Anti-arrhythmic drugs in arrhythmogenic right ventricular cardiomyopathy: The importance of optimal beta-blocker dose titration

In this issue of the International Journal of Cardiology, Cappelletto and colleagues summarize their experience with the use of anti-arrhythmic drugs (AADs) in the management of ventricular arrhythmias (VAs) for patients with Arrhythmogenic Right Ventricle Cardiomyopathy (ARVC) [ [1] ]. One-hundred and twenty-three patients (39 ± 16 years, 70% male, 75% probands) with a definite diagnosis of ARVC according to the 2010 International Task Force Criteria and with at least 2 clinical evaluations were extracted from the Trieste Heart Muscle Disease Registry, a long-running cardiomyopathy registry from a third level, high-volume referral center in Italy. The study cohort had a very long median follow-up time (132 months), during which 83 major VA events occurred in 37 (30%) patients. After the initial diagnosis, 13% of patients were started on at least one AAD at initial diagnosis, while 25%, 26%, and 24% were started on beta-blockers, sotalol, and amiodarone during follow-up, respectively. Multiple AADs were started in 27 patients and 19 patients received a beta-blocker dosage >50% of the full target dose. At a propensity score analysis, prolonged exposure to beta-blockers, sotalol and amiodarone did not seem to affect the rates of SCD/VA. However, patients in whom beta-blockers were titrated at >50% of target dose showed marked reduction in risk compared to those not taking beta-blockers (HR 0.10, 95% CI 0.02–0.46, p = 0.004). The authors conclude that adequately titrated beta-blockers represent the most promising pharmacological strategy to reduce arrhythmic burden and likelihood of major adverse events in ARVC.