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Anti-arrhythmics Flashcards

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1
Q

Rapid depolarization due to influx of Na ions.

Action potential -> cell depolarizes and contraction begins

A

Phase 0

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2
Q

Early rapid depol due to K+ moving out of the cell

Contraction is in process

A

Phase 1

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3
Q

Plateau phase mainly due to inward mvmt of Ca+ into muscle cell

A

Phase 2

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4
Q

Repolarizaion, as K+ moves out of cell

A

Phase 3

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5
Q

K+ flows out and Na+ seeps into cell (return to resting level)

A

Phase 4

Sympathetic stimulation increases the rate of pahse 4 depol, increasing HR

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6
Q

Interval during which a 2nd action potential cannot be initiated, no matter size

A

Absolute refarctory period

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7
Q

Interval following the relatiev refractory period when a second action potential is inhibited, but not impossivle

A

Relative refractory period

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8
Q

Electrical impulses travel through AV node slowly, but reach ventricles

Results in PR prolongation

A

1st degree heart block

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9
Q

Impulses travel slowly and occasionally get blocked, causing ventricles to beat out of sequence

A

2nd degree heart block

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10
Q

Atrial impulses do not reach ventricles so ventricles create their own impulse, cause them to beat out of sequence

Life threatening

A

3rd degree heart block

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11
Q

Torsades de Pointes typically occurs at QT interval > 500 ms.

What are some causes of TDP?

A

Hypokalemia

Hypomagnesemia

Drugs (see next slide/card)

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12
Q

Anti-arrhythmics that cause TDP?

A

Sotalol
Amiodarone
Quinidine

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13
Q

Abx that cause TDP?

A

Macrolides (Azithromycin!, Clarithromycin, Erythromycin)

Fluoroquinolones (Moxifloxacin)

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14
Q

Anti-nausea drugs that cause TDP?

A

Odansetron

Granisetron

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15
Q

Antidepressants that cause TDP?

A

Citalopram
Fluoxetine
Amitriptyline

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16
Q

Antipschotics that casue TDP?

A

Typical anti-psychotics (Haloperidol, chiefly)

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17
Q

Can sumatriptan cause TDP?

A

Yes

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18
Q

Supraventricular arrhythmias?

A

AFib (Fast/irregular, HF, Ischemic stroke)

Aflutter (Fast/regular, reentrant rhythm)

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19
Q

Paroxysmal SVTs can occur due to?

A

digitalis toxicity, caffeine intake, anxiety, alcohol, WP

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20
Q

V Tach?

A

More than 3 straight beats at a rate > 120

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21
Q

Lengthen refractory period

Decrease automaticity

Decrease conduction velocity

A

Class 1A (Na channel blocker)

Procainamide
Disopyramide
Quinidine

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22
Q

Weak Na channel blocker

Shorten phase 3 repolarization

Possess local anesthetic acitivity

A

Class 1B (Fast Na channel blocker)

Lidocaine
Mexiletine

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23
Q

Slow conduction velocity with little effect on refractory period

Useful in supraventricular and ventricular arrhythmias (caution w/ ventriculars, however?)

A

class 1C (potent Na channel blocker)

Flecainide
Propafenone

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24
Q

Block catecholamines

Lengthen refractory period

Decrease automaticity

A

Class 2 (beta b’s)

