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Antiarrhythmic Agents Flashcards

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1
Q

Class 1 Agents

A

Sodium Channel Blockers
treat: SVT, afib, WPW (re-entry)
depression of phase 0 depolarization
slows conduction and decreases rate of depolarization in phase 0

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2
Q

Class 1A Agents

A

moderate depression and prolonged repolarization
not used much anymore d/t toxicity & may precipitate HF
quinidine, procainamide, disopyramide

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3
Q

Class 1C Agents

A

strong depression with little effect on repolarization

flecainide, propafenone, moricizine

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4
Q

Class 1B Agents

A

weak depression and shortened repolarization

lidocaine, mexiletine, phenytoin, tocainide

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5
Q

Class 2 Agents

A

Beta Adrenergic Blockers
work at phase 4
esmolol, propranolol, metoprolol, timolol, pindolol, atenolol, acebutolol, nadolol, and carvedilol

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6
Q

Class 3 Agents

A

Potassium Channel Blockers
work at phase 2 & 3
amiodarone, bretylium, sotalol, ibutilide, dofetilide

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7
Q

Class 4 Agents

A

Calcium Channel Blockers
work at phase 2
verapamil, diltiazem

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8
Q

Adenosine (class v)

A

binds to A1 purine nucleotide receptors to open K+ channels and increase K+ currents
used for SVT (ACUTE RX ONLY)
slows AV node conduction

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9
Q

Digoxin (class v)

A 
cardiac glycoside (foxglove plant) 
increases vagal activity 
decreases HR, preload and afterload 
decrease AV conduction 
positive inotrope (treats CHF, increases contractility) 
narrow therapeutic range
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10
Q

Phenytoin

A

1B agent
effects resemble lidocaine
used in suppression of ventricular arrhythmias associated with digitalis toxicity, Vtach or tosades

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11
Q

Atropine (class v)

A 
muscarinic receptor antagonist
used to treat unstable bradyarrhythmias 
0.4-1 mg and repeat as needed
liver metabolism 
onset: <1 min 
DOA: 30-60 min 
using <0.4 mg --> paradoxical response
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12
Q

Magnesium (class v)

A

works at sodium, potassium, and calcium channels
used w/ torsades
1g IV over 20 min, can be repeated

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13
Q

Procainamide Dosing

A

Loading 100 mg IV every 5 min until rate controlled (max 15 mg/kg); then infusion 2-6 mg/min

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14
Q

Class 1C Agents

A 
slow dissociation agent 
decrease depolarization rate of phase 0 
decrease conduction rate 
increased AP 
inhibit conduction through HIS-purkinje system 
good for PVCs & Vtach
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15
Q

Flecainide

A

Class 1C prototype
suppresses vtach & PVCs, also WPWS (reentry rhythm)
oral agent
pro-arrhythmic side effects

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16
Q

Propafenone

A

suppression of ventricular & atrial tachyarrhythmias
oral agent
pro-arrhythmic side effects

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17
Q

Class 1B Agents

A

fast dissociation, binds to OPEN channels
alters AP by inhibiting Na ion influx via rapidly binding to and blocking Na channels
shortens AP duration and refractory period
decreases automaticity

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18
Q

Propafenone

A

suppression of ventricular & atrial tachyarrhythmias
oral agent
pro-arrhythmic side effects

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19
Q

Pro-arrhythmic side effects

A

potentially torsades occuring

sudden death associated with V fib.

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20
Q

Lidocaine

A

Class 1B Agent prototype

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21
Q

Lidocaine

A

Class 1B Agent prototype
Use: treat ventricular arrhythmias, effective in suppression of reentry rhythms, Vtach, Vfib, and PVCs
PPB: 50%

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22
Q

Mexiletine

A

oral class 1b agent
chronic suppression of ventricular cardiac tachyarrhythmias
150-200 mg Q 8hrs
used for neuropathic pain
amine side group that promotes oral admin and avoids first pass hepatic metabolism

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23
Q

Lidocaine dosing

A

1-1.5 mg/kg IV
1-4 mg/min infusion
(max dose 3 mg/kg)

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24
Q

Lidocaine metabolism

A

hepatic metabolism
active metabolite that prolongs elimination half time
Cimetidine & propranolol can impair metabolism of lidocaine
barbs, phenytoin or rifampin can induce metabolism of lidocaine

