Arrhythmias: Treatment Flashcards

1
Q

Recognize how different underlying arrhythmia mechanisms determine the relevant treatment approaches

A

Mechanism guides treatment options
1) Reentry
• Break the circuit: antiarrhythmic drugs, catheter ablation, overdrive pacing, defibrillation

2) Abnormal automaticity
Depress conduction:
• Na+ channel block by lidocaine (Ib) for reentrant VT
• Ca2+ channel block by verapamil (IV) for AVNRT
Increase effective refractory period:
• K+ channel block by procainamide (Ia) for reentrant VT
• K+ channel block by dofetilide (III) for VT
• K+ channel block by sotalol (III) for AF
Bradyarrhythmias: speed up
• Remove reversible causes (ex. Drugs, ischemia)
• Pacemaker
Tachyarrhythmias: slow down
• Antiarrhythmic drugs
• Ablation
• Reduce rate of spontaneous depolarization in automatic tissues (ex. Metroprolol)
• Increase threshold for AP generation (ex. Lidocaine)

3) Triggered activity
EADs triggering Torsades de pointes → shorten APD
• Remove reversible causes (ex. Hypokalemia, drugs, ischemia)
• Pacing to increase rate = shortens APD
• Mg to stabilize and blunt EADs, rarely aa drugs
DADs triggering ventricular tachycardia → eliminate Ca2+ overload
• Treat digoxin toxicity, ischemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Identify the preferred antiarrhythmic drug treatment for short excitable gap and long excitable gap reentrant arrhythmias.

A

Short excitable gap
o Drugs to prolong refractory period (prolong APD)
o Increases wavelength of reentrant circuit and eliminates excitable gap → wave front head-tail collision and extinction

Long excitable gap
o Drugs to inhibit the conduction in abnormally slow region
o Breaks reentrant cycle
o Other option: overdrive pacing suppression
• Electronic pacemaker paces at rate fast enough to capture cycle in excitable gap → extinguish arrhythmia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Describe the Vaughan Williams classification for antiarrhythmic drugs

A
  • Groups based on shared cardiac electrophysiology effects
  • Some drugs have action in >1 class

• Class I: primarily block cardiac Na+ channels; some can block repolarizing K+ current (end effect = reduce Phase 0)
o Higher affinity for open or inactivated ion channels
o Types a, b, & c
• Class II: beta-blockers = competitive antagonists for β adrenergic receptors
• Class III: APD prolongation
• Class IV: Ca2+ channel blockers
• Class V: other (Digoxin, adenosine)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Describe Type Ia antiarrhythmic Drugs

A

Intermediate recovery kinetics from Na+ channel block; prolong AP duration (longer phase 3)
• ECG: increase in QT interval and some mild QRS prolongation
• Ex. Procainamide

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Describe Type Ib antiarrhythmic Drugs

A

Block rapid recovery Na+ channels; no effect on AP duration
• ECG: no clear changes
• Ex. Lidocaine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Describe Type Ic antiarrhythmic Drugs

A

Block Na+ channels with slow recovery; little effect on AP duration
• ECG: increase PR and QS intervals (slow conduction times); little effect on QT interval (because little effect on ventricular repolarization)
• Ex. Flecainide (not to be used in post-MI patients = increase mortality; patients with LV dysfunction)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Describe Type II antiarrhythmic Drugs

A

beta-blockers = competitive antagonists for β adrenergic receptors
o Decrease phase 4 depolarization in nodal cells→ decreased HR
o Reduce sympathetic stimulation to AV node → prolongs AV conduction
o On surface ECG = slowing of sinus rate and increase in PR interval
o Types:
• Non-selective (β1 and β2) ex. Propranolol
• Selective (β1) ex. Metoprolol

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Describe Type III antiarrhythmic Drugs

A

APD prolongation
o Block voltage-dependent K+ channels → Increase APD and ERP throughout myocardium
Ex. Dofetilide:
• Pure IKr blocker
• ECG: QTc prolongation
Ex. Amiodarone
• Same as Dofetilide but many other targets too
• Most effective antiarrhythmic drug
• BUT major side effects: pulmonary fibrosis, liver, thyroid dysfunction
• Half life ~ 50 days (long!)
• Significant drug interactions (ex. With warfarin)
ECG: PR and QT interval prolongation, variable prolongation of QRS interval; reduction in sinus rate common

