Migotanie przedsionków i choroba wieńcowa – czy możemy bezpiecznie sięgnąć po sotalol?

Luty 13, 2015  |  Udostępnij  | 

Sotalol jest jednym z leków częściej zalecanych pacjentom z napadowym migotaniem przedsionków (FA) w celu zwiększenia szans na utrzymanie rytmu zatokowego. Powszechnie przyjmuje się, że jest on dobrą alternatywą dla chorych z towarzyszącą chorobą niedokrwienną serca, którzy z jej powodu nie powinni przewlekle przyjmować propafenonu. Bezpieczeństwo sotalolu u chorych z CHD nie zostało jednak dotychczas dostatecznie potwierdzone naukowo. Co więcej niektóre metaanalizy wykazywały, iż stosowanie tego leku nieznacznie (w sposób nieistotny statystycznie) zwiększa ryzyko zgonu z powodu arytmii. Nowe światło na to zagadnienie rzucił niedawno opublikowany artykuł[1] Piccniego i współpracowników.
shutterstock_115054471

Źródłem informacji dla wspomnianego zespołu badawczego była baza danych jednostek medycznych Duke University, zawierająca dane ponad 100 tys. osób. Do badania włączono wszystkich pacjentów leczonych po napadzie FA od lipca 1993 roku do końca 2007 roku, którzy mieli zdiagnozowaną także chorobę wieńcową (potwierdzone koronarograficznie zwężenie przynajmniej 1 tętnicy wieńcowej ≥50%). Wyłączono natomiast chorych z implantowanym kardiowerterem-defibrylatorem, istotnymi wadami zastawkowymi oraz wrodzonymi wadami serca. Ponadto do analizy włączono jedynie chorych leczonych sotalolem lub amiodaronem – pacjentów przyjmujących oba preparaty jednocześnie lub leczonych dodatkowo innym lekiem antyarytmicznym odrzucano. Przyjętym punktem końcowym była śmierć niezależnie od przyczyny. Łącznie przeanalizowano dostępne dane medyczne ponad 2,8 tys. pacjentów z napadowym migotaniem przedsionków i towarzyszącą chorobą wieńcową. Przeciętny czas obserwacji wyniósł ponad 4 lata. Chorych podzielono na trzy grupy – leczonych sotalolem (n=226), leczonych amiodaronem (n=856) oraz osoby nie leczone antyarytmicznie (n=1756). Biorąc pod uwagę dane demograficzne oraz parametry medyczne pomiędzy grupami występowało kilka istotnych różnic. Chorzy leczeni sotalolem statystycznie rzadziej mieli istotną dysfunkcję skurczową lewej komory (EF<40%) w porównaniu z „grupą amiodaronu” oraz grupą osób nie leczonych antyarytmicznie (13% vs. odpowiednio 26% i 21%). Także pod względem odsetka pacjentów po przebytym zawale serca „grupa sotalolu” prezentowała się lepiej (35% vs 51% vs 48%). Co szczególnie istotne, większość osób leczonych antyarytmicznie przyjmowała leki przez nie więcej niż 25% czasu obserwacji (dla sotalolu odsetek takich chorych wyniósł 97%). Sugeruje to jednoznacznie niską tolerancję stosowanej farmakoterapii. Jednocześnie wśród osób nieleczonych antyarytmicznie na początku okresu obserwacji, ponad 50% przyjmowało następnie leki antyarytmiczne. Analizując wyniki, z uwzględnieniem różnic w wyjściowych charakterystykach pacjentów, najlepszą przeżywalność pacjentów odnotowano w grupie osób leczonych sotalolem (śmiertelność roczna ~10%), gorszą u osób nieleczonych antyarytmicznie (~14%), a najgorszą wśród osób przyjmujących amiodaton (~20%). Te korzystne dla sotalolu rezultaty uległy jednak istotnej zmianie, gdy pod uwagę wzięto rzeczywisty czas trwania terapii. Po włączeniu tej zmiennej do obliczeń okazało się, że co prawda leczenie sotalolem poprawia rokowanie, w porównaniu z leczeniem amiodaronem (HR=0,72), ale już w porównaniu z brakiem leczenia antyarytmicznego zwiększa względne ryzyko zgonu (HR=1,53)

Podsumowując, wydaje się, że terapia sotalolem, chociaż bezpieczniejsza od leczenia amiodaronem, może nasilać ryzyko zgonu w porównaniu z brakiem leczenia w grupie pacjentów z FA i chorobą wieńcową. Warto więc krytycznie podejść do stosowania tego leku, zwłaszcza jeśli u danego chorego nie daje on całkowitego uwolnienia od napadów arytmii.

1. Piccini JP et al., Comparison of Safety of Sotalol Versus Amiodarone in Patients With Atrial Fibrillation and Coronary Artery Disease. Am J Cardiol 2014 Sep 1;114(5):716-22


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