Antiarrhythmic Drugs- Leah (3)* Flashcards Preview

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Flashcards in Antiarrhythmic Drugs- Leah (3)* Deck (50):
1

Anti-arrhythmic effects (4)

1) Decreased automaticity
2) Decrease/ restore, block conduction
3) Make ERPs homogeneous OR...
4) ^ ERP --> slow heart rate

2

Describe the four classes of arrhythmia drugs:

1. Class I- Na Channel block
2. Class II- B block
3. Class III- K+ block/ ^ APD/ERP
4. Class IV- Ca++ channel block

3

How do Na channel blockers effect heart rate/rhythm? (3)

1. DECREASE depolarization
(phase 0 slope decreased on AP plot for MYOCYTES)
2. DECREASE conduction + automaticity
(Decrease phase 4 slope on AP plot for pacemaker cells SA/AV)
3. Intuitive: increase THRESHOLD for AP

4

Most common cause of persistent arrhythmias?
How do infarctions facilitate this process (3)

Anatomical re-entry = heterogenous ERP

- INFARCTION = SLOWER conduction + ERP
- Normal conduction does not initially pass through infarcted site (longer ERP)
- Conduction RE-ENTERs infarct @ wrong time/ wrong direction after ERP is over

5

Risk associated with drugs that increase effective refractory period?

Relevance (2)?

***Torsades de points: polymorphic V Tach--> fatal V Fib

*Many drugs that increase QT are reserved for emergency or fatal arrhythmias
*Not used in asymptomatic arrhythmias because of their high risk

6

Type I drugs are "state dependent": what does this mean?

Describe the three subclasses of type 1 anti-arrhythmic drugs.

*Na channel blockers are state dependent.
- Only bind Na channels in the open/ active state.
- Disassociate from inactive/ closed channels with varying speed
- Speed of disassociation determines subclass.

1A- moderate effects
1B- small effects because (rapidly disassociate)
1C- large effects (slowly disassociate)

7

What are three class 1A drugs?
Which is actually used in practice? Why?

1. Procainamide***
2. Quinidine
3. Disopyramide
"(I)A QUeen PROClaims DISO's PYRAMID."

*PROCAINAMIDE is still used
- IA drugs have some anti-Ach effects --> may ^AV conduction--> unpredictable effects
- May increase or decrease AV conduction

PROCAINAMIDE: lowest anti-ach effects
DISCOPYRAMIDE: highest anti-Ach effects
(L Dose may precipitate CHF: no longer used)

8

What are two class 1B drugs?
When are they effective?

1. Lidocaine***
2. Mexiletine
"I'd Buy LIDdy's MEXIcan Tacos"
I would NOT. I heard they make you delirious & might even give you seizures.

-Only effective in the diseased heart
- In a normal heart, they rapidly disassociate from inactive Na channels, have little efficacy.

9

What are two class IC drugs?
Important limiting factor in their use

1. Flecainide***
2. Propafenone
"Can I have Fries Please"

**Cannot be used in patients with an organic heart disease
- INCREASES CHF MORTALITY
- Only used for patients with an idiopathic refractory arrythmia

10

Three important class II drugs?
Range of use for this class (4)?

1. Propranolol (non selective)
2. Esmolol (selective)
3. Metoprolol (selective)

**Widest range of use; Not labeled for "only emergencies".
Tx: CHF, postMI, PVCs, SV arrhythmias (afib/flutter)

11

Class III drugs (5)
Common side effect of this class?

1. AMIODARONE ***most important, always on boards.
2. Drondarone
3. Ibutilide
4. Dofetilide
5. Sotalol* (Amiodarone substitute)
"AIDS"

*Because this class increases APD/ERP predominately, most drugs increase QRS/QT
- ^ risk of torsade
- Most reserved for emergency/refractory cases*

12

Most important class IV drug:

Verapamil

*Widest range of use second to B blocks

13

When might atropine and isoproterenol be used to treat arrythmias? How long are patients treated with these drugs?

Bradycardia, AV blocks
(When heart rate needs to INCREASE)
* Short-term until pacemaker is placed

14

What are three "vagomimetics" used to treat arrythmias?
What are their uses?

1. Valsalva
2. Carotid sinus massage
3. Digoxin

* Valsalva and carotid massage mimic increased BP; may terminate PSVT
* Digoxin slows ventricular rate in a-flutter/fib
Why? Because AV node NEEDS Na/K pump for action potential. Digoxin increases contraction BUT decreases AP rate for AV node!!

15

Adenosine:
Cardiac effects (2) / MOA
Cardiac use/DOC (1)
ROA (1)
ADR (3)
CI + Replacement drug (2):

Effects/MOA:
^ K+ out of cell--> Hyperpolerization--> DECREASE automaticity + AV conduction

Use: *DOC* terminates PSVT
ROA: IV only (w/ short half life)
ADR: Bronchospasm, Flushing, Impending Doom
CI: COPD, Asthma (use verapamil)

16

Two drugs that markedly prolong QT on ECG:

Procainamide (I-A), amiodarone (III)

17

Three drugs that markedly increase QRS on ECG:

Procainamide (I-A)
Flecainide (I-C)
Amiodarone (III)

18

Most class I-IV anti-arrythmics slow down AV conduction and increase PR interval on ECG. What are two exceptions?

1. Procainamide/ Class 1A.
- anti-Ach properties make AV node effects unpredictable
-PR could increase, decrease, or remain the same.

2. Lidocaine/Class 1B:
-Rapidly disassociate from Na channels
-Often leave the PR interval unchanged

19

What drug classes cause increased risk of torsades?

Class 1A
Class III

*I believe dronadrone also causes torsades, yes! Sorry--forgot to respond earlier!