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Describe Type IV antiarrhythmic Drugs

A

Ca2+ channel blockers
o Slows rate of phase 4 depolarization in SA nodal cells → reduce HR
o Inhibits conduction through AV node
o ECG: increases PR interval (slow AV node conduction); slows sinus rate (increase RR interval)
Ex. Verapamil and diltiazem
• Note: different than dihydropyridine Ca2+ channel blockers (these have no effect on cardiac Ca2+ channels, specific Ca2+ channels in vascular smooth muscle)
• All: act on L-type Ca2+ channels in vascular smooth muscle → all reduce BP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Describe Type V antiarrhythmic Drugs

A

Other (Digoxin, adenosine)
Digoxin:
• Cardiac glycoside
• Inhibits Na+/K+ ATPase → increased intracellular [Na+]
• Reduced Na+ gradient → reduced Ca2+ efflux via Na+/Ca2+ exchanger → increased intracellular Ca2+ in SR → greater Ca2+ release → increased contractility
• Affects parasympathetic neurons: increases vagal tone to heart
• ECG: decrease HR, increase PR interval

Adenosine:
• Endogenous nucleoside
• Acts via A1 receptor via Gi = inhibits AC → reduces L-type Ca2+ currents and activates GIRK (IK, Ado)
• Slows rate of phase 4 depolarization through AV node
• Prolongs AV nodal refractory period
• IV infusion only = short half life (<10 sec!)
• ECG: decrease HR, increase PR interval

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Describe what arrhythmias are treated with pacemakers and how

A

Goal: eclectically pace heart to maintain adequate CO
Types:
o Transcutaneous → emergency
o Temporary transvenous → emergency
o Permanent transvenous → long term care (pace atria, ventricles, or both)
Treat:
o Slow rhythms:
• Sinus arrest
• Sinus bradycardia
• Heart block
• Atrial fibrillation with slow ventricular response
o Heart failure for resynchronization (bi-ventricular pacing)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Explain how catheter based-ablation can treat arrhythmias.

A
•	Destroys area of myocardium that generates arrhythmia 
o	Uses heat (radiofrequency catheters)
o	Uses cold (cryoablation) 
•	Most often for reentrant arrhythmias with well-defined circuitry 
Complications: 
o	Thromboembolism
o	Perforation, tamponade
o	AV block
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Identify when a defibrillator is used to treat arrhythmias

A

Purpose: provide strong electrical shock to stop tachycardia (stops reentrant circuit) and restore normal rhythm
Types:
o Standard external defibrillator (in ambulances and hospitals)
o Automatic external defibrillators
o Implantable cardioverter-defibrillators (ICDs)
o Life-vest defibrillators (temporary treatmet)
Treat:
o Atrial fibrillation
o Ventricular fibrillation
o Ventricular tachycardia
o Other tachyarrhythmias

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Describe how a vagal reflex can be used to treat certain arrhythmias.

A

To treat AVNRT and AVRT → induce vagal response = activate parasympathetic stimulation of the heart → slows AV node conduction
Valsalva maneuver:
o Forcibly exhale while keeping mouth and nose closed
o Or tense abdomen like having a bowel movement
Carotid sinus massage:
o Soft pressure unilaterally on carotid → stimulates carotid body → reflex activation of vagal (parasympathetic) tone
o Avoid: older patients, or patients with vascular disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Identify the relevant options for clinical treatment of Atrial fibrillation and atrial flutter

A

Emergent cardioversion in cases with rapid ventricular response and hemodynamic compromise (shock)
-Rate control
• Drugs causing AV block: beta-blockers, Ca2+ channel blockers, digoxin
• Stubborn cases amiodarone
-Rhythm control = restore sinus rhythm
• Drugs slowing atrial conduction or prolong refractory period of atrium: Class Ia, Class Ic, Class III
• If drugs not work = cardioversion electively done
• When rhythm restored: keep using drugs to reduce likelihood of recurrence (side effects = caution)
-Antithrombotic therapy to prevent thromboembolism
• Antiplatelet (aspirin) or antithrombotic (warfarin) therapy
• Consider risk of bleeding with anticoagulant treatment
-Catheter ablation
• Symptomatic patients who fail medical therapy
• High success rate (>90%) for atrial flutter

