Sotalol (hydrochloride (Betapace -Berlex; Sotacor -Bristol Laboratories of Canada), an antiarrhythmic drug that prolongs repolarization (Class III) and also has beta-adrenergic-blocking activity (Class II), was recently approved by the US Food and Drug Administration (FDA) for oral treatment of life-threatening ventricular arrhythmias.

Flecainide (Tambocor -3M Pharmaceuticals), first introduced in 1985 for treatment of ventricular arrhythmias, was recently approved by the US Food and Drug Administration for oral use to prevent supraventricular arrhythmias. The indications for using flecainide to treat ventricular arrhythmias were limited after a controlled trial found that post-myocardial infarction patients with asymptomatic ventricular arrhythmias who took the drug had twice as high a mortality rate as patients who took placebo (DS Echt et al, N Engl Med, 324:781, 1991).

Midodrine hydrochloride (ProAmatine - Roberts), an alpha1-selective adrenergic agonist, is now available for treatment of severe symptomatic orthostatic hypotension. Other treatments for this condition include other sympathomimetics, constrictive garments, erythropoietin (Epogen; Procrit) and fludrocortisone with salt (D Robertson and TL Davis, Neurology, 45 suppl 5: S26, 1995).

Trospium chloride (Sanctura - Indevus/Odyssey) has been approved by the FDA for treatment of overactive bladder with symptoms of urge urinary incontinence, urgency and urinary frequency. It has been available in Europe for many years.

Older patients are especially susceptible to drug-induced cognitive impairment. They are more likely to be taking multiple drugs, to have higher blood levels of those drugs because of renal or hepatic dysfunction, and to have pre-existing cognitive problems that make it difficult to detect the role of drugs causing new symptoms or making old ones worse.

Vardenafil (Levitra -Bayer) is the second oral drug approved by the FDA for treatment of erectile dysfunction. Sildenafil (Viagra - Medical Letter 1998; 40:51), the first oral drug, has been available for 5 years. Pharmacokinetics, effectiveness, adverse effects, dosage and cost of the new drug are reviewed. Whether it offers any benefits over sildenafil is discussed.

The drugs of choice for treatment of common cardiac arrhythmias are listed in Tables 1 and 2. Some drugs are recommended for indications that have not been approved by the FDA.

Ever-increasing specialization has made it difficult for many physicians to keep up with therapeutic standards in intensive-care units (ICUs). This issue of Treatment Guidelines offers current recommendations for use of cardiovascular drugs in the ICU for treatment of hypertensive emergencies; shock, cardiac arrest or decompensated heart failure; and ventricular arrhythmias.