Patient Selection and Protocol Description
Administration of IV sotalol began in August 2021 using the protocol described in the Supplementary Appendix. Adult patients with a creatinine clearance (CrCl) greater than 30 mL/min and a primary indication of atrial or ventricular arrhythmias were included. Patients with bradycardia less than 60 bpm or corrected QT (QTc) interval greater than 450 ms were excluded, except in select cases with the approval and oversight of an attending cardiac electrophysiologist. Those with a paced QRS or bundle branch block were permitted a QTc interval up to 500 ms. Patients had their baseline electrolytes drawn and repleted, and a baseline electrocardiogram (ECG) was obtained. If they presented in a sustained atrial arrhythmia, cardioversion to sinus rhythm was performed prior to infusion. IV sotalol was then infused over 60 minutes with one-to-one nursing, frequent vital signs, and continuous cardiac telemetry. If the heart rate dropped below 60 bpm, the QT interval was used instead of the QTc interval for decision making. ECGs were obtained every 15 minutes during infusion. The infusion was stopped if the patient developed bradycardia less than 50 bpm or had prolongation of the QT/QTc interval to greater than 500 ms (550 ms for those with paced QRS or bundle branch block). After completion of infusion, patients were admitted to the inpatient telemetry unit for the remaining two oral doses, with subsequent ECGs 2-4 hours after each oral dose.
Patients undergoing oral sotalol initiation for atrial and ventricular arrhythmias from January 2021 to June 2022 were included for comparison with IV sotalol. Inclusion and exclusion criteria were identical. Oral doses were given based on standard prescribing regimens using CrCl, with ECGs similarly performed 2-4 hours after each dose of sotalol. Patients were required to be monitored for five oral doses before discharge. Patients with sustained atrial arrhythmias were cardioverted after the fifth oral dose of sotalol and monitored for an additional day after cardioversion. Those who experienced bradycardia less than 50 bpm or QT/QTc prolongation greater than 500 ms (550 ms for those with paced QRS or bundle branch block) either had their oral sotalol dose reduced or discontinued.