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25
Prolongs phase 3 K channel blcoker
Class 3
26
Inhibits SA/AV node, prolonging refarctory period SLows conduction Decrease automaticity
Class 4 (CCBs)
27
Increase QRS and QT Used for Atrial/Ventricular arrhythmias ****
class 1A Procainamide Disopyramide Quinidine
28
Decrease QT interval Used for ventricular arrhythmias ***
Class 1B Lidocaine Mexiletine
29
Increase QRS USed for Atrial and ventricular arrhythmias
Class 1C Flecainide Propafenone
30
Decrease HR and increase PR Used for Tachyarrhythmias caused by sympathetic activity and Supraventricular/ventricular arrhythmias
Class 2 (beta b's) Metoprolol Atenolol Propranolol Esmolol
31
Increase QT interval Used for Atrial and ventricular arrhythmias (note that these DO NOT increase QRS like the class 1As... otherwise very similar) ****
Class 3 (K-channel blocker) ``` Amiodarone Sotalol (beta-ish) Ibutilide Difetilide Dronedarone ```
32
Decrease HR and increase PR USed for Atrial arrhythmias (fib/flutter) and reentrant Supraventricular
Class 4 (CCBs) Verapamil Diltiazem
33
Class 1A drug Anticholinergic properties Atrial flutter/A-fib Metabolized by CYP3A4 Inhibited by CYP450
Quinidine | by inhibiting CYP450 = increase digoxin effects/toxicity as well as anticoagulation effects of warfarin
34
Diarrhea Anticholinergic properties Skeletal muscle weakness High doses -> fatal v-tac and arrhythmias Cinchonism
Quinidine
35
Most frequently used 1A agent Used after lidocaine/amioadarone for ventricular arrhythmias associated w/ MI Oral route common -- IV can lead to HOTN Short half life NAPA (prolongs AP)
Procainamide
36
QT interval prolongation Long term = lupus-like syndrome (increases ANAs) Arthralgia/arthritis
procainamide
37
Reserved only for tx of ventricular arrhythmias unresponsive to procainamide/quinidine (fallen out of favor)
disopyramide
38
USed in v-tac w/ a pulse Alternative agent for pulseless VT/VF (if amiodarone isn't available) IV/IM only (extensive first pass effect) Adjusts dose in CHF/hepatic dz
Lidocaine (class 1B)
39
Least cardio toxic of Na channel blockers BUT contraindicated in 3rd degree HB
Lidocaine (class 1B)
40
Orally active form of Lidocaine Narrow therapeutic index Dyspepsia (most common SE) Contraindicated in 3rd degree HB (like lido) (off label for diabetic neuropathy/nerve injury)
mexiletine (class 1B)
41
Class 1C "pill in pocket" Possesses neg inotrope effects which can exacerbate HF Contraindicated in HF, CAD, valvular dz
Flecainide
42
Class 1C w/ weak beta-blocking properties "pill in pocket approach" metallic taste
Propafenone
43
DOC in a-fib/a-flutter? What else should a pt w/ a-fib be started on?
Class 2 (beta b's) Also start on anticoagulation therapy to prevent clot prevention
44
Caution w/ DM, asthma, lipid abnormalities DO NOT use acutely to control ventricular response in HF
Class 2 (beta b's) Metoprolol Atenolol Propranolol Esmolol
45
Given its very short half life (IV only), what would you use for an emergency (e.g., aortic dissection)? Also used intraoperatively for BP/HR?arrhythmias Metabolized extensively by esterase (no drug interaction)
Esmolol
46
Prolongs phase 3 - block K-channel Used for rhythm control, rate control and atrial/ventricular arrhythmias
``` Amiodarone Sotalol Ibutilide Dofetilide Dronedrone ```
47
Related to iodine/thyroxine DOC in pulseless v-tac (cardiac arrest) BUT contraindicated in: - iodine sensitivty/hyperthyroidism - 3rd degree HB
amiodarone (class 3)
48
LONNNNGGGG half life (1-3 month effect) Inhibits CYP3A4 (so increases statins, digoxin, warfarin) Additive brady w/ (nonDHP CCBs, b-blockers)
amiodarone (class 3)
49
Adverse effects... CNS, liver toxicity (monitor), hypo/hyperthyroidism (monitor), **BLUE GRAY SKIN ***PULMONARY FIBROSIS (CXR, pulmonary function test q 6-12 months)
amiodarone (class 3)
50
derivative of amiodarone Shorter half life Inhibitor of CYP3A4 QT prolongation
dronedarone (class 3)
51
Contraindicated: higher level HF QT>500 Severe hepatic impairment 2nd, 3rd degree HB (like sotalol) Bradycardia
dronedarone (class 3)
52
