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CVB by Minnie (Madeleine) > SM 140a - Pharmacology of Anti-Arrhythmic Drugs > Flashcards

SM 140a - Pharmacology of Anti-Arrhythmic Drugs Flashcards

1
Q

Procainamide, Quinidine, and Disopyramide are Class ___ anti-arrhythmic agents that block _____

A

Procainamide, Quinidine, and Disopyramide are Class IA** agents that block **Na+ and K+ channels

Slow AP upstroke, prolong AP duration

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2
Q

Problems with ________ usually cause Ventricular Fibrillation

A. Automaticity

B. Reentry

C. Triggered Activity

A

B. Reentry

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3
Q

Most drugs that block _______ channels are proarrythmic for Torsades de Pointes.

Why?

A

Most drugs that block potassium channels are proarrythmic for Torsades de Pointes

Blocking potassium channels increases the length of the action potential (phases 2 and 3). Anything that prolongs phases 2 and 3 has the potential to cause Early After Depolarizations (EADs), which is the triggered activity that leads to Torsades de Pointes

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4
Q

Which agents can be used to suppress symptomatic PVCs and VT in the setting of MI?

A
  • Class II
  • Class III: Amiodarone only
  • Class IB
  • Class IA: Procainamide occasionally
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5
Q

Lidocaine, Mexelitine, and Phenytoin are Class ___ anti-arrhythmic agents that block _____

A

Lidocaine, Mexelitine, and Phenytoin are Class IB** agents that block **Na+ channels moderately (No K+ blocking action)

Slow AP upstroke

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6
Q

What are the general treatment principles for treating an arrhythmia that is caused by triggered activity?

(Ex: Monomorphic VT, Polymorphic VT)

A
  • Cause: Early After Depolarizations (Phase 2-3)
    • Common if action potential is prolonged
    • Ex: Torsades de Pointes
    • Treat by shortening the action potential
      (without messing with Na+ or Ca2+ channels)
  • Cause: Delayed After Depolarizations (Phase 4)
    • Common if intracellular Ca2+ is too high
    • Ex: Digitalis Toxicity
    • Treat by reversing the underlying cause of high Ca2+
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7
Q

Procainamide is a class ____ anti-arrhythmic that blocks _________ channels.

It can be used to ___________, and ____________.

A

Procainamide is a class IA anti-arrhythmic that blocks Na+ and K+ channels.

It is used to treat Sustained VT , and Prevent VT after MI.

(But it is rarely used because amiodarone and lidocaine are more effective)

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8
Q

Which tachycardias can arise from triggered activity?

A
  • Monomorphic Ventricular Tachycardia**
  • Polymorphic ventricular tachycardia

** = Can also arise from reentry (major cause) or automaticity

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9
Q

Veramapil is a class ____ anti-arrhythmic that blocks ______ channels. It _\_creases conduction time and _\_creases the refractory period in the AV node

It can be used to _____________ and _____________..

A

Veramapil is a class IV** anti-arrhythmic that blocks **Ca2+ channels. It increases conduction time and increases the refractory period in the AV node

It can be used to control heart rate in A-fib and A-flutter** and **terminate supraventricular tachycardia.

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10
Q

What are the major side effects of disopyrimide?

A

Typical anti-muscarinic side effects

  • Urinary retention
  • Constipation
  • Blurred vision
  • Dry mouth
  • Closed angle glaucoma

Proarrythmic -> Torsades de Pointes, heart block

(Disopyrimide = class IA)

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11
Q

Which subclass (A, B, or C) of Class I anti-arrythmic drugs has the greatest potassium channel blocking action?

A

Class IA (Moderate Na+ and K+ channel blocking)

(Procainamide, Quinidine, Disopