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Antiarrhythmic TherapyAntiarrhythmic Therapy
UTHSCSA Pediatric Resident Curriculum for the PICUUTHSCSA Pediatric Resident Curriculum for the PICU
Antiarrhythmic TherapyAntiarrhythmic Therapy
EmpiricArrhythmia Diagnosis
Interventions
Clinical OutcomesInterventions
Clinical Outcomes
PathophysiologicArrhythmia Diagnosis
Known or suspected mechanisms
Critical components
Vulnerable parameters
Targeted subcellular units
BLACK BOX
Antiarrhythmic TherapyAntiarrhythmic Therapy
PathophysiologicArrhythmia Diagnosis
Interventions
Clinical Outcomes
Known or suspected mechanisms
Critical components
Vulnerable parameters
Targeted subcellular units
AV node reentrant tachycardia
AV node reentry
Anatomical fast/slow pathwayAV node (slow conduction)AV nodal action potential
L-type Ca++ channel
Ca++ channel blocker-blocker
Sinus rhythm
Vaughn-Williams Vaughn-Williams ClassificationClassification
• Based on cellular properties of normal His-Purkinje cells
• Classified on drug’s ability to block specific ionic currents (i.e. Na+, K+, Ca++) and beta-adrenergic receptors
• Advantages:– Physiologically based– Highlights beneficial/deleterious effects
of specific drugs
Antiarrhythmic TherapyAntiarrhythmic Therapy
EmpiricArrhythmia Diagnosis
Interventions
Clinical Outcomes
BLACK BOX
Goals•Identify the type of dysrhythmia•Be familiar with more common antiarrhythmics and their Vaughn-Williams Classification
Arrhythmia TypesArrhythmia Types
• Slow
• Fast Fast wide Fast narrow Too fast
Arrhythmia-focused Arrhythmia-focused TherapyTherapy
• Fast Narrow
• Supraventricular tachycardias– Re-entry type• Orthodromic SVT
– Automatic• A.E.T. , Atrial Flutter• J.E.T.
Arrhythmia-focused Arrhythmia-focused TherapyTherapy
• Fast Wide– (rare) Antidromic SVT or SVT with
abberancy– Ventricular tachycardia • Inappropriate automaticity of
ventricular or His-Purkinje tissue
Arrhythmia-focused Arrhythmia-focused TherapyTherapy
• Select one antiarrhythmic or a limited group of antiarrhythmics to treat the disorder.
Antiarrhythmic AgentsAntiarrhythmic AgentsVaughn-Williams ClassificationVaughn-Williams Classification
• Class I - Na+ - channel blockers (direct membrane action)
• Class II - Sympatholytic agents• Class III - Prolong repolarization• Class IV- Ca++ - channel blockers• Purinergic agonists• Digitalis glycosides
The Action PotentialThe Action Potential
Phase 0
Phase 4
Phase 3
Phase 2
Phase 1
- 90 mV
0 mV
30 mV
Class I Class I Na+ Channel BlockersNa+ Channel Blockers
• IA - Quinidine/Procainamide/Disopyramide• IB - Lidocaine/Mexiletine/Phenytoin• IC - Flecainide/Propafenone/Ethmozine
1
0
2
3
4
ERP RRP
AffectsPhase 0
Class IA - Class IA - Na+ Channel BlockersNa+ Channel BlockersProcainamide/Quinidine/DisopyramideProcainamide/Quinidine/Disopyramide
• Mode of action– Depress conduction and prolong refractoriness
• Atrial, His-Purkinje, ventricular tissue
– Peripheral alpha block– Vagolytic– Negative inotrope
• ECG changes– Increase PR, QRS (Diso: PR > QRS )– Toxicity: QTc increases by 30% or QT > 0.5 sec– Ca++ channel blockade / potent anticholinergic
(Diso)
Class IA - Na+ Channel BlockersClass IA - Na+ Channel Blockers ProcainamideProcainamide
• Uses– SVT (reentry) or VT– Afib/flutter (on digoxin)
• Drug interactions-Decrease metabolism of Amiodarone
• Dose– IV: load 15 mg/kg over 1 hour, then 30-80 g/kg/min – (level 5-10 ng/ml)– PO: 30-70 mg/kg/day
• Side effects: Lupus- in slow acetylators– ANA 50-90% Symptoms: 20-30 %
