Anti-arrhythmic

Question 1

Implantable defib and ablations

Answer 1

May increase the risk of death

Question 2

Treatment of dysrhythmia

Answer 2

2 stages: termination and long term suppression
Empiric treatment, require trial and error approach
SV dysrhythmias: not harmful. class 2 and 4 agents and adenosine and digoxin
V dysrhythmias significant. Class 1 and 3

Question 3

A-Fib

Answer 3

BB and Non-dihydropyridine CCB

Prevent stroke via aspirin, warfarin, dabigatran, rivaroxaban, edoxaban, or apixaban

Question 4

A Flutter

Answer 4

Cardioversion. Electrical or ibutilide
Long term: Class IC (flecainide or propafenone) or III (amiodarone, dronedarone, sotalol, dofetilide)
Prevent stroke: same as a fib, reduce risk with anticoagulants

Question 5

SVT

Answer 5

Valsalva, ice, blowing thru straw
Adenosine (chemical cardioversion)
BB and non-dihydropyridine CCBs: rate control short and long term

Question 6

V-tach/V-FIb

Answer 6

Not life compatible
Cardioversion
Lidocaine, procainamide, amiodarone if cardioversion fails
Long term: amiodarone

Question 7

Class 1 Na Channel Blockers

Answer 7

Block cardiac Na channels: decrease conduction velocity

1a: delay repolarization
1b: accelerate
1c: pronounced prodysrhythmic actions

Question 8

Procainamide

Answer 8

Class 1a
Ventricular and SV arrhythmia
BOX: positive ANA test, Mortality increase (CAST Trial), blood dyscrasias
CONTRA: allergy to ester type local anesthetics, complete heart block, 2nd degree, lupus, torsade’s
ADR: + ANA titer, Lupus-like syndrome, QT prolongation
Hepatic and renal adjustments

Question 9

Lidocaine

Answer 9

1B
Acute Ventricular arrhythmia, local and regional anesthesia, nerve block, epidurals
CONTRA: Allergies to amide type anesthetic, Stokes-Adam syndrome, WPW, severe SA or AV or intraventricular heart block
ADR: bradycardia, edema, hypotension. Drowsy, confusion. Seizures and resp. arrest

Question 10

Mexiletine

Answer 10

1B
Ventricular arrhythmia
BOX: increased mortality (CAST), acute liver injury
CONTRA: cardiogenic shock, 2/3 degree AV block (unless pacemaker present)
ADR: dysrhythmias, dizzy, ataxia, nervousness, unsteady gait, psychosis, GI disturbance (N/V/D), tremors

Question 11

Flecainide

Answer 11

1C
Paroxysmal a fib/flutter and ventricular arrhythmia or PSVT PREVENTION
BOX: increased mortality (CAST), Ventricular proarrhythmic effects in pts with afib/flutter
CONTRA: 2/3 degree heart block, cardiogenic shock, use of Ritonavir
ADR: Ventricular arrhythmias, dizzy, visual disturbances

Question 12

Propafenone

Answer 12

1c
Ventricular arrhythmia treatment. Afib/flutter and SVT prevention
BOX: Mortality CAST
CONTRA: SA, AV, Intraventricular disorders (unless pacemaker is present), Brugada, bradycardia, cardiogenic shock, HF, Hypotension, Broncho reactive disorders, or electrolyte imbalances
ADR: Taste disturbances, dizzy

Question 13

Beta blockers Class II

Answer 13

Propanolol, acebutolol, esmolol, sotalol. Metoprolol used w/o FDA indication
Beta1 receptor blockade. Stops sympathetic stimulation of the heart

Question 14

K+ channel blockers

Answer 14

Class 3

Delay repolarization by prolonging QT interval

Question 15

Amiodarone

Answer 15

Class III K+ blocker
BOX: only for life threatening situations, pulm toxicity (MUST MONITOR with CXR for 3-6 MONTHS), hepatotoxic, worsening arrhythmia
CONTRA: cardiogenic shock, iodine allergy, SSS, 2/3 AV block, bradycardia
ADR: bradycardia, hypotension, thyroid effects, visual, blue-gray skin
Hepatic adjustments

Question 16

Dronedarone

Answer 16

Class III K+ Blocker
Paroxysmal or persistent Afib
BOX: mortality (CAST)
CONTRA: SYMPTOMATIC HEART FAILURE and SEVERE LIVER IMPAIRMENT
ADR: AKI (increased SCr)

Question 17

Sotalol

Answer 17

Beta blocker with Class 3 properties
Ventricular arrhythmia, afib/flutter
Beta blocker that also delays repolarizing
BOX: life threatening proarrhthymias (QT prolongation)
CONTRA: BRONCHO REACTIVE DISORDERS, BRADY, 2/3, qt PROLONGATION, SHOCK, DECOMPENSATED heart failure
ADR: brady, cpain, palps, dizzy, fatigue, headache
Renal adjustment required

Question 18

Dofetilide

Answer 18

Class 3
Afib/flutter treatment and prevention
BOX: requires 3 days in a facility for continuous EKG monitoring
CONTRA: QT prolongation, severe renal impairment
ADR: Torsades, cardiac failure, MI
LOTS of drug interactions, call a pharmacist

Question 19

Ibutilide

Answer 19

Class 3
Afib/flutter treatment
BOX: life threatening arrhythmias
CONTRA: NONE
ADR: NONE

Question 20

Class 4

Verapamil and Diltiazem

Answer 20

HTN, angina, Afib/flutter, SVT prevention and treatment
N-D CCB = vasodilation with reduced HR, conduction, and force of contraction
CONTRA: severe LV dysfunction, hypotension, cardio shock, 2/3 (unless pacemaker)
ADR: (reduced CO), bradycardia, headache, constipation
M/E Strong CYP 3A4 Inhibitors means that Verapamil requires a 20-30% adjustment with liver failure

Question 21

Adenosine

Answer 21

SVT treatment (chemical cardioversion)
Interrupts AV node re-entry to restore sinus rhythm
CONTRA: 2/3, brady
6mg IV, flush, 12......
ADR: hit by a truck

Question 22

Digoxin

Answer 22

HFrEF and Afib/flutter
Decreases HR and slows AV conduction velocity
CONTRA: Ventricular fib
ADR: Digoxin toxicity