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HWN Suggests

Amiodarone vs Procainamide for Stable VT

Procainamide is a Class Ia antiarrhythmic agent. It is an older drug that tends to be less well-known. I suspect it is only the popularity of amiodarone that has stunted procainamide’s use as a first-line agent in the minds of many emergency physicians and/or cardiologists. It is usually administered one of two different ways – 17 mg/kg given at a max rate of 50 mg/min, or 100 mg over 2 minutes every 5 minutes until conversion. For now, it sits a little uncomfortably in the driver’s seat with a Class IIa recommendation from the AHA.

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 Procainamide More Effective and Safer for VT

IV procainamide is the only agent that carries a class IIA indication for the pharmacologic conversion of VT, and it is listed ahead of IV amiodarone (class IIB) in the ACLS guidelines. Frequently, IV procainamide is used for terminating VT, followed by IV amiodarone for preventing recurrence.

Articles of Interest

Podcast #164: Procainamide

Procainamide was also shown to be more successful at cardioversion than amiodarone or lidocaine. This suggest Procainamide should be our first line stable V-Tach medication.

Procainamide Dosing

ACLS recommendation for procainamide in tachycardic rhythms is: Loading dose 20 mg/minute (up to 50 mg/minute for more urgent situations) until: Arrhythmia is controlled

Procainamide for atrial fibrillation/flutter conversion

Overall, procainamide, especially in the setting of AF, seems to have ~50% success rate. Patients who convert with procainamide spend less time in the ER (4 hours vs 7 hours) and avoid the need for procedural sedation.

Quick, No-Shock Cardioversion for Afib Feasible in EDs

By administering the class IA antiarrhythmic over just 30 minutes and using a weight-based dosing (15 mg/kg), site investigators reported that procainamide infusion alone converted 52% of patients in a median 23 minutes without need for sedation or electrical cardioversion -- a potential advantage of a drug-first strategy.

The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia

Although this is a small clinical study, it is a well done randomized controlled trial that shows procainamide is associated with less major cardiac adverse events, more efficacious in terminating tachycardia, and more importantly more efficacious in both endpoints in a subgroup of patients with structural heart disease. Procainamide should be first line chemical therapy in patients with stable ventricular tachycardia.

Resources

StatPearls

Procainamide is a medication used to manage and treat ventricular arrhythmias, supraventricular arrhythmias, atrial flutter/fibrillation, and Wolf-Parkinson-White syndrome. It is in the antiarrhythmic Agent Class 1A class of medications.

WikEM

Drug of Choice for stable wide complex tachycardia (Class IIa recommendation): 100 mg IV x 2 min q5min as needed to max dose 17 mg/kg.