Arrhythmia-focused Arrhythmia-focused TherapyTherapy
• Procainamide has been a long-used intravenous• infusion for a wide range of dysrhythmias:
– Narrow complex tachycardia: • Atrial tachycardia, resistant re-entrant
tachycardia– Wide-complex tachycardia:
• Ventricular tachycardia• Downside: • Side effects, negative inotrope, pro-
arrhythmic
Class IBClass IBLidocaine/Mexiletine/PhenytoinLidocaine/Mexiletine/Phenytoin
• Mode of action– Little effect on normal tissues– Decreases Purkinje ERP/ automaticity– Increases Ventricular fibrillation threshold– Depresses conduction, esp. at high rates
(Mexiletine)– Suppresses dig-induced delayed
afterdepolarizations (Phenytoin)
• ECG changes– Slight QTc (Lidocaine/Phenytoin)
Class IBClass IBLidocaineLidocaine
• Use: VT (acute)– Acts rapidly; no depression of contractility/AV
conduction
• Kinetics– t1/2 : 5-10 min (1st phase); 80-110 min (2nd
phase)
• Drug interactions– Decreased metabolism w/ CHF/hepatic failure,
propranolol, cimetidine– Increased metabolism w/ isuprel, phenobarbital,
phenytoin
• Use: VT (acute)– Acts rapidly; no depression of contractility/AV
conduction
• Kinetics– t1/2 : 5-10 min (1st phase); 80-110 min (2nd
phase)
• Drug interactions– Decreased metabolism w/ CHF/hepatic failure,
propranolol, cimetidine– Increased metabolism w/ isuprel, phenobarbital,
phenytoin
Class IBClass IBLidocaineLidocaine
• Dose– 1 mg/kg, then 20-50 g/kg/min (level: 2-5
g/ml)
• Side effects– CNS toxicity w/ levels > 5 g/ml
• Dose– 1 mg/kg, then 20-50 g/kg/min (level: 2-5
g/ml)
• Side effects– CNS toxicity w/ levels > 5 g/ml
Class IBClass IBMexiletineMexiletine
• Use: VT (post-op CHD)• Kinetics: t1/2 = 8 - 12 hrs• Drug interactions- rare• Dose
– 3-5 mg/kg/dose (adult 200-300mg/dose) po q 8 hrs
• Side effects– Nausea (40%)– CNS - dizziness/tremor (25%)
Class IBClass IBPhenytoinPhenytoin
• Uses– VT (post-op CHD), digoxin-induced
arrhythmias• Drug interactions
– Coumadin- PT; Verapamil- effect (displaces from protein)
• Dose– PO: 4 mg/kg q 6 hrs x 1 day, then 5-6
mg/kg/day ÷ q 12hr– IV: bolus 15 mg/kg over 1 hr; level 15-20 g/ml
• Side effects– Hypotension, gingival hyperplasia, rash
Arrhythmia-focused Arrhythmia-focused TherapyTherapy
• Class IB antiarrhythmics are very effective and very safe.
• Little or no effect on “normal” tissues• First line for ischemic, automatic
arrhythmia's (Ventricular tachycardia)• Not a lot of effect on normal conduction
tissue – not a good medicine for reentry and atrial tachycardias.
Class ICClass ICFlecainide/Propafenone/EthmozineFlecainide/Propafenone/Ethmozine
• Mode of action– Depresses abnormal automaticity (Flec/Ethmozine)– Slows conduction in AV node, AP, ventricle
(Flec/Prop)– Shortens repolarization (Ethmozine)– Negative inotrope (Propafenone)– Prolongs atrial/ventricular refractoriness
(Propafenone)
• ECG changes PR, QRS QTc (Propafenone)
Class ICClass ICFlecainideFlecainide
• Uses: PJRT, AET, CAT, SVT, VT, Afib
• Kinetics– t1/2 = 13 hrs (shorter if between 1-15 mos old)
• Drug interactions– Increases digoxin levels (slight)– Amiodarone: increases flecainide levels
Class ICClass ICFlecainideFlecainide
• Dose– 70-225 mg/m2/day ÷ q 8-12 hr
– Level: 0.2-1.0 g/ml
• Side effects– Negative inotrope- use in normal hearts only
• (NO POST-OPs)– PROARRHYTHMIA - 5-12% (CAST)
Arrhythmia –focused Arrhythmia –focused TherapyTherapy
• IC’s have a lot of side effects that make them appropriate for use only by experienced providers.
