eMedicine Specialties > Cardiology > Arrhythmias
Lown-Ganong-Levine Syndrome: Treatment & Medication
Updated: Sep 4, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Because LGL is an outdated diagnosis, no specific therapy is indicated. In the acute setting of tachycardia, the goals of medical care include identifying the cause of tachycardia and, in symptomatic cases, controlling the ventricular rate. Treatment should be based on the cause of tachycardia. As with any tachycardia, hospitalization is warranted in cases of hemodynamic instability.In the outpatient setting, empiric therapies for recurrent PSVT may be instituted. These therapies may include beta-blockers, calcium channel blockers, and digoxin. A full discussion of these therapies lies outside the scope of this article (see Paroxysmal Supraventricular Tachycardia).
Surgical Care
Rare patients for whom the criteria of LGL are met may have no inducibility of tachyarrhythmias by EP study. Rarely, medical therapy fails in these patients, who continue to have recurrent, intolerable symptoms. In such extreme cases, pacemaker implantation, followed by
radiofrequency (RF) ablation of the AV node or bundle of His may be considered.
Consultations
An immediate cardiology consultation is warranted if the patient has presyncope, syncope, hypotension with tachycardia, angina, or other evidence of instability at the time of evaluation.- Conditions appropriate for consideration of RF catheter ablation and referral to an electrophysiologist include the following:
- Failure of pharmacologic therapy to control symptoms
- Recurrence of any signs of hemodynamic instability or of intolerable symptoms under medical management
- Patient's desire to avoid daily medication
- Intolerable adverse effects of medication
Diet
No dietary restrictions are required.
Activity
Patients who have experienced an episode of syncope should be counseled to not drive or operate vehicles of public transport for 6 months from the time of the most recent episode of syncope, or until the cause of syncope has been identified and adequately treated.
Medication
No medication therapy is specific to LGL. The goals of therapy are to identify the cause of tachycardia and to treat this cause appropriately.
Beta-blockers
Inhibit chronotropic, inotropic, and vasodilatory responses to beta-adrenergic stimulation and slow AV nodal conduction.
Metoprolol (Lopressor, Toprol XL)
Selective beta1-adrenergic receptor blocker that decreases automaticity of contractions. During IV administration, carefully monitor BP, heart rate, and ECG.
Adult
50 mg/d PO qd or divided bid/tid initially and increase at 1-wk intervals prn to total of 200 mg/d if necessary
Pediatric
1-5 mg/kg/24h PO divided bid
Aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease bioavailability and plasma levels of metoprolol, possibly resulting in decreased pharmacologic effects
Sparfloxacin, phenothiazines, astemizole, calcium channel blockers, quinidine, flecainide, and contraceptives may increase toxicity
May increase toxicity of digoxin, flecainide, clonidine, epinephrine, nifedipine, prazosin, verapamil, and lidocaine
Documented hypersensitivity; uncompensated CHF; bradycardia; asthma; cardiogenic shock; AV conduction abnormalities
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Beta-adrenergic blockade may reduce signs and symptoms of acute hypoglycemia and may decrease clinical signs of hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm; monitor patient closely and withdraw the drug slowly; during IV administration, carefully monitor blood pressure, heart rate, and ECG
Atenolol (Tenormin)
Selectively blocks beta1-receptors with little or no effect on beta2 types.
Adult
50 mg PO qd; increase to 100 mg/d if necessary
Pediatric
1-2 mg/kg/dose PO qd
Aluminum salts, barbiturates, calcium salts, cholestyramine, NSAIDs, penicillins, and rifampin may decrease effects; haloperidol, hydralazine, loop diuretics, and MAOIs may increase toxicity
Documented hypersensitivity; CHF; pulmonary edema; cardiogenic shock; AV conduction abnormalities; heart block (without pacemaker)
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Beta-adrenergic blockade may reduce symptoms of acute hypoglycemia and mask signs of hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism and cause thyroid storm; monitor patients closely and withdraw drug slowly; during IV, carefully monitor BP, heart rate, and ECG
Calcium channel blockers (nondihydropyridine)
In specialized conducting and automatic cells in the heart, calcium is involved in the generation of the action potential. Calcium channel blockers inhibit movement of calcium ions across the cell membrane, depressing both impulse formation (automaticity) and conduction velocity.
Verapamil (Calan, Covera, Isoptin)
Can diminish PVCs associated with perfusion therapy and decrease risk of ventricular fibrillation and ventricular tachycardia. By interrupting reentry at AV node, can restore normal sinus rhythm in patients with PSVT.