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25
Lidocaine adverse effects
hypotension, bradycardia, seizures, CNS depression, drowsiness, dizziness, lightheadedness, tinnitus, confusion, apnea, myocardial depression, sinus arrest, heart block, ventilatory depression, cardiac arrest and can augment preexisting neuromuscular blockade
26
Phenytoin dosing
1.5 mg/kg IV every 5 min up to 10-15 mg/kg therapeutic blood levels: 10-18 mcg/mL
27
Phenytoin dosing
``` 1.5 mg/kg IV every 5 min up to 10-15 mg/kg therapeutic blood levels: 10-18 mcg/mL mixed in NS and NS line!! can cause pain on injection severe hypotension if given rapidly!! ```
28
Phenytoin Toxicity
mainfests as CNS disturbances, vertigo, slurred speech, and ataxia
29
Phenytoin Metabolism
liver | E 1/2 time: 24hrs
30
Phenytoin Adverse effects
CNS disturbances, partially inhibits insulin secretion, bone marrow depression and nausea
31
Class 2 Agents
``` Block beta adrenergic receptors (phase 4) decreases SA node discharge decreases rate of depolarization slow HR prolongation of PR interval decreases automaticity of heart ```
32
Class 2 Agents Uses
CAD, MI decreases myocardial O2 demands prevents catecholamines from binding to beta receptors SVT, atrial and ventricular arrhythmias suppresses/treats ventricular dysrhythmias during MI and reperfusion Tachyarrhythmias secondary to digoxin toxicity, and atrial fib or flutter
33
Propranolol
Class 2 Agent prototype nonselective antagonist prevents recurrence of tachyarrhythmias both SVT and ventricular precipitated by sympathetic stimulation
34
Esmolol
Class 2 Agent selective for beta 1 dose: 0.5 mg/kg IV bolus over 1 min followed by 50-300 mcg/kg/min infusion DOA: <10 mins effects HR without decreasing BP significantly in small doses
35
Metoprolol
``` Class 2 Agent selective for beta 1 dose: 5 mg IV over 5 min max dose: 15 mg over 25 min onset: 2.5 min half-life: 3-4 hours used in mild CHF ```
36
Propranolol facts
``` onset: 2-5 min peak effect: 10-15 min DOA: 3-4 hours E 1/2 time: 2-4 hours CV effects: decreased HR, contractility, CO, increased PVR, coronary vascular resistance, O2 demand lowered ```
37
Propranolol facts
``` onset: 2-5 min peak effect: 10-15 min DOA: 3-4 hours E 1/2 time: 2-4 hours CV effects: decreased HR, contractility, CO, increased PVR, coronary vascular resistance, O2 demand lowered ```
38
Class 3 Agents
block potassium ion channels work at phase 3 of repolarization increases repolarization and extends AP duration Reduces membrane excitability in all myocardial tissue
39
Class 3 Agent Uses
treat supraventricular and ventricular arrhythmias can prolong QT interval --> torsades (proarrhythmic) prophylaxis in CV surg r/t high incidence of afib preventative for sudden cardiac death survivors and not candidate for ICD Rhythm control for Afib
40
Amiodarone
``` Class 3 prototype also has class 1, 2, and 4 antiarrhythmic properties (potassium, sodium, calcium channel blocker, alpha and beta adrenergic antagonist) 1st line for VT/Vfib when resistant to electrical defib Can develop thyroid dysfunction due to iodine component ```
41
Dronedarone
``` oral class 3 agent lacks iodine less lipophilic (less side effects) ```
42
Amiodarone Uses
prophylaxis or acute treatment of atrial and ventricular arrhythmias (refractory SVT, VT/VF, and AF) patient with recent MI or abnormal heart tissue (irritable) LONG LASTING
43
Amiodarone Dosing
bolus 150-300 mg IV over 2-5 mins, up to 5 mg/kg then 1 mg/hr x6hrs then 0.5 mg/hr x18 hrs
44
Amiodarone Facts
``` Prolong E 1/2 time: 29 days hepatic metabolism with active metabolite biliary/intestinal excretion Therapeutic plasma level 1-3.5 ug/mL PBB: 98%, large Vd ```
45
Amiodarone Uses
prophylaxis or acute treatment of atrial and ventricular arrhythmias (refractory SVT, VT/VF, and AF) patient with recent MI or abnormal heart tissue (irritable) monitor K level
46
Amiodarone Facts
Prolong E 1/2 time: 29 days hepatic metabolism with active metabolite biliary/intestinal excretion Therapeutic plasma level 1-3.5 ug/mL PBB: 98%, large Vd give in central vein PO preop cardiac surge to decrease afib incidence
47
Amiodarone Adverse Effects
long time, high doses can cause pulmonary toxicity, pulmonary edema, ARDS, hypotension, heart block, abnormal LFT 20%, inhibits hepatic P450!
48
Sotalol
Class 2 and 3 agent nonselective beta blocker and potassium channel blocker treats severe VT/Vfib, prevent reoccurrence of tachyarrhythmias, especially aflutter and AF
49
Sotalol Side Effects