20

Effects of all class 1, 2, and 4 drugs on:

Conduction
Phase 0 slope on AP plot
Automaticity
APD
ERP

-Decrease conduction
-Decrease automaticity
-Decrease phase 0 slope on AP plot
-^ APD
-^ ERP

21

Effects of class 3 drugs on:
Conduction
Automaticity
ARP
ERP

+ important caveat

On their own, "class 3" drugs only ^ ERP/APD

HOWEVER, most drugs in this class have mixed mechanisms allowing them to also decrease conductivity/ automaticity

Ex: amiodarone has class III effects mainly, but it also has class I/IV activity

22

Two drugs in the cardiac unit that may cause a reversible lupus-like syndrome?

Procainamide; Hydralazine

23

Procainamide:
Class
Use
ROA
ADRs (4)
Active metabolite

1A
Emergency ventricular arrythmias
IV/oral

ADRs:
1. ^QT/torsades esp with hypokalemia
2. LUPUS
3. AGRANULOCYTOSIS
4. leukopenia

Active metabolite: NAPA (also has Na blocking properties)


24

Lidocaine:
Class
Use(2)
ROA
ADRs (2)

-Class 1B
-Digoxin arrythmia/ life threatening ventricular arrythmia
- IV only (first pass elimination)
-***delirium and seizures***

25

How is mexiletine different than lidocaine?

Same other than:
orally effective + some GI ADRs

26

In what cases are lidocaine and mexilitine contraindicated?

Seizures/ hepatic disease

27

Flecainide:
Class
Use

Class: IC
Use: deadly ventricular arrythmias/ SVT IN THE ASBENCE OF ORGANIC HEART DISEASE

28

How does Propafenone differ from Flecainide?

Propafenone has some Beta blocking properties
(Negative ionotropic)

29

Three important ADRs to keep in mind for B-blockers when using them to treat cardiac patients

1) Bronchospasm- (only B1 selective for asthma/COPD pts)

2)CHF/ AV block

3) Insulin induced hypoglycemia + loss of hypoglycemic tachycardia

30

Esmolol:
Most common uses (2)
ROA?
Half life:

IV admin POST OP for control of:
Atrial arrythmias (sinus tacky/ or Afib/flutter)

Very short half life

31

Amiodarone***
Class
Use
ADRs (7)

Class III, with some I and IV properties
**DOC: emergency ventricular arrythmias**

ADRs:
1. Pulmonary fibrosis
2. Hepatotox
3. Hypo/hyper thyroid
4. QT ^/ torsades
5. AV block + bradycardia
6. Corneal microdeposits, photosensitivity
7. Blue/gray nose + cheeks

("DIRTY" drug due to having multiple mechanisms)

32

Half life amiodarone

Very long because it is a lipophilic drug (up to 107 days)

33

Drondarone
Class
Use
ADRs
Half life

Class III with some class I activity
A fib/flutter
Liver injury/ CHF
24 hr t1/2

*INCREASES CHF MORTALITY = RARELY USED*

34

Ibutilide/ dofetilide
Class
Use
ADR

Class three
Tx: A flutter/ fib
ADR: Torsades

*HIGHEST TORSADES DUE TO SINGULAR K+ ACTIVITY = RARELY USED*

35

Sotolol***
Class
Use
ADR

Class III/ II (non-cardioselective BBer Ends in --olol!!!!!!!!!)
Tx: V tach
ADR: Torsades

*CAN REPLACE AMIODARONE IN INTOLERANT PATIENTS*

36

Verapamil
Class
CV Effects
Uses

Class IV

-Vasodilation
-DECREASED contractility

Use: atrial arrhythmia (SVA, PSVT, AFIB /flutter)

37

Drug of choice for ventricular arrythmias (commonly used by paramedics)

Amiodarone

38

What drugs cannot be in patients with organic heart disease (2)

1. Flecainide
2. Propafenone

39

Which drug has an active metabolite "NAPA"?

Procainamide

40

What drugs cause delirium and seizures (2)?

Lidocaine
Mexilitine

41

Drug that is lipophilic and has an extremely long half life?

Amiodarone

42

Drug that may cause pulmonary fibrosis

Amiodarone

43

Four pro-arrythmic conditions:

1) Conduction block/re-entry
2) Any change in effective refractory period (ERP)
3) Increased automaticity (i.e. abnormal foci)
4) After depolarization

44

Verapamil:
ADR (3):
CONTRA:

1. HypoTN
2. CHF/ AV block
3. Constipation (Why? Because it blocks SM calcium release NONspecifically! Stops GI SM contraction too!!)

Contra: Sick Sinus Syndrome

45

Verapamil:
DD interactions

1. B-blockers (^ - inotropic effects)
2. Digoxin (double decrease in AV cndxn)
3. Anti-arrhthmics
4. CYP3A4s (cimetidine)

"same 4 listed in the vasodilator lecture!!"

46

First Aid:
Drugs causing Long QT

("ABCDE")
1. AntiArrhythmics (class Ia, III)
2. AntiBiotics (macrolides)
3. Anti"C"ycotics (haloperidol)
4. AntiDepressants (TCAs)
5. AntiEmetics (ondansetron)

47

Drugs contraindicated in Asthmatics/COPD

1. non-specific Beta Blockers
2. Adenosine

48

What is ondansetron?
Why is it relevant to this deck of cards?

Anti-emetic!!
At a party with alcohol and feeling queasy?
Keep ON DANCing with ONDANSetron.

****It prolongs QT like many of the anti- arrhythmics, ^ Torsades risk.

49

Drug of choice for PVST?

Adenosine

50

Drug that replaces amiodarone in patients who cannot tolerate amiodarone?

Sotolol, has the same main MOA
Also treats ventricular arrythmias