RANEXA FOR VT

  -It might be reasonable to try Ranexa.
                -There are small studies that suggest that Ranexa can reduce the
                VT burden and ICD shocks in patients with AAD-refracotry VT.
                [Bunch, T et al.  "Ranolazine reduces ventricular tachycardia
                burden and ICD shocks in patients with drug refractory ICD
                shocks."  Pacing Clin Electrophysiol. 2011 Dec;34(12):1600-6]
                -Ranexa could have two main benefits:
                        (1) It has anti-ischemic effects
                        (2) It has anti-arrhythmic effects, most likely through
                            its IKr blockade as well as late INa currents, in
                            combination with other Class III AADs
                -It has been described a possible option for AAD-refractory
                ICD shocks secondary to VT
                -It is an off-label indication for the drug, and I have
                explained this to the patient.  He acknowledges this, and is
                willing to try it.
                -Of note, it is true that Ranexa can potentially prolong the QTc
                via blockade of IKr
                        -Per the MERLIN-TIMI 36 trial, lengthening of the QT
                        interval has been observed.  However, there was no
                        increased risk of proarrhythmia or SCD observed with
                        this.
                -If Ranexa is started, it might be more reasonable to start with
                500 mg po BID given his renal dysfunction