain to be established. Crit Care. 2013 Aug 12;17(4):R173. doi: 10.1186/cc12852. Antiarrhythmia drugs for cardiac arrest: a systemic review and meta-analysis. Huang Y, He Q, Yang M, Zhan L. Bretylium and sotalol were not shown to be beneficial. Cochrane Database Syst Rev. 2012 May 16;(5):CD005049. doi: 10.1002/14651858.CD005049.pub3. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Lafuente-Lafuente C1, Longas-Tejero MA, Bergmann JF, Belmin J. CONCLUSIONS: Several class IA, IC and III drugs, as well as class II (beta-blockers), are moderately effective in maintaining sinus rhythm after conversion of atrial fibrillation. However, they increase adverse events, including pro-arrhythmia, and some of them (disopyramide, quinidine and sotalol) may increase mortality. Possible benefits on clinically relevant outcomes (stroke, embolisms, heart failure) remain to be established. Europace. 2011 Mar;13(3):329-45. doi: 10.1093/europace/euq450. Epub 2011 Jan 11. Mixed treatment comparison of dronedarone, amiodarone, sotalol, flecainide, and propafenone, for the management of atrial fibrillation. Freemantle N1, Lafuente-Lafuente C, Mitchell S, Eckert L, Reynolds M. CONCLUSIONS: Amiodarone has been demonstrated to be the most effective drug in maintaining sinus rhythm. Differences in outcomes between the anti-antiarrhythmic drugs were reported, with sotalol and possibly amiodarone increasing mortality and dronedarone possibly decreasing the incidence of serious adverse events and proarrhythmia. Am Heart J. 2002 Sep;144(3):422-30. Overview of randomized trials of antiarrhythmic drugs and devices for the prevention of sudden cardiac death. Heidenreich PA1, Keeffe B, McDonald KM, Hlatky MA. RESULTS: Randomized trials of type I antiarrhythmic agents used as secondary prevention after myocardial infarction show an overall 21% increase in mortality rate. Randomized trials of amiodarone suggest a 13% to 19% decrease in mortality rate, and sotalol has been effective in several small trials. Trials of pure type III agents, however, have shown no mortality benefit. An overview of implantable defibrillator trials shows a 24% reduction in mortality rate (CI 15%-33%) compared with alternative therapy, most often amiodarone. CONCLUSION: Amiodarone is effective in reducing the total mortality rate by 13% to 19%, and the implantable defibrillator reduces the mortality rate by a further 24%. Acad Emerg Med. 2001 Feb;8(2):117-24. Meta-analysis of the Risk of Torsades de Pointes in patients treated with intravenous racemic sotalol. Marill KA1, Runge T. RESULTS: The search included 1,005 publications. There were 37 reports in which 962 patients received IV sotalol and met the inclusion criteria. There was one report of self-terminating TdP lasting 10 seconds among the 962 patients included in the study. There was no report of TdP associated with only IV racemic sotalol administration in any of the excluded studies. If it is assumed that the risk of TdP is homogeneous in the population of patients treated with IV sotalol, then based on the 962 included patients, the rate of TdP is 0.1% (95% CI = 0.003% to 0.6%). CONCLUSIONS: The overall risk of TdP in patients treated with a single infusion of IV sotalol is low compared with that in patients given chronic oral sotalol therapy. Am J Cardiol. 1999 Nov 4;84(9A):109R-114R. Class III antiarrhythmic agents in cardiac failure: lessons from clinical trials with a focus on the Grupo de Estudio de la Sobrevida en la Insuficiencia Cardiaca en Argentina (GESICA). Doval HC The results of previous clinical trials, in a variety of clinical settings, showed that class I agents may consistently increase mortality in sharp contrast to the effects of beta blockers. Attention has therefore shifted to class III compounds for potential beneficial effects on long-term mortality among patients with underlying cardiac disease. Clinical trials with d-sotalol, the dextro isomer (devoid of beta blockade) of sotalol, showed increased