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Identify the relevant options for clinical treatment of AVNRT

A

o Vagal maneuvers
o Acute pharmacological therapy
• IV adenosine
• Others: IV Ca2+ channel antagonists or Beta-blockers
o Chronic suppressive pharmacological therapy
• Oral beta-blockers, Ca2+ channel blockers, digoxin
• Block AV node
• Rarely use other antiarrhythmic drugs (ex. Class Ic)
o Catheter ablation therapy
• High success rate (>90%) but small risk of heart block

17
Q

Identify the relevant options for clinical treatment of AVRT

A

o Vagal maneuvers
o Acute pharmacological therapy
• IV adenosine
• Others: IV Ca2+ channel blockers or beta-blockers
• Some cases: Class Ia or amiodarone
o Chronic therapy
• Rapid accessory pathway: catheter ablation
• Otherwise: treat with suppressive therapy → AV blocking drugs (beta-blockers or Ca2+ channel blockers) in combination with drugs affecting accessory pathway (class Ia, Ic, and III)
• Caution if atrial fibrillation, never use AV nodal block alone

18
Q

Identify the relevant options for clinical treatment of bradycardia due to sinus node disease

A

Emergent therapy
• Rapid IV atropine injections
• Some cases use sympathetic stimulators: epinephrine, dopamine, norepinephrine, others
• If not work → temporary pacemaker
Chronic therapy
• Remove causal drugs or treat underlying electrolyte abnormalities
• Place permanent transvenous pacemaker

19
Q

Identify the relevant options for clinical treatment of Ventricular tachycardia and fibrillation in setting of acute MI

A

o Emergent cardioversion/defibrillation
o Acute antiarrhythmic drug therapy
• IV lidocaine (class Ib) in ischemia
• If fails, use amiodarone (rarely use procainamide)
o Chronic therapy
• Beta-blocker if tolerated
• May need implantable defibrillator if sustained ventricular tachycardia/ high-risk patients
• Sometimes combine with antiarrhythmic drugs: dofetlide or amiodarone

20
Q

Identify the relevant options for clinical treatment of Ventricular tachycardia in setting of chronic systolic LV dysfunction

A

o Emergent cardioversion/defibrillation
o Acute antiarrhythmic drug therapy
• IV amiodarone
• Others that act on ventricular myocardium but careful because potential side effects
o Chronic therapy
• If chronic LV dysfunction and ejection fraction <35% = implant ICD
• Combined with antiarrhythmic therapy (ex. Amiodarone, dofetilide) to reduce symptoms and ICD discharges
• No chronic drugs in heart failure patients due to increased risk of pro-arrhythmia

21
Q

Identify the relevant options for clinical treatment of Torsades de pointe ventricular tachycardia

A

o Emergent therapy
• Emergent cardioversion is hemodynamic collapse (but only briefly treats)
• Goal: shorten APD, treat underlying hypokalemia, give supplemental Mg
• Drugs to increase heart rate (naturally shortens APD): pacing or beta-adrenergic receptor stimulation (isoproterenol)
• Little use of anti-arrhythmic drugs, can try lidocaine (avoid class Ia, III)
o Chronic therapy
• Avoid precipitating factors: drugs that prolong APD/refractory period or electrolyte abnormalities
• Avoid bradycardia with a pacemaker
• Treat any ischemic heart disease
• Congenital long QT → consider pacemaker

22
Q

Class I Sodium Channel blockers

A
  • Procainamide (Ia)
  • Lidocaine (Ib)
  • Flecainide (Ic)
23
Q

Class II beta-blockers

A

Propranolol (non-selective)

Metoprolol (selective)

24
Q

Class III APD prolongation drugs

A

Dofetilide

Amiodarone

25
Q

Class IV Ca2+ channel blockers drugs

A

Verapamil

Diltiazem

26
Q

Class V Drugs

A

Digoxin

Adenosine