Mortality reduction by antiadrenergic modulation of arrhythmogenic substrate: significance of combining beta blockers and amiodarone

Over the last 3 decades, there have been numerous experimental and clinical studies that utilized β blockers for acute as well as chronic myocardial syndromes, especially in the setting of myocardial infarction in which the focus has been on mortality reduction. The results of these studies demonstrated the benefits of these agents at all stages of coronary artery disease. Although these data have always indicated that β blockade per se is an antiarrhythmic as well as an antifibrillatory mechanism, the recognition of this phenomenon has been slow in finding universal appreciation. More recent studies have evaluated the additive role of β blockers to newer therapies. A number of investigations have now established that this class of drugs does exert antifibrillatory action in preventing the occurrence of ventricular tachycardia (VT) and ventricular fibrillation (VF), thereby reducing sudden arrhythmic death and prolonging survival. It is of interest that 2 of the leading antiarrhythmic drugs, amiodarone and sotalol, also have antiadrenergic properties. This article reviews the expanding role of β-blocking drugs in the control and prevention of life-threatening ventricular tachyarrhythmias with a particular focus on the evidence for synergistic benefits when they are combined with other interventions, especially amiodarone.