mortality in patients with low ejection fraction after myocardial infarction and in those with heart failure; whereas in the case of dofetilide, the impact on mortality was neutral. Because of the complex effects of its actions as an alpha-adrenergic blocker and a class III agent, the impact on mortality of amiodarone in patients with heart failure is of particular interest. A meta-analysis of 13 clinical trials revealed significant reductions in all-cause and cardiac mortality among patients with heart failure or previous myocardial infarction. Among these were 5 controlled clinical trials that investigated the effects of amiodarone on mortality among patients with heart failure. None of these trials was large relative to the beta-blocker trials in the postinfarction patients. However, the larger 2 of the 5 amiodarone trials produced discordant effects on mortality, neutral in one and significantly positive in the other. Some of the differences may be accounted for by the differences in eligibility criteria and baseline characteristics. Future trials that may be undertaken to resolve the discrepancies may need to allow for the newer findings on the effects of concomitant beta blockers, implantable devices, and possibly, spironolactone. All these modalities of treatment have been shown in controlled clinical trials to augment survival in patients with impaired ventricular function or manifest heart failure. Additional trials, some of which are currently in progress, compare amiodarone with implantable devices and other therapeutic interventions, and should help to clarify the optimal management strategy for patients with underlying heart failure. Lancet. 1996 Jul 6;348(9019):7-12. Effect of d-sotalol on mortality in patients with left ventricular dysfunction after recent and remote myocardial infarction. The SWORD Investigators. Survival With Oral d-Sotalol. Waldo AL1, Camm AJ, deRuyter H, Friedman PL, MacNeil DJ, Pauls JF, Pitt B, Pratt CM, Schwartz PJ, Veltri EP. BACKGROUND: Left ventricular dysfunction after myocardial infarction is associated with an increased risk of death. Other studies have suggested that a potassium-channel blocker might reduce this risk with minimal adverse effects. We investigated whether d-sotalol, a pure potassium-channel blocker with no clinically significant beta-blocking activity, could reduce all-cause mortality in these high-risk patients. METHODS: Patients with a left ventricular ejection fraction of 40% or less and either a recent (6-42 days) myocardial infarction or symptomatic heart failure with a remote (> 42 days) myocardial infarction were randomly assigned d-sotalol (100 mg increased to 200 mg twice daily, if tolerated) or matching placebo twice daily. FINDINGS: After 3121 of the planned 6400 patients had been recruited, the trial was stopped. Among 1549 patients assigned d-sotalol, there were 78 deaths (5.0%) compared with 48 deaths (3.1%) among the 1572 patients assigned placebo (relative risk 1.65 [95% CI 1.15-2.36], p = 0.006). Presumed arrhythmic deaths (relative risk 1.77 [1.15-2.74], p = 0.008) accounted for the increased mortality. The effect was greater in patients with a left ventricular ejection fraction of 31-40% than in those with lower ( <or= 30%) ejection fractions (relative risk 4.0 vs 1.2, p = 0.007). INTERPRETATION: Among the 1549 patients evaluated, administration of d-sotalol was associated with increased mortality, which was presumed primarily to be due to arrhythmias. The prophylactic use of a specific potassium-channel blocker does not reduce mortality, and may be associated with increased mortality in high-risk patients after myocardial infarction. Äîïîëíèòåëüíî îòìå÷ó, ÷òî ñòàòåé ïî ëå÷åíèþ æåëóäî÷êîâûõ àðèòìèé ñîòàëîëîì çà ïîñëåäíèå 15 ëåò ÿ íå íàøåë.
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#3
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Ê ÷åìó ýòî ÿ?
Ïðåäëàãàþ ñîâìåñòíûìè óñèëèÿìè íà÷àòü ïîõîðîíû ñîòàëîëà, ÷òîáû îí íå õîðîíèë íàøèõ ïàöèåíòîâ.
