Enhanced efficacy with MgSO4 due to an additive, alternative, or dual mode of action?

Abstract

Pharmacological conversion of atrial fibrillation–atrial flutter (AF–AFl) is still an important therapeutic modality in daily patient care. Frequently used drugs are the class III anti-arrhythmics dofetilide, sotalol, and ibutilide. By blocking (specific) potassium currents, they will prolong the duration of the action potential (APD) providing less space for re-entry to manoeuvre. Their effectiveness is still not optimal and is also hampered by their pro-arrhythmic risk due to dose-dependent lengthening of the (ventricular) repolarization times. Their use is therefore restricted, including hospitalizations when therapy is started, as was the case in this single site (Hartford Hospital) retrospective investigation (2000–08) about the effectiveness of dofetilide to acutely convert AF–AFl.1 To protect their patients for dofetilide-induced torsade de pointes (TdP) arrhythmias, some ( n = 50) from the 160 eligible patients with AF–AFl received adjunctive magnesium sulfate (Mg). The evaluation demonstrated that a single or repeated bolus of Mg (mean ± 3 g MgSO4) did not only protect for drug-induced adverse effects (0/50 vs. 1/110 TdP occurrences), but also improved the efficacy of dofetilide to suppress/prevent AF–AFl: 38% without vs. 50% with Mg, P < 0.05. This important improvement with this combination (doubling of the odds), which was recently also shown for ibutilide and Mg by … *Corresponding author. Tel: +31 30 2538900, Fax: +31 30 2539036, Email: m.a.vos{at}umcutrecht.nl