Pharm - Anti-Arrhythmia Drugs

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MOA of class I A (eg. Procainamide), class IB (eg. Lidocaine), and class IC (eg. Flecainide) antiarrhythmics

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Sodium channel blockers

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SE of procainamide

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Lupus-like syndrome

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Limiting side effect of Quinidine

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Prolongs QT interval

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Other side effects of Quinidine

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Thrombocytopenic purpura, and CINCHONISM

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Major drug interaction with Quinidine

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Increases concentration of Digoxin

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DOC for management of acute Ventricular arrhythmias

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Lidocaine

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DOC for digoxin induced arrhythmias

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Phenytoin

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SE of phenytoin

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Gingival hyperplasia

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Class of anti-arrhythmics that has a pro-arrhythmic effect (CAST trial), therefore are used as last line agents

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Class IC (flecainide, propafenone)

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Class II antiarrhythmics are

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B-blockers

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Antiarrhythmic that exhibits Class II and III properties

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Sotalol

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Side effect of sotalol

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prolongs QT and PR interval

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Used intravenously for acute arrhythmias during surgery

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Esmolol

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Anti-arrhythmics that decrease mortality

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B-blockers

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MOA of class III antiarrhythmics

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Potassium channel blockers

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Class III antiarrhythmic that exhibits properties of all 4 classes

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Amiodarone

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Specific pharmacokinetic characteristic of amiodarone

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Prolonged half-life, up to six weeks

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Antiarrhythmic effective in most types of arrhythmia

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Amiodarone

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SE of Amiodarone

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Dysfunction, photosensitivity, skin (blue smurf syndrome), Pulmonary fibrosis, thyroid and corneal deposits

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MOA of class IV antiarrhythmics

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Calcium channel blockers

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Life threatening cardiac event that prolong QT leads to

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Torsades de pointes

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Agent to treat torsades de pointes

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Magnesium sulfate

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Drug used supraventricular arrhythmias

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Digoxin

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DOC for paroxysmal supraventricular tachycardia (PSVT)

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Adenosine

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Adenosine's MOA

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Activates acetylcholine sensitive K+ channels in SA and AV node

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Anti-arrhythmic with 15 second duration of action

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Adenosine

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Effects of class 1A drugs

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slows conduction and pacemaker rate, prolongs AP, depresses SA and AV nodes

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Indication for class 1A drugs

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atrial and ventricular arrhythmias

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Toxicities for class 1A drugs

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hypotension, lupus related syndrome

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Class 1A drugs:

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procainamide, disopyramide

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Effects of class 1B drugs

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may shorten AP

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Toxicities for class 1B drugs

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large first pass metabolism (IV only), neurologic sx

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Class 1B drugs:

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lidocaine, mexilentine

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Indication for class 1B drugs

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ventricular tachyarrhytmias

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Indication for class 1C drugs

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supraventricular arrhythmias, do not use post-MI

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Toxicities for class 1C drugs

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proarrhythmic

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Class 1C drugs:

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flecainide, propafenone

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Effects of class 2 drugs

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prolongs AP, slows SA automaticity and AV conduction

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Toxicities for class 2 drugs

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asthma, AV block, acute heart failure

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Class 2 drugs:

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propranolol, esmolol (short acting)

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Effects of class 3 drugs

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prolongs AP and QT interval, slows HR and AV conduction

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Class 3 drugs:

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amiodarone, dofetilide, sotalol, ibutilide

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Class 4 drugs:

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verapamil, diltiazem

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Effects of class 4 drugs

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slows SA automaticity and AV conduction, decreases contractility and BP

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Effect of adenosine

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AV block

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Toxicity of adenosine

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flushing, dizziness (short acting)

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Effect of Mg

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normalizes/increases plasma Mg; depresses digoxin-induced and torsade de pointes arrhythmias

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Effect of K

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slows ectopic pacemakers and conduction

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MOA of K

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increases K permeability and currents

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Pt with RA/chronic heart disease is taking digoxin, HCTZ and K: Which would be most relevant with decision to use procainamide? may worsen or precipitate hyperthyroidism, not effective for atrial arrhythmias, prolongs AP and may precipitate TDP arrhythmia, induces thrombocytopenia, induces HA and tinnitus

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procainamide prolongs AP and may precipitate TDP arrhythmia

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Pt with RA/chronic heart disease is taking digoxin, HCTZ and K: In deciding to tx with procainamide which is most correct? possible drug interaction with digoxin suggest blood levels should be obtained before/after starting, hyperkalemia should be avoided to reduce likelihood of toxicity, cannot be used if pt has asthma due to beta blocking effect, has duration of action of 20-30 h, not active by oral route

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hyperkalemia should be avoided to reduce likelihood of toxicity

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Pt with RA/chronic heart disease is taking digoxin, HCTZ and K: if pt manifests severe acute procainamide toxicity from overdose, you should admin? Ca chelator like EDTA, digitalis, KCl, nitroprusside, Na lactate

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Na lactate

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When used as antiarrhythmic, lidocaine typically? increases AP duration, increases contractility, increases PR interval, reduces abnormal automaticity, reduces resting potential

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reduces abnormal automaticity

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Which drug is NOT suitable for chronic oral therapy of arrhythmias? amiodarone, disopyramide, esmolol, quinidine, verapamil

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esmolol (because it is so short acting)

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16 yo with paroxysmal tachycardia; antiarrhythmic of choice in most acute AV nodal tachycardia is? adenosine, amiodarone, flecainide, propranolol, quinidine

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adenosine (short duration of action so less toxic)

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Pt with abnormal EKG; overdose of antiarrhythmic is considered; which is paired correctly? quinidine-increased PR and decreased QT, flecainide-increased PR, QRS, QT, verapamil-increased PR, lidocaine-decreased QRS, PR, metoprolol-increased QRS

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verapamil-increased PR

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Which drug does NOT consistently reduce Ik repolarizing current and thereby prolong AP duration? amiodarone, ibutilide, lidocaine, quinidine, sotalol

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lidocaine

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Adverse effects of quinidine include? cinchonism, constipation, lupus erythematous, increase in digoxin clearance, pulmonary fibrosis

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cinchonism

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What is cinchonism?

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triad of HA, vertigo, tinnitus

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Drug that hyperpolarizes and prevents conduction of impulses in AV node? adenosine, digoxin, lidocaine, quinidine, verapmil

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adenosine (by activating Ik to hyperpolarize)

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Which drug used orally blocks Na channels and decreases AP in ischemic tissue? adenosine, amiodarone, disopyramine, esmolol, flecainide, lidocaine, mexiletine, procainamide, quinidine, verapamil

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mexiletine

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Which drug slow conduction through AV node and acts primarily on L-type Ca channels? adenosine, amiodarone, disopyramine, esmolol, flecainide, lidocaine, mexiletine, procainamide, quinidine, verapamil

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verapamil

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Which drug has longest half-life? adenosine, amiodarone, disopyramine, esmolol, flecainide, lidocaine, mexiletine, procainamide, quinidine, verapamil

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amiodarone