Class II AgentsClass II AgentsBeta-blockersBeta-blockers
• Propranolol• Atenolol• Metoprolol• Nadolol• Esmolol• d,l-Sotalol
Class IIClass IIPropranololPropranolol
• Uses– SVT (reentry, ectopic)– Sinus tachycardia (thyrotoxicosis)– VT (exercise-induced)
• Kinetics– t1/2 = 3 hrs (increased if cyanotic)
• Drug interactions– Verapamil
• Hypotension• Decreased LV function
Class IIClass IIPropranololPropranolol
• Dose– PO: 2-4 mg/kg/day q 6 hrs– IV: 0.05-0.15 mg/kg
• Side effects– Avoid in asthma/diabetes– CNS effects
• Nonpolar - crosses BBB
– BP• Suppresses renin-aldo-angiotensin
axis
Arrhythmia-focused Arrhythmia-focused TherapyTherapy
• Beta-blockers are good for re-entry circuits and automatic dysrhythmias.
• Their effect of decreasing contractility may be limiting.
Class III Class III KK++ - channel blockers - channel blockers
• Properties– Prolong repolarization– Prolong action potential duration– Contractility is unchanged or increased
• Agents– Amiodarone– Sotalol– Bretylium– N-acetyl Procainamide (NAPA)
Arrhythmia-focused Arrhythmia-focused TherapyTherapy Can be very powerful antiarrhythmics
but limited indications for first-line use – beyond the spectrum of primary care providers
Amiodarone: may become a first-line medicine for a broad spectrum of arrhythmias, currently still high-risk
Purinergic AgonistsPurinergic AgonistsAdenosineAdenosine
• Mode of action– Vagotonic– Anti-adrenergic– Depresses slow inward Ca++ current– Increases K+ conductance
(hyperpolarizes)
• ECG/EP changes– Slows AV node conduction
Purinergic AgonistsPurinergic AgonistsAdenosineAdenosine
• Uses– SVT- termination of reentry– Aflutter- AV block for diagnosis
• Kinetics– t1/2 = < 10 secs– Metabolized by RBCs and vascular
endothelial cells
• Dose– IV: 100-300 g/kg IV bolus
Purinergic AgonistsPurinergic AgonistsAdenosineAdenosine
• Drug interactions– Methylxanthines (caffeine/theophylline)
• Side effects– AFib/ sinus arrest/ sinus bradycardia– Bronchospasm– Flushing/headache– Nausea
• Great medicine: quick onset, quick degradation.
DigoxinDigoxin
• Mode of action– Na-K ATPase inhibition– Positive inotrope– Vagotonic
• ECG changes– Increases PR interval– Depresses ST segment– Decreases QT interval
DigoxinDigoxin
• Use: SVT (not WPW)• Kinetics
– t1/2 = preemie (61hrs), neonate (35hrs), infant (18hrs), child (37hrs), adult (35-48hrs )
• Interactions Coumadin- PT Digoxin level
Quinidine, amiodarone, verapamil renal function/renal tubular excretion
(Spironolactone) Worse with K+, Ca++
Digoxin ToxicityDigoxin Toxicity
• Nausea/vomiting, lethargy, visual changes• Metabolic
– Hyper K+, Ca++
– Hypo K+, Mg++
– Hypoxemia– Hypothyroidism
• Proarrhythmia– AV block- decreased conduction– SVT- increased automaticity– VT- delayed afterdepolarizations
Digoxin ToxicityDigoxin ToxicityTreatmentTreatment
• GI decontamination– Ipecac/lavage/charcoal w/ cathartic
• Arrhythmias– SA node /AV node depression- Atropine; if dig >
6, may need pacing– SVT- Phenytoin or -blocker– VT- Lidocaine (1 mg/kg) or Phenytoin
• DC Cardioversion may cause refractory VT/VF!!
ProarrhythmiaProarrhythmiaTorsades de PointesTorsades de Pointes
• Class IA– Quinidine 2-8%– Procainamide 2-3%– Disopyramide 2-3%
• Class III– d,l-Sotalol 1-5%– d-Sotalol 1-2%– NAPA 3-4%– Amiodarone < 1%
SummarySummary
• SVT: Initial – Adenosine– ?Propranolol– Procainamide
• SVT: Long Term– Nothing– Propranolol– Digoxin
SummarySummary
• VT : Initial– Lidocaine– Procainamide
• VT: Long Term– Lidocaine/Procainamide– Beta-blockers– Cardiologist
60 Cycle Interference60 Cycle Interference
Atrial FlutterAtrial Flutter
SVTSVT
Ventricular TachycardiaVentricular Tachycardia
Ventricular FibrillationVentricular Fibrillation