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#4
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Àëåêñàíäð Èâàíîâè÷, äà êîìó òà ñîòàëîëüñêàÿ ñìåðòíîñòü â ÐÔ èíòåðåñíà? Åñëè è ñëó÷èòñÿ, òî ãäå-òî è êîãäà-òî, íî íå â áîëüíèöå, èëè íà ïðèåìå â ïîëèêëèíèêå, à â ñòàöèîíàðå îí æåæ î÷åíü ïîëåçåí, íàïðèìåð, ìåíÿåò àäðåíåðã. ÷óâñòâèòåëüíîñòü ñîãëàñíî ïóáëèêàöèè â ÒåðÀðõå çà 2016
Ter Arkh. 2016;88(1):35-39. doi: 10.17116/terarkh201688135-39. [A change in adrenal responsiveness in sotalol-treated patients with paroxysmal atrial fibrillation depending on autonomic nervous system tone].
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#5
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Âàäèì Âàëåðüåâè÷, ðàçäåëÿþ Âàø ïåññèìèçì. Íî è íàäåæäó íå òåðÿþ. È âîäà êàìåíü òî÷èò, ÈÌÕÎ. ß øóìëþ êàê ìîãó, åñëè åùå íåñêîëüêî ÷åëîâåê ïîäêëþ÷àòñÿ, òî è õîðîøî.
 íà÷àëå íóëåâûõ ïðèìåðíî òàê õèíèäèí ïîãèáàë, òîæå áûëî ìíîãî ëþáèòåëåé - âåäü ðèòì õîðîøî âîññòàíàâëèâàë, ôèãíÿ, ÷òî ëèöî çåëåíûì íà âòîðîé äåíü ñòàíîâèëîñü. Äîðîãó îñèëèò èäóùèé, ÿ ëèøü ïðèçûâàþ ïîäêëþ÷àòüñÿ ê íåíàçíà÷åíèþ ñîòàëîëà. Ïðîñòî ê íåíàçíà÷åíèþ.
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#6
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Àëåêñàíäð Èâàíîâè÷,
Áûòü ìîæåò, â ÐÔ è áåç âñÿêîãî ïîâîäà íàçíà÷àþò ñîòàëîë, íî ñîãëàñíî íàïðèìåð ïóáëèêàöèè íèæå: The role of sotalol is well established for maintenance of sinus rhythm after successful restoration of normal sinus rhythm (NSR).[2] ñî ññûëêîé íà 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014 Dec 2;130 (23):e199–267. åãî ïîáî÷íûå äåéñòâèÿ ïðè õð. íàçíà÷åíèè ïðè ÔÏ ìàëî ÷åì îòëè÷àþòñÿ îò òîãî æå àìèîäàðîíà: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Sotalol versus Amiodarone in Treatment of Atrial Fibrillation J Atr Fibrillation. 2016 Feb-Mar; 8(5): 1359 [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#7
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 îäíîé ñòðàíå òàê:
There is a decline in the use of amiodarone and sotalol consistent with the growing safety concerns with these drugs along with neutral results from landmark trials comparing rate and rhythm control.// The evolving landscape of oral anti-arrhythmic prescriptions for atrial fibrillation in England: 1998-2014 à â äðóãîé - è òàê, õîòÿ ñëåäóþò îäíèì è òåì æå ìåæäóíàðîäíûì ðåêîìåíäàöèÿì: A rhythm control strategy is frequently utilized for AF management in Australia. Consistent with international guidelines which advocate safety over efficacy when choosing a rhythm control strategy, the prescriptions of amiodarone have been consistently decreasing since 2002, whereas sotalol and flecainide prescriptions have largely increased, with a peak in 2015. //Trends in outpatient anti-arrhythmic prescriptions for atrial fibrillation and left atrial ablation in Australia: 1997-2016.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
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#8
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Êîðîòêàÿ ïàìÿòü - ýòî îáùåìèðîâàÿ ïðîáëåìà. Â ðóêîâîäñòâàõ (ÍÆÒ, ÔÏ) îí ïðîïèñàí è îñòàåòñÿ, ê ñîæàëåíèþ.
