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PBL Pharm Block 3 > Pharm 23 - Anti-Arrhythmics > Flashcards

Pharm 23 - Anti-Arrhythmics Flashcards

1
Q

MOA Moderate block of voltage-gated Na+ channels; block K+ channels in ventricular myocytes (decreased phase 0 upstroke velocity, prolongs depolarization) and SA nodal cells (shifts threshold to more positive potentials and decreases slope of phase 4 depolarization)

A

Class IA

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2
Q

Class IA Drugs (3)

A

Quinidine, Procainamide, Disopyramide

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3
Q

Also Blocks K+ channels that are opened upon vagal stimulation of muscarinic receptors in the AV node (vagolytic effect)

A

Quinidine

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4
Q

Clinical applications Conversion of atrial flutter/fibrillation; maintenance of normal sinus rhythm; paroxysmal SVT; Premature atrial/ventricular contractions; paroxysmal AV junctional rhythm or atrial/ventricular tachycardia

A

Quinidine

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5
Q

Clinical applications Symptomatic premature ventricular contractions (PVCs); life-threatening ventricular tachycardia; maintenance of normal sinus rhythm after conversion of atrial flutter; MALIGNANT HYPERTHERMIA

A

Procainamide

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6
Q

Clinical applications PVCs; Ventricular tachycardia; Conversion of atrial fibrillation/flutter and paroxysmal atrial tachycardia to normal sinus rhythm

A

Disopyramide

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7
Q

Adverse effects Torsades de pointes ( & syncope w/ quinidine), complete AV block, ventricular tachycardia, agranulocytosis, thrombocytopenia, hepatotoxicity, acute asthma attack, respiratory arrest, angioedema, SLE; also fatigue, headache, lightheadedness, widening of QRS, lengthening of QT and PR, hypotension, PVCs, tachycardia, diarrhea, cinchonism (More SLE and less anticholinergic w/ Procainamide; More anticholinergic and less GI w/ Disopyramide)

A

Class IA

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8
Q

Contraindications Hx of torsades de points, Hx of prolonged QT interval, concurrent use of drugs that prolong QT interval (thioridazine, ziprasidone), Conduction defects, Myasthenia gravis; also SLE for Procainamide

A

Class IA

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9
Q

Therapeutic considerations - Inhibits conversion of codeine to morphine -> reduced analgesic effect

  • Digoxin toxicity
  • Amiodarone, amprenavir, azole antifungals, cimetidine, and ritonavir increase quinidine levels
  • Avoid co-administration with anticholinergics b/c increases anticholinergic effects
  • Agent that slows AV conduction (beta blocker/CCB) should be used w/ quinidine in pts w/ atrial flutter to prevent too rapid ventricular response
A

Quinidine

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10
Q

Therapeutic considerations - Does not alter plasma levels of digoxin

  • Consider pre-treatment w/ cardiac glycoside to prevent accelerated ventricular rate due to vagolytic effects on AV node
  • Take baseline ANA and monitor during therapy for development of lupus-like syndrome
A

Procainamide

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11
Q

Therapeutic considerations - Rifampins impair efficacy
- Consider pre-treatment w/ cardiac glycoside to prevent accelerated ventricular rate due to vagolytic effects on AV node

A

Disopyramide

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12
Q

MOA Use-dependent block of voltage gated Na+ channels in ventricular myocytes (decreased phase 0 upstroke velocity), may shorten REpolarization

A

Class IB

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13
Q

Class IB Drugs (3)

A

Lidocaine, Mexiletine (oral analog of lidocaine), Phenytoin

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14
Q

Clinical applications Ventricular arrhythmias when they occur w/ MI, cardiac manipulation, or cardiac glycosides; status epilepticus; Local anesthesia of skin/mucus membranes; pain, burning, itching; Postherpetic neuralgia

A

Lidocaine/Mexiletine

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15
Q

Adverse effects Seizures, asystole/cardiac arrest, new/worse arrhythmias, bradycardia, respiratory depression, anaphylaxis, status asthmaticus; also restlessness, stupor, tremor, hypotension, diplopia/blurred vision, tinnitus

A

Lidocaine/Mexiletine

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16
Q

Contraindications Stokes-Adams syndrome; Wolff-Parkinson-White syndrome; severe conduction blocks; don’t give spinal/epidural block w/ inflammation, infection, septicemia, severe HTN, spinal deformities, neuro disorders

