The PROCAMIO Trial: Intravenous Procainamide vs. Amiodarone for Tolerated Wide QRS Tachycardia

The PROCAMIO study is a multicentre, randomized, open-labelled trial comparing the safety and efficacy of intravenous (IV) procainamide and IV amiodarone in the acute treatment of haemodynamically stable, sustained monomorphic wide QRS complex tachycardia (presumed to be ventricular tachycardia).

The trial provides high-level evidence that procainamide is significantly safer and more effective than amiodarone in this clinical context. Patients treated with procainamide experienced a significantly lower incidence of major cardiac adverse events (9% vs. 41%) and a significantly higher rate of tachycardia termination (67% vs. 38%) within the 40-minute study period. These findings remained consistent even among the high-risk subgroup of patients with known structural heart disease.--------

Episode Summary: In this Lit Hit, we break down the PROCAMIO trial and highlight the key evidence emergency clinicians need for rapid, informed decision-making when treating stable wide QRS tachycardia. This short episode delivers high-yield takeaways you can apply on your next shift.

• Safety Superiority: Procainamide is associated with a significantly lower risk of major cardiac adverse events—specifically severe hypotension requiring electrical cardioversion—compared to amiodarone.
• Efficacy Advantage: Procainamide is more likely to successfully terminate stable wide QRS tachycardia within 40 minutes than amiodarone.
• Structural Heart Disease: The safety benefits of procainamide extend to patients with structural heart disease, a group often considered high-risk for antiarrhythmic complications.
• Dosing Protocols: Understand the specific regimens used: Procainamide (10 mg/kg over 20 min) and Amiodarone (5 mg/kg over 20 min).
• Clinical Tip: While guidelines have historically listed both drugs with Class II recommendations, PROCAMIO suggests procainamide should be the preferred pharmacological choice for hemodynamically stable wide complex tachycardia. If pharmacological therapy fails or instability develops, immediate electrical cardioversion remains the definitive treatment.

Primary Reference: Ortiz M, Martín A, Arribas F, et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. European Heart Journal. 2017;38(17):1329-1335.