×àñòî åãî âûáèðàþò êàê çàìåíó àìèîäàðîíó, ò.ê. ïîñëåäíèé íàêàïëèâàåòñÿ. Íî çàáûâàÿ ïðî ïðîàðèòìîãåííîñòü. Åñëè ñðàâíèâàòü àìèîäàðîí è ñîòàëîë ïî ïðîãíîçó, òî ïðè ÔÏ ïðîàðèòìîãåííîñòü áëèçêà. Íî ïðè ÆÒ è ÂÑÑ àìèîäàðîí âûèãðûâàåò, à ñîòàëîë ñèëüíî ïëîõ è íå ïðèìåíÿåòñÿ. Ò.å. àìèîäàðîíó åñòü ìåñòî â àðèòìîëîãèè (æåëóäî÷êîâûå àðèòìèè), à ñîòàëîëó êàê-òî âîîáùå íåò ìåñòà. Âîññòàíîâëåíèå è óäåðæàíèå ñèíóñîâîãî ðèòìà - ýòî õîðîøî, íî ðàçâå ðàäè ýòîãî ëþäåé ëå÷àò? Ðàçâå ìîæíî ýòî äåëàòü â óùåðá ïðîãíîçó? Õèíèäèí òîæå õîðîøî âîññòàíàâëèâàë è óäåðæèâàë ðèòì. P.S. Ãèáðèäíîñòü íàøåãî âðåìåíè ñèëüíî íèâåëèðîâàëà ñëîâî "ñìåðòü". È ñëîâà "some of them (disopyramide, quinidine and sotalol) may increase mortality" â êîêðåéíîâñêîì îáçîðå Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation óæå íèêîãî íå ïóãàþò, äàæå â áëàãîïîëó÷íîé Àâñòðàëèè... Ïðàâäà äèçîïèðàìèä è õèíèäèí óæå íàéòè ñëîæíî, à ñîòàëîë ïî÷åìó-òî ñïëîøü è ðÿäîì...
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#9
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Âîò åùå äëèòåëüíîå íàáëþäåíèå çà èíäèâèäàìè ñ ÔÏ â Äàíèè - íè îäèí èç ïåðå÷èñëåííûõ òàì àíòèàðèòìèêîâ íå ïîâûøàë ñìåðòíîñòü, õóæå âñåãî äåëî îáñòîÿëî ñ àìèîäàðîíîì:
Multivariable Cox proportional-hazard models did not show increased risk of death associated with any of the AADs. Hazard ratio (95% confidence interval) for flecainide 0.38 (0.32–0.44), propafenone 0.65 (0.58–0.71), sotalol 0.65 (0.63– 0.67), and amiodarone 0.94 (0.89–1.00). In an unselected cohort of patients with AF, antiarrhythmic treatment with flecainide, propafenone, sotalol, or amiodarone was not associated with increased risk of death. //Antiarrhythmic therapy and risk of death in patients with atrial fibrillation: a nationwide study. Europace (2009) 11, 886–891. Ïóáëèêàöèè çà ïîñëåäíèå 10 ëåò î ïðèìåíåíèè ýòèõ ïð-òîâ ïðè ÔÏ ó àìèîäàðîíà ïîêàçàòåëè ïî âûæèâàåìîñòè õóæå â êàêîé áû ñòðàíå íå ïóáëèêîâàëè ðåòðî-íàáëþäåíèÿ.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#10
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Âîëíîîáðàçíîñòü òå÷åíèÿ èñòîðèè ñ ïåðåãèáàìè íà ïèêàõ ïîïóëÿðíîñòè âîçâðàùàåò ìåíÿ â 90-å ãîäû ïðîøëîãî âåêà, êîãäà ïðè ÔÏ áîðîëèñü çà ñèíóñîâûé ðèòì ëþáûìè ñðåäñòâàìè.