prolonged QT interval (proarrhythmic), bradycardia, myocardial depression, fatigue, dyspnea, AV block caution in asthma patients, excreted in urine
50
Dofetilide & Ibutilide
Class 3 agents used for conversion of afib or flutter to NSR used for maintenance of sinus rhythm after afib conversion to sinus proarrhythmic
51
Dofetilide & Ibutilide
Class 3 agents used for conversion of afib or flutter to NSR used for maintenance of sinus rhythm after afib conversion to sinus proarrhythmic
52
Calcium Channel Blockers MOA
bind to receptor on voltage gated calcium ion channel and maintain channel in an inactive or closed state focused on L-type (alpha 1 subunit) slow channel located in skeletal, cardiac, and mesenteric muscles, neurons, and glandular cells GOOD AT CORONARY ARTERY DILATION!
53
CCB Vascular Uses
``` angina (complementary to nitrates) systemic HTN pulmonary HTN cerebral arterial spasm raynaud's disease migraines ```
54
Verapamil
Class 4 Agent Prototype Phenyl-alkyl-amines-AV node: blocks the channel at the binding site depresses AV node and negative chronotropic effect on SA node primarily used as antiarrhythmic
55
Diltiazem
``` Benzothiaxepines-AV node MOA unclear 1st line treatment for SVT primary site of action is AV node intermediate potency b/w verapamil and nifed minimal CV depressant effects ```
56
Nifedipine
1, 4-dihydropyridines-arterial beds modulation of channel at binding site Clinical use: angina d/t coronary artery dilation
57
CCB Non-Vascular Uses
bronchial asthma esophageal spasm dysmenorrhea premature labor
58
Class IV Agents
block slow calcium channels phase 2 to slow conduction at AV node and SA node shortens phase 2 (plateau) and rate of conduction decreases AP decreases contractility of heart
59
CCB Effects
decreases contractility, HR, activity at SA node, rate of conduction of impulses via AV node vascular smooth muscle relaxation (decreased SVR and BP arterial greater than venous)
60
CCB Treatment
SVT & ventricular rate control in afib and flutter prevent reoccurrence of SVT NOT USED IN VENTRICULAR ARRHYTHMIAS
61
Verapamil PK
``` PPB: 87-90% Large PO doses, extensive 1st pass in liver Oral peaks: 30-45 min IV peaks: 15 min E 1/2: 6-12 hrs active metabolite: norverapamil excreted in urine and bile ```
62
Verapamil Dosing
2.5-10 mg IV over 1-3 min (max dose 20mg) Infusion: 5mcg/kg/min DO NOT USE WITH BETA BLOCKER
63
CCB side effects
myocardial depression, hypotension, constipation, bradycardia, nausea, prolongation of NMBDs risk of cancer, cardiac problems (heart block) and bleeding time prolonged vertigo, HA, flushing, paresthesias, induces renal dysfunction, coronary vasospasm with abrupt d/c
64
Diltiazem Dosing
PO or IV 0.25-0.35mg/kg over 2 min can repeat in 15 min IV infusion 10 mg/hr
65
Diltiazem Facts
PO onset: 15 min, peak at 30 min PPB: 70-80% E 1/2 time: 4-6 hrs liver disease may need to decrease dose
66
Nifedipine
primary site of action peripheral arterioles decreases SVR and BP Reflex tachycardia no effect at SA or AV node
67
Nifedipine Dosing
IV, oral, or sublingual Oral effects in 20 min, peaks 60-90 min E 1/2 time: 3-7 hrs
68
Nifedipine Facts
PPB: 90% hepatic metabolism excreted in urine
69
CCB Drug interactions
inhalation agents can cause myocardial depression and vasodilation NMBD prolong beta-blockers (verapamil) verapamil increases LA toxicity dantrolene and verapamil causes hyperkalemia Digoxin & CCB increases digoxin plasma concentration H2 antagonists: increase plasma concentration of CCB
70
CCB Toxicity
IV calcium or dopamine
71
Adenosine Dosing
6mg IV, rapid bolus repeated if needed after 3 mins with 6-12 mg IV E 1/2 T: <10 secs eliminated by plasma and vascular endothelial cell enzymes
72
Adenosine Side Effects
CONTRAINDICATED IN ASTHMA & HEART BLOCK | excessive AV or SA nodal inhibition, facial flushing, HA,, dyspnea, chest disomfort, nausea, and bronchospasm
73
Digoxin dosing
``` 0.5-1 mg in divided doses over 12-24 hrs Onset: 30-60 min E 1/2t: 36 hrs Therapeutic levels: 0.5-1.2 ng/mL reduce dose in elderly/renal impairment ```
74
Digoxin Adverse Effects
arrhythmias, heart block, confusion, agitation, anorexia, nausea, and diarrhea MUST MAINTAIN NORMAL ELECTROLYTE BALANCE (hypokalemia, hypomagnesemia)
75
Digoxin Uses
management of atrial fibrillation or flutter (controls ventricular rate) especially with impaired heart fxn
76
Digoxin Toxicity Tx
Phenytoin for ventricular arrhythmias | pacing and atropine

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