From the Guidelines
Sotalol is not recommended as a first-line treatment for heart failure with mid-range ejection fraction (HFmrEF) due to its potential to worsen heart failure symptoms and prolong QT interval, as evidenced by the 2020 ACC/AHA clinical performance and quality measures for adults with heart failure 1. When considering the use of sotalol in patients with HFmrEF, it is essential to weigh the potential benefits against the risks. The 2020 ACC/AHA guidelines recommend the use of beta blockers proven to reduce mortality, such as bisoprolol, carvedilol, and sustained-release metoprolol succinate, for all patients with current or prior symptoms of heart failure with reduced ejection fraction (HFrEF), unless contraindicated 1. Some key points to consider when using sotalol in HFmrEF patients include:
- Initiating therapy at a low dose and titrating gradually while monitoring for signs of worsening heart failure
- Closely monitoring QT interval and electrolyte levels to minimize the risk of torsades de pointes
- Considering alternative treatments, such as those recommended by the 2020 ACC/AHA guidelines, which have a more established safety and efficacy profile in HFmrEF patients 1. It is crucial to prioritize the patient's safety and well-being, and the use of sotalol in HFmrEF should be approached with caution and only considered when the potential benefits outweigh the risks, as supported by the highest quality evidence available 1.
From the Research
Sotalol Contraindication in Heart Failure with Mid-Range EF
- The use of sotalol in patients with heart failure, including those with mid-range ejection fraction (HFmrEF), is a topic of ongoing debate 2, 3.
- According to the American College of Cardiology and American Heart Association, the use of sotalol in patients with left ventricular dysfunction is not recommended due to inconclusive and conflicting results regarding safety 2.
- However, some studies suggest that patients with HFmrEF may benefit from medications that target the neurohormonal axes, similar to those with heart failure and reduced ejection fraction (HFrEF) 3.
- The risk of ventricular tachycardia (VT) and sudden cardiac arrest (SCA) is increased in patients with HFmrEF prescribed dofetilide or sotalol, although the overall SCA risk was not associated with an increased risk in these patients 4.
- A small-scale study found that d-sotalol was moderately effective as an antiarrhythmic agent in patients with ventricular tachycardia and a low ejection fraction, with no signs of worsening of congestive heart failure or proarrhythmogenic activity 5.
Clinical Implications
- The current evidence suggests that sotalol may not be contraindicated in heart failure with mid-range EF, but its use should be approached with caution and careful consideration of the individual patient's risk factors and clinical status 2, 3, 4.
- Further studies are needed to fully understand the safety and efficacy of sotalol in patients with HFmrEF 2, 3.
- The use of sotalol in these patients should be guided by the latest clinical guidelines and evidence-based recommendations 6, 3.