Outpatient Initiation of Sotalol: Reappraising Risk, Monitoring, and Modern Care Pathways

Sotalol remains an important antiarrhythmic drug for rhythm control in atrial fibrillation and other supraventricular arrhythmias. However, sotalol is traditionally initiated in the inpatient setting because of concerns regarding QT prolongation and torsades de pointes. This practice is based on early observational data collected before the availability of contemporary risk stratification, standardized protocols, and modern rhythm monitoring technologies. Over the past two decades, evidence from observational studies using device-based monitoring, protocolized outpatient clinics, and remote electrocardiographic technologies has demonstrated low rates of malignant ventricular arrhythmias in carefully selected patients. These data also highlight the importance of longitudinal surveillance, as clinically relevant QT prolongation may occur beyond the conventional inpatient monitoring window. Thus, this review examines the pharmacologic basis of sotalol-related proarrhythmia, critically reassesses the rationale for inpatient initiation, synthesizes contemporary evidence supporting outpatient strategies in carefully selected patients with protocolized monitoring, and proposes a practical, risk-stratified framework for outpatient sotalol initiation while identifying key knowledge gaps that still require prospective validation.