Adult
80-120 mg PO tid or 120-360 mg SR formulation; alternatively, 5-10 mg IV followed by second dose 15-30 min later if PSVT does not respond satisfactorily to initial dose
Pediatric
Not established
May increase carbamazepine, digoxin, and cyclosporine levels; amiodarone can cause bradycardia and decrease in cardiac output; beta-blockers may increase cardiac depression; cimetidine may increase levels; may increase theophylline levels
Documented hypersensitivity; severe CHF; sick sinus syndrome; second- or third-degree AV block; hypotension (<90 mm Hg systolic)
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Hepatocellular injury may occur; transient elevations of transaminases with and without concomitant elevations in alkaline phosphatase and bilirubin have occurred (elevations have been transient and may disappear with continued treatment); monitor liver functions periodically
Diltiazem (Cardizem)
During depolarization, inhibits calcium ions from entering slow channels and voltage-sensitive areas of vascular smooth muscle and myocardium.
Adult
30-90 mg PO tid, or 120-300 mg PO qd of CD formulation
Pediatric
Not established
May increase carbamazepine, digoxin, cyclosporine, and theophylline levels; amiodarone may cause bradycardia and decrease in cardiac output; beta-blockers may increase cardiac depression; cimetidine may increase levels
Documented hypersensitivity; severe CHF; sick sinus syndrome; second- or third-degree AV block; hypotension (<90 mm Hg systolic)
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in impaired renal or hepatic function; may increase LFT levels, and hepatic injury may occur
Cardiac glycosides
Decrease AV nodal conduction, primarily by increasing vagal tone.
Digoxin (Lanoxin)
Cardiac glycoside with direct inotropic effects in addition to indirect effects on cardiovascular system. Acts directly on cardiac muscle, increasing myocardial systolic contractions. Indirect actions result in increased carotid sinus nerve activity and enhanced sympathetic withdrawal for any given increase in mean arterial pressure.
Adult
0.125-0.375 mg PO qd
Pediatric
<5 years: Not established
5-10 years: 20-35 mcg/kg loading dose PO
>10 years: 10-15 mcg/kg loading dose PO
Maintenance dose: 25-35% of PO loading dose administered qd
Alprazolam, benzodiazepines, bepridil, captopril, cyclosporine, propafenone, propantheline, quinidine, diltiazem, aminoglycosides, oral amiodarone, anticholinergics, diphenoxylate, erythromycin, felodipine, flecainide, hydroxychloroquine, itraconazole, nifedipine, omeprazole, quinine, ibuprofen, indomethacin, esmolol, tetracycline, tolbutamide, and verapamil may increase levels
Aminoglutethimide, antihistamines, cholestyramine, neomycin, penicillamine, aminoglycosides, oral colestipol, hydantoins, hypoglycemic agents, antineoplastic treatment combinations (including carmustine, bleomycin, methotrexate, cytarabine, doxorubicin, cyclophosphamide, vincristine, procarbazine), aluminum or magnesium antacids, rifampin, sucralfate, sulfasalazine, barbiturates, kaolin/pectin, and aminosalicylic acid may decrease levels
Documented hypersensitivity; beriberi heart disease; idiopathic hypertrophic subaortic stenosis; constrictive pericarditis; carotid sinus syndrome
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hypokalemia may reduce positive inotropic effect; IV calcium may produce arrhythmias in digitalized patients; hypercalcemia predisposes patient to digitalis toxicity, and hypocalcemia can make digoxin ineffective until serum calcium levels are normal; magnesium replacement therapy must be instituted in patients with hypomagnesemia to prevent digitalis toxicity; patients with incomplete AV block may progress to complete block when treated with digoxin; use caution in hypothyroidism, hypoxia, and acute myocarditis
More on Lown-Ganong-Levine Syndrome |
| Overview: Lown-Ganong-Levine Syndrome |
| Differential Diagnoses & Workup: Lown-Ganong-Levine Syndrome |
 Treatment & Medication: Lown-Ganong-Levine Syndrome |
| Follow-up: Lown-Ganong-Levine Syndrome |
| Multimedia: Lown-Ganong-Levine Syndrome |
| References |
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References
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Further Reading
Keywords
Lown-Gangong-Levine syndrome, LGL syndrome, Clerc-Levy-Critesco syndrome, enhanced atrioventricular nodal conduction, accelerated atrioventricular nodal conduction, short PR/normal QRS syndrome, short PR/narrow QRS syndrome, accessory pathway, WPW syndrome, Wolff-Parkinson-White syndrome
