Anti-Arrhythmic Drugs By Shano T.

Generalizations: - QT interval: Class 1a, Class 3 but only Amiodarone NO torsade de point -class 2 and 4: SA and AV nodes -class 1 and 3: muscles of ventricles and atria Classifications Class 1A: Na+ Channel Blockers (Disopyramide, Procainamide, Quinidine) [Intermediate] -Graph: slow rate of change of phase 0; prolong phase 3 by inhibit K+ channel a) Disopyramide -Treats: supraventricular/ventricular arrhythmia b) Procainamide -Treats: supraventricular/ventricular arrhythmia c) Quinidine -Treats: suppress supraventricular/ventricular arrhythmia; convert/prevent relapse into atrial fibrillation and/or flutter Class 1B: Na+ Channel Blockers (Lidocaine, Mexiletine, Tocainide, Phenytoin) [Fastest thus shortest] -Graph: slow phase 0, decreased slope of phase 4; shortened phase 3 repol via Na+ channel -Treats ventricular arrhythmias a) Lidocaine -Treats: DOC for terminating ventricular tachycardia and prevent ventricular fibrillation after cardioversion in setting of acute ischemia (ie: MI) b) Mexiletine -Treats: management of severe ventricular arrhythmia c) Tocainide d) Phenytoin -Treats: ventricular arrhythmias Class 1C: Na+ Channel Blockers (Flecainide, Propafenone) [Slowest thus longest] -Graph: normal AP duration; greatest depression of phase 0 -Treat: supraventricular and ventricular arrhythmia BUT note its likely to cause arrhythmia a) Flecainide -Treats: severe symptomatic ventricular arrhythmias (life threatening only), severe symptomatic Supraventricular arrhythmias, prevent paroxysmal atrial fibrillation b) Propafenone -Treats: life threatening supraventricular/ventricular arrhythmia; to maintain normal sinus rhythm in pt w/ symptomatic atrial fibrillation Class 2: Blocker (Esmolol, Metoprolol, Propanolol) -Graph: decreased phase 4 slope, prolonged repolarisation -Treats: major: control supraventricular tachycardia (atrial fibrillation & flutter, AV nodal reentrant tachycardias); minor: ventricular tachycardia d/t catech-induced arrhythmias or dixogin toxicity); reduce incidence of sudden arrhythmic death after MI a) Esmolol: -Treats: acute arrhythmias during surgery or in emergency situations b) Metoprolol c) Propanolol

Class 3: K+ Channel Blocker (Amiodarone, Dofetilide, Sotalol) -Graph: prolonged AP due to increased PR interval and QT interval thus longer refractory -Treat: supraventricular and ventricular arrhythmias a) Amiodarone -Treats: commonest to manage supraventricular/ventricular arrhythmias; low dose for maintain normal sinus rhythm in pt w/ atrial fibrillation b) Dofetilide -Treats: maintain normal sinus rhythm in chronic atrial fibril/flutter for >1 wk who have Been converted to normal sinus rhythm; conversion of atrial fibrillation/flutter to normal sinus rhythm c) Sotalol -Treats: life threatening ventricle arrhythmias; maintains sinus in atrial arrhythmias; maintain sinus rhythm in pt w/ atrial fibrillation & flutter who are currently in sinus rhythm Class 4: Ca2+ Blocker (Diltiazem, Verapamil) -Graph: slow rise of AP so less spontaneous phase 4 depolarization -Treats: better for atrial than ventricular arrhythmias; supraventricular tachycardia is major arrhythmia indication; reduction of ventricular rate in atrial fibrillation and flutter a) Diltiazem b) Verapamil Miscellaneous a) Digoxin: -Treats: control of ventricular response rate in atrial fibrillation and flutter w/ impaired left ventricular function or heart failure; useful in treating atrial flutter/fibrillation (by controlling ventricular rate) b) Adenosine: -Treats: DOC to abolish acute supraventricular tachycardia; also for paroxysmal supraventricular tachycardia c) Magnesium: -Treats: torsade de point, digitalis induced arrhythmia, prophylaxis of arrhythmias in acute MI d) Atropine: -Treats: bradyarrhythmia so less vagal tone Atrial Fibrillation; Rate Control: -ve dromotropic: Ca ch blocker, B blocker, digoxin (1st line IFF HF too) Rhythm Control: class 1Cs flecainide, propafenone; class 3s amiodarone, dofetilide Thromboemboli Prevention: give for atleast 4 weeks Heparin IV (unstable pt) Warfarin Oral (stable pt)