Íî ïðîïàôåíîí ïðîòèâîïîêàçàí ïðè íàìåêå íà ÈÁÑ, à ñîòàëîë è àìèîäàðîí ïðîñòî íå íóæíû. Æåëóäî÷êîâûå àðèòìèè. Ïîâòîðþñü, àìèîäàðîí äîêàçàíî ïîìîãàåò. À âîò ïðîïàôåíîíó è ñîòàëîëó ìåñòà íåò. Ïî÷åìó îäíè ëåêàðñòâà ñòàíîâÿòñÿ ïîïóëÿðíûìè, à äðóãèå íåò? È êàê íàì íà ýòî ïîâëèÿòü? Åñòü ðàçíûå ïîó÷èòåëüíûå èñòîðèè: - ïåðèíäîïðèë, - êàïòîïðèë, - ïàíàíãèí, ðèáîêñèí, - ìåòîïðîëîë, - àìèîäàðîí, - ìåêñèäîë, òðèìåòàçèäèí. Êîãäà ÷óøü òèïà ðèáîêñèí-ìåêñèäîë òî âðîäå ïðîñòî è ïîíÿòíî, íî è òî ïîáåäèòü íå î÷åíü ðåàëüíî, ïî÷åìó-òî... À êîãäà íå ÷åðíî/áåëûé, à ðàçíîöâåòíûé, òî êàê íå çàïóòàòüñÿ? Âîò òóò îíè è íàõîäÿòñÿ - àíòèàðèòìèêè. Âîëíà ïîõîðîí I êëàññà VW çàáûëàñü è îíè âîñêðåñàþò. Ïðîïàôåíîí óæå íèêîìó íå ñòðàøåí. III êëàññ VW âñåãäà áûë ïîãîíåé çà àìèîäàðîíîì, íî âñåãäà íåóäà÷íîé (áðåòèëèé, ñîòàëîë, íèáåíòàí, äðîíåäàðîí). È ñîòàëîë ïðåêðàñíî óäåðæèâàåò ñèíóñîâûé ðèòì... Íåò â ìîåé ïðàêòèêå ïðîïàôåíîíà ïðè ÈÁÑ è âîîáùå íåò è íå áóäåò ñîòàëîëà. È àìèîäàðîí ïðè ÔÏ äëÿ óäåðæàíèÿ ðèòìà íóæíî èñêîðåíÿòü.
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#11
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Ïðî æåëóäî÷êîâûå àðèòìèè âîçðàæåíèé íåò, ïðîñòî ìíå ïîêàçàëîñü, ÷òî Âû âîîáøå åãî êàê ëåêàðñòâî çàïðåòèòü õîòèòå (êàê ëèïîáàé èëè ðîôåêîêñèá)
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#12
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Áûëà áû ìîÿ âîëÿ, íàâåðíîå, çàïðåòèë.
Ïðèâåäåííûå ïðèìåðû çàïðåùåíèé ïðè äåòàëüíîì ðàññìîòðåíèè ìîæåò íàíåñëè è ìåíüøåå çëî, ÷åì ñîòàëîë.
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |
#13
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Çðÿ Âû òàê: ëþáîå äàæå ñàìîå çëîâðåäíîå ëåêàðñòâî, ìîæåò îêàçàòüñÿ æèçíåííî íåîáõîäèìûì äëÿ óçêîãî êðóãà êàðäèî-ïàöèåíòîâ ñî ñïåöèôè÷åñêèìè ïðîáëåìàìè, êàê ïðèìåð - ïóáëèêàöèÿ î äâóõ ïð-òàõ, êîòîðûå ïåðåñòàëè âûïóñêàòü èç-çà èõ íåïîïóëÿðíîñòè.