Used for Life-threatening ventricular tachyarrhythmia and supraventricular arrhythmias and maintenance of sinus rhythm in pts w/ a fib
sotalol (beta blocker properties, BUT classified as a K channel blocker)
53
BLACK BOX warning: if initiated on this drug, should be be monitored in a facility that can provide cardiac resuscitation for 3 days
Sotalol (k-channel blocker) Also be wary of bronchospam
54
Contraindicated in: HFrEF<40 CrCl < 40 Sinus bradycardia 2nd/3rd degree HB (like dronedrone)
Sotalol (k-channel blocker)
55
Indicated for conversion of a-fib/a-flutter and maintenance of normal sinus rhythm 100% bioavailable Black box: must be hospitalized for initiation and obtain a QTc 2-3 hours after first 5 doses
Dofetilide
56
Contraindicated in pts w/ CrCl < 20 or QTc>400 TDP risk is high
Dofetilide
57
Effect on the SA node is to slow depolarization and decrease HR But more importantly, it slows conduction at the AV node More effective agaisnt atrial (than ventricular) arrhythmias
CCB (class 4) Verapamil Diltiazem Both nonDHPs
58
Cardiac glycoside slightly increasing cardiac contractility Stimulates vagus nerve SO, slows SA/AV nodes -> slowing HR
Digoxin
59
Positive inotrope that is rec'd to cotnrol ventricular respone to a-fib/a-flutter CYP3A4 (minor substate)
Digoxin
60
Potassium and digoxin... sup with it?
They compete for binding sites. So, hypokalemia results in increased digoxin effects (and hyperkalemia decreases digoxin effects)
61
Concentration greater than 2ng/ml can cause ectopic ventricular bears -> v-tac -> fibrillation -> cardiac arrest Also, Xanthopsia, anorexia, HA, disorientation
digoxin
62
DOC for acute covnersion of regular rhythm paroxysmal supvraventricular tachycardia Increases K efflux, decreases Ca influx (SO, causes a slowing of HR) Only used in acute/emergencies
Adenosine
63
***Super mega ultra short half life FOllow each dose with a NaCl push!! 6 then 12 mg dose
Adenosine | can lead to asystole
64
Most common arrhythmia... prevalence increases w/ age | can develop from a flutter
A fib (ventricular rate > 140)
65
Paroxysmal a fib? Persisent a fib?
Paroxysmal = self resolves w/ in 7 days Persistent > days
66
Rate control vs rhythm control?
Rate is AT LEAST as good as rhythm, but rhythm drugs have more risks than risk drugs
67
In patients w/ HF, what arrhythmia drugs should be avoided?
Class 1A, 1C (also avoid these in acute MI) Dronedarone is also CI
68
For ventricular rate control, beta blockers are effective for controlling exercise-associated HR increases... What three beta blockers can be considered in pts w/ stable HF? BUT avoid these in WPW
Bisoprolol Carvedilol Metoprolol
69
Given beta blockers pulmonary effects, what could we use for ventricular rate control in pts w/ COPD/asthma?
Class 4 (nonDHP CCBs) Verapamil Diltiazem
70
Can be used as an additional HR control measure (w/ b-blocker, diltiazem, or verapamil) but never alone?
Digoxin
71
Amiodaraone can be use for ventricular control when?
AFTER trying b-blockers, non-DHP CCBs, and digoxin
72
If patients have a-fib, what what to determine reisk of stroke?
CHA2DS2VASc (>2 = anticoagulant warfarin; less than 2 cosnider aspirin)
73
Electrical cardioversion is first line for stable pts in A-Fib . What should you ensure absence of?
Ensure absence of atrial thrombi! (use a transesophageal echocardiogram)
74
Chemical cardioversion for A-fib?
Pill in pocket approach... Class 1C antiarrhythmics (flecainamide, propafenone) Contraindicated in patients w/ structural heart dz
75
Another method for chemical cardioveaion of A-Fib if Class 1C drugs don't work... (or if they're contraindicated)
Amiodarone
76
What coudl we use in symptomatic bradycardia?
Atropine Blocks effects of Ach on vagus nerve. Elevates sinus rate and AV nodal/SA conduction
77
In an acute setting, what could we use for Paroxysmal supraventricular tachycardia?
Adenosine | alternatively, try a vagal maneuver, verapamil, diltizaem, beta-blockers, or digoxin
78
Drugs for v-tac/pulseless fibrillation
Epi (NOT an antiarrhytmic) 1. Amiodarone (slow IV) 2. Lidocaine 3. Procainamide
79
Drugs for TDP?
1. Magnesium (IV!) | slows rate of SA node

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