From the Guidelines
Sotalol is not a first-line medication in Advanced Cardiac Life Support (ACLS) protocols but serves as an alternative antiarrhythmic agent for specific situations, as indicated by the 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations 1.
Role of Sotalol in ACLS
It functions as a Class III antiarrhythmic with additional beta-blocking properties, making it useful for managing ventricular arrhythmias and atrial fibrillation, particularly when other agents have failed or are contraindicated.
- The typical dosing for sotalol in acute settings is 1-1.5 mg/kg IV over 5 minutes, with maintenance infusions of 75-150 mg every 12 hours based on patient response and QT interval monitoring.
- Sotalol requires careful consideration due to its potential to prolong the QT interval, which can lead to torsades de pointes, a life-threatening ventricular arrhythmia, as noted in the 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1.
Key Considerations
This risk increases in patients with electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, so electrolyte levels should be normalized before administration.
- Additionally, sotalol should be used cautiously in patients with renal impairment as it is primarily excreted by the kidneys, and dose adjustments are necessary for creatinine clearance below 60 mL/min.
- Continuous cardiac monitoring is essential during sotalol administration to detect QT prolongation or other adverse effects.
Recent Guidelines
The 2020 ESC guidelines for the management of patients with supraventricular tachycardia suggest sotalol as a first-line therapy for SVT in ACHD patients, but this is not directly applicable to the ACLS setting 1.
- The 2010 ESC guidelines for the management of atrial fibrillation provide further context on the use of sotalol in managing atrial fibrillation, highlighting its efficacy and potential risks 1.
From the Research
Role of Sotalol in ACLS
- Sotalol is a nonselective beta-adrenoceptor antagonist with class III antiarrhythmic properties, which prolongs cardiac repolarisation independently of its antiadrenergic action 2.
- It is effective in controlling paroxysmal supraventricular tachycardias and the ventricular response to atrial fibrillation/flutter in Wolff-Parkinson-White syndrome, in maintaining sinus rhythm after cardioversion of atrial fibrillation/flutter, and in preventing initiation of supraventricular tachyarrhythmias following coronary artery bypass surgery 2.
- Sotalol shows promise in the control of nonmalignant and life-threatening ventricular arrhythmias, particularly those associated with ischaemic heart disease, and is effective in suppressing complex forms of ventricular ectopy 2.
- The drug has been shown to be safe and effective in maintaining sinus rhythm in patients with symptomatic atrial fibrillation and/or flutter, with a dose of 120 mg twice daily appearing to provide the most favorable benefit and/or risk 3.
- Sotalol's usefulness in treatment of atrial fibrillation and atrial flutter has been evaluated, and it has been found to be effective in preventing recurrences of paroxysmal atrial fibrillation or atrial flutter and controlling ventricular rate (in chronic atrial fibrillation or relapse of paroxysmal atrial arrhythmias) 4.
- A study on the population pharmacokinetics and pharmacodynamics of sotalol following expedited intravenous loading in patients with atrial arrhythmias found that sotalol PK after IV loading and two oral maintenance doses was adequately described by a two-compartment model with first-order elimination in patients with atrial arrhythmias 5.
- The study also found that weight and creatinine clearance (CrCl) were identified as covariates with significant influence on sotalol PK, and a linear regression model adequately described the relationship between QTc and plasma sotalol levels 5.
Mechanism of Action
- Sotalol's antiarrhythmic action appears to arise predominantly from its class III properties, which lead to increases in action potential duration and refractory period throughout the heart and in QT interval on the surface electrocardiogram 6.
- The drug's nonselective beta-blocking action also contributes to its antiarrhythmic effects, and its better hemodynamic tolerance than other beta-blockers may be a result of enhanced inotropy associated with class III activity 6.
Clinical Use
- Sotalol is used to prevent recurrence of atrial fibrillation and/or atrial flutter, and to control ventricular rate in patients with chronic atrial fibrillation or relapse of paroxysmal atrial arrhythmias 4.
- The drug is also used to maintain sinus rhythm in patients with symptomatic atrial fibrillation and/or flutter, and to prevent initiation of supraventricular tachyarrhythmias following coronary artery bypass surgery 2, 3.
- Sotalol has been found to be effective in suppressing complex forms of ventricular ectopy, and in preventing recurrences of paroxysmal atrial fibrillation or atrial flutter 2, 4.