J Cardiovasc Med (Hagerstown). 2010 Feb;11(2):143-4. 'Orphan drugs' in cardiology: nadolol and quinidine. Inama G, Durin O, Pedrinazzi C, Berisso MZ, Furlanello F. The recent withdrawal from the market of nadolol (Corgard; Bristol-Myers Squibb, Sermoneta, Italy) and quinidine polygalacturonate (Ritmocor; Malesci, Bagno A Ripoli, Italy) has been causing clinical problems to many cardiologists and patients, frequently leading to discontinuance of an effective and well-tolerated pharmacological treatment. Nadolol is useful in the treatment of severe and refractory arrhythmias, particularly in some genetically determined ion-channel diseases, such as long-QT syndrome and catecholaminergic polymorphic ventricular tachycardia.Quinidine is still used in refractory atrial fibrillation recurrences. Recent studies have demonstrated the clinical efficacy of quinidine in the treatment of rare genetically determined ion-channel diseases at high risk of sudden death, such as Brugada syndrome and short-QT syndrome. We hope that scientific societies can influence healthcare and pharmaceutical institutions, in order to restore the availability of two cardiovascular drugs that are extremely important in the care of arrhythmic patients. Íà ñâîåé ïàìÿòè â Øâåéöàðèè çàñòàë ïðåêðàùåíèå âûïóñêà òðàíåêñàìà êîìïàíèåé Ñàíîôè òîæå ïî ïðè÷èíå ïëîõîé ïðîäàâàåìîñòè, à îíè òîãäà áûëè åäèíñòâåííûìè, êòî ïðîèçâîäèë åãî â Åâðîïå.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#14
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Åùå êàê ïðèìåð îò ìåñòíûõ äîêòîðîâ, êîãäà ïðèõîäèòñÿ ïðèáåãàòü ê âîò òàêîé íåîáû÷íîé êîìáèíàöèè ó äåòåé, êîãäà àáëàöèþ òåõíè÷åñêè òðóäíîâûïîëíèìà è ÷ðåâàòà îñëîæíåíèÿìè:
Ten patients (median age: 29 days, range: 1 to 241 days) failed at least two antiarrhythmic agents including either flecainide or sotalol as single agents before initiating combination therapy. Efficacy was achieved in all patients. The failure rate for therapy was reduced from 100% to 0% (95% confidence interval: 0% to 26%). The median doses used were: flecainide 100 mg/m(2)/day (range: 40 to 150 mg/m(2)/day) and sotalol 175 mg/m(2)/day (range: 100 to 250 mg/m(2)/day). Median duration of therapy was 16 months (range: 5 to 35 months). No proarrhythmia occurred. The combination of flecainide and sotalol can safely and effectively control refractory SVT and may obviate the need for RFA in children <1 year. --- J Am Coll Cardiol. 2002 Feb 6;39(3):517-20. Flecainide and sotalol: a new combination therapy for refractory supraventricular tachycardia in children <1 year of age. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#15
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Âàäèì Âàëåðüåâè÷, ïðèçíàþ, êîíå÷íî Âû ïðàâû. Ïðîñòî óæ î÷åíü õî÷åòñÿ ðåçêî ñóçèòü øèðîòó åãî íàçíà÷åíèÿ îò ïîãîëîâíîãî äî òùàòåëüíî ðàçóìíî âçâåøåííîãî.
ß åãî, ïðàâäà, íèêîìó âîîáùå íå íàçíà÷àþ, ñîâñåì. Íå áûëî åùå íè îäíîãî ñëó÷àÿ, êîãäà îí ìíå ïîíàäîáèëñÿ. Ïðàâäà ÿ ôèëîñîôñêè îòíîøóñü ê óäåðæàíèþ ñèíóñîâîãî ðèòìà ïðè ÔÏ. Ïî ìíå òàê Ð×À è ÷àñòîå êóïèðîâàíèå èëè îñòàâëåíèå õðîíè÷åñêîé ôîðìû ïðåäïî÷òèòåëüíåå, ÷åì äëèòåëüíûé ïðèåì ÿäîâ/àíòèàðèòìèêîâ. Èíà÷å ëå÷åíèå íàäæåëóäî÷êîâîé àðèòìèè ïåðåõîäèò â ëå÷åíèå (èëè êîíñòàòàöèþ ) æåëóäî÷êîâîé.  ïîãîíå çà îäíèì íåëüçÿ çàáûâàòü îáî âñåõ îñòàëüíûõ àñïåêòàõ. È îñîáåííî î ãëàâíîì - î æèçíè è ñìåðòè. Êðîìå ñîòàëîëà ó ìåíÿ åñòü è îò÷åòëèâûé âòîðîé âðàã: ïðîïàôåíîí ïðè ÈÁÑ. ß î÷åíü ëþáëþ ïðîïàôåíîí, íî åãî íåëüçÿ êàòåãîðè÷åñêè ïðè ÈÁÑ. À ýòî ñåé÷àñ íà ðîñòå åãî ïîïóëÿðíîñòè ñïëîøü è ðÿäîì...
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Àëåêñàíäð Èâàíîâè÷ ñ ïîæåëàíèÿìè êðåïêîãî çäîðîâüÿ |