A

Lidocaine/Mexiletine

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17
Q

Dose adjustment if coadministered w/ CYP450 inhibitors (cimetidine) or inducers (barbiturates, phenytoin, rifampin); In severely-ill pts, seizures are 1st sign of toxicity; IM injection of lidocaine can greatly increase serum CK

A

Lidocaine/Mexiletine

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18
Q

Clinical applications Generalized tonic-clonic seizures, status epilepticus, non-epileptic seizures, eclampsia seizures; Neuralgia, Ventricular arrhythmias that don’t respond to lidocaine/procainamide, Arrhythmias induced by cardiac glycosides

A

Phenytoin

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19
Q

Adverse effects Agranulocytosis, leukopenia, pancytopenia, thrombocytopenia, hepatitis, Stevens-Johnson syndrome, TOXIC EPIDERMAL NECROLYSIS; also ataxia, confusion, slurred speech, diplopia, nystagmus, gingival hyperplasia, hirsutism, N/V

A

Phenytoin

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20
Q

Contraindications Hydantoin (whatever THAT is) hypersensitivity, Sinus bradycardia, SA block, 2nd/3rd degree AV block, Stokes-Adams syndrom

A

Phenytoin

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21
Q

Therapeutic considerations Metabolized by P450 2C9/10 and 2C19 - coadministration w/ other drugs metabolized by same enzymes can increase plasma phenytoin; Can induce P450 3A4 - increased metabolism of oral contraceptives, etc.

A

Phenytoin

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22
Q

MOA Block of voltage gated Na+ channels in ventricular myocytes (decreased phase 0 upstroke velocity)

A

Class IC

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23
Q

Class IC Drugs (4)

A

Encainide; Flecainide; Moricizine; Propafenone

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24
Q

Clinical applications Last resort-type drug for sustained ventricular tachycardia, paroxysmal SVT, and paroxysmal atrial fibrillation

A

Class IC

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25
Q

Adverse effects Cardiac arrest, heart failure, new/worsened arrhythmia (especially in pts with atrial fibrillation/flutter), SA dysfunction, decreased conduction velocity, conduction block; also - if you survive all that - dizziness, headache, syncope, dyspnea, visual disturbances

A

Class IC

26
Q

Contraindications Cardiogenic shock, 2nd/3rd degree AV block, RBBB w/ left hemi-block

A

Class IC

27
Q

Therapeutic considerations Only use in pts who have failed other measures; may suppress ventricular escape rhythms; monitor levels in pts w/ hepatic impairment

A

Class IC

28
Q

MOA Beta-blockers; antagonize stimulation of Beta1-adrenergic receptors in SA/AV nodes -> decrease slope of phase 4 depolarization (SA node) and prolonging repolarization (AV node); SEE PHARM 10

A

Class II

29
Q

MOA Block K+ channels, prolonging action potential plateau and repolarization

A

Class III

30
Q

Class III Drugs (6 random multi-syllable words)

A

Ibutilide; Dofetilide (oral only); Sotalol; Bretylium; Amiodarone; Dronederone

31
Q

Clinical applications Conversion of atrial fibrillation/flutter, maintenance of normal sinus rhythm afterwards

A

Ibutilide/Dofetilide

32
Q

Adverse effects AV block, brady cardia, SVT, torsades de points

A

Ibutilide/Dofetilide

33
Q

Contraindications Hx of polymorphic ventricular tachycardia (torsades de points), Preexisting long QT syndrome, creatinine clearance < 20mL/min

A

Ibutilide/Dofetilide

34
Q

Therapeutic considerations May increase potential for prolonged refractoriness; drugs that prolong QT (antihistamines, phenothiazines, TCAs) increase risk of arrhythmia; Monitor QT interval

A

Ibutilide

35
Q

Therapeutic considerations Reserved for pts w/ very symptomatic atrial fibrillation/flutter b/c of risk of ventricular arrhythmia; reduce dose in pts w/ renal dysfunction

A

Dofetilide

36
Q

Clinical applications Life-threatening ventricular arrhythmias; maintenance of normal sinus rhythm in symptomatic atrial fibrillation/flutter

A

Sotalol

37
Q

Adverse effects Bradycardia, torsades de points, PVCs, ventricular fibrillation/tachycardia, AV block, heart failure, bronchospasm; also dyspnea, chest pain, fatigue

A

Sotalol

38
Q

Contraindications Severe SA dysfunction, sinus bradycardia, 2nd/3rd degree AV block, long QT syndrome, cardiogenic shock, heart failure, ASTHMA

A

Sotalol

39
Q

Therapeutic considerations Mixed Class II/III agent; Used for pts that can’t tolerate amiodarone; use w/caution in renal failure and DM; avoid coadministration with ziprasidone and sparfloxacin b/c of risk of prolonged QT interval

A

Sotalol

40
Q

Clinical applications Life-threatening ventricular arrhythmias

A

Bretylium

41
Q

Adverse effects Arrhythmia; also orthostatic hypotension, bradycardia, dizziness, anxiety, increased body temp.

A

Bretylium

42
Q

Bretylium contraindications

A

Digitalis-induced arrhythmias

43
Q

Bretylium therapeutic considerations

A

Also works as an antihypertensive agent

44
Q

Clinical applications Recurrent ventricular fibrillation, unstable ventricular tachycardia, atrial fibrillation, supraventricular arrhythmia

A

Amiodarone

45
Q

Adverse effects Arrhythmias, asystole, bradycardia, heart block, heart failure, hypotension, sinus arrest neutropenia, pancytopenia, hepatic failure, pulmonary toxicity (pneumonitis, alveolitis, fibrosis), thyroid dysfunction; also fatigue, corneal micro-deposits, photosensitivity, BLUE-GRAY SKIN PIGMENTATIONS

A

Amiodarone

46
Q

Contraindications Pts taking ritonavir, severe SA-node disease, 2nd/3rd degree AV block, bradycardia w/ syncope

A

Amiodarone

47
Q

Therapeutic considerations IV form causes “gasping syndrome” (gasping respiration/cardiovascular collapse) in neonates; Coadministration w/ beta blockers increases risk of sinus bradycardia/arrest and AV block; Coadministration w/ cholestyramine increases amiodarone elimination; Coadministration with cyclosporine, digoxin, flecainide, lidocaine, phenytoin, procainamide, quinidine, or theophyline increases amiodarone levels; Coadministration w/ drugs that prolong QT interval (disopyramide, thioridazine, quinidine, TCA) increase risk of prolonged QT/torsades de pointes; Coadministration w/ phenytoin can decrease amiodarone levels (do not ask why - I don’t understand it either…)

A

Amiodarone

48
Q

Dronederone clinical applications

A

Atrial fibrillation/flutter

49
Q

Adverse effects Heart failure, hepatic failure; also prolonged QT interval, abdominal pain, D, indigestion, asthenia, elevated serum creatinine (does not affect GFR)

A

Dronederone

50
Q

Contraindications Bradycardia, prolonged QT/PR, AV block, heart failure, hepatic impairment, PREGNANCY, use of QT-prolonging drugs, use of CYP3a inhibitors

A

Dronederone

51
Q

Therapeutic considerations Similar to amiodarone but less thyroid toxicity and shorter T1/2

A

Dronederone

52
Q

MOA Calcium Channel Blockers: preferentially block cardiac Ca2+ channels; slow action potential upstroke in SA and AV nodes; SEE PHARM 21

A

Class IV

53
Q

MOA Opens G protein-coupled K+ channel and suppresses Ca2+ dependent action potential -> inhibits SA/AV/atrial conduction

A

Adenosine

54
Q

Adenosine clinical applications

A

Conversion of paroxysmal SVT

55
Q

Adverse effects Facial flushing, bronchoconstriction (in pts w/asthma), chest pressure, diaphoresis, excessive SA/AV node inhibition

A

Adenosine

56
Q

Contraindications 2nd/3rd degree AV block, atrial fibrillation/flutter

A

Adenosine

57
Q

Therapeutic considerations Coadministration w/ carbamazepine may increase degree of heart block; may cause transient arrhythmia when first administered

A

Adenosine

58
Q

Ranolazine clinical applications

A

Chronic angina

59
Q

Adverse effects Prolonged QT interval, syncope, acute renal dysfunction; also D/C, HA

A

Ranolazine

60
Q

Contraindications Use of QT-prolonging drugs, preexisting prolonged QT, use of CYP 3A inhibitors, hepatic dysfunction

A

Ranolazine

61
Q

Therapeutic considerations Use in combination w/ beta blockers, amlodipine, or nitrates if needed; avoid use in pts w/ severe renal impairment

A

Ranolazine

PBL Pharm Block 3 (14 decks)

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