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Definition
An arrhythmias : Is abnormality in the rate, regularity, or site of origin or a disturbance in conduction that disrupts the abnormal sequence of activation in the atria or ventricles.
Arrhythmias have a varying degree of severity & significance based on: Site of origin Symptoms Frequency Duration The clinical implications of disordered cardiac activation range from asymptomatic palpitations to lethal arrhythmias
Treatment Goals
Prevent morbidity and mortality associated with cardiac arrhythmias
Class I drugs
These drugs act by blocking voltage-sensitive sodium channels via the same mechanism as local anesthetics.
Class Ia :
Mechanism of action
Act by blocking the fast (sodium) channels & prevents sodium influx thus slowing the rapid upstrock during phase 0. It is also decreases the slope of phase 4 spontaneous depolarization. The direct action is a generalized slowing of both automaticity conduction velocity in the SA node, AV node, and His-Purkinje system. In addition, all three agents are negative inotropes via their sodium channel blockade.
Therapeutic uses
Class Ib : Lidocaine
Mexiletine Tocainide
These drugs act by blocking fast sodium channels, they exhibit fast on off characteristics as opposed to class Ia [intermediate] & class Ic [slow]. Thus, the action of class Ib agents are manifested when the cardiac cell is depolarized or firing rapidly.
Lidocaine
useful in tretment of ventricular tachyarrhythmias arising during myocardial ischemia. little effect on atrial or AV junction arrhythmias. drug of choice for emergency treatment of cardiac arrhythmias.
tachyarrhythmias . Tocainide has pulmonary toxicity, which may lead to pulmonary fibrosis
Propafenone
arrhythmias [e.g; sustained ventricular tachycardia] It is effective in supraventricular arrhythmias, & considered drug of choice in wolff parkinson white syndrome (WPW)
Flecainide
Used in treating refractory ventricular arrhythmias,& in suppressing premature ventricular contraction. Orally effective. Has a negative inotropic effect & can aggravate CHF.
Class II drugs
adrenergic antagonists [ blockers] are antiarrhythmic in addition to antagonize sympathetic activity, resulting in reduced automaticity in the sinus node & conduction velocity through the AV node. blockers : are most commonly used for rapid control of the ventricular rate during supraventricular tachycardia such as atrial fibrillation & atrial flutter.
Propranolol
: reduce the incidence of sudden arrhythmic death after myocardial infarction. Metoprolol : 1 specific drugs, used by IV administration mainly to reduce the risk of bronchospasm.
Esmolol
: is a very short acting blockers used for IV administration in acute arrhythmias that occur during surgery or emergency situation.
Contains iodine & is related structurally to thyroxine. -It has complex effects, showing class I, II, III, IV actions. -Its dominant effect is prolongation of the action potential duration & refractory period. -It has antianginal as well as antiarrhythmic activity. -Effective in the treatment of sever refractory supraventricular , ventricular tachyarrhythemias and atrial fibrillation. -Its the most commonly employed antiarrythmic.
Amiodarone
Sotalol
Has potent blockers activity. -Blocks a rapid outward potassium current, known as delayed rectifier, this blockade prolongs both repolarization & duration of the action potential, thus lengthening the effective refractory period. -Effective in the management of life threatening ventricular arrhythmias.
Class IV drugs
Are calcium channel blockers. They decrease the inward current carried by calcium, resulting in a decreased rate of phase 4 spontaneous depolarization, & slowing the conduction in AV node.
Miscellaneous Antiarrhythmics
Adenosine
Naturally occurring nucleoside, but at high doses, the drug decreases conduction velocity, prolongs the refractory period, & decreases automaticity in the AV node. IV adenosine is the drug of choice for abolishing acute supraventricular tachycardia. It has low toxicity very short duration of action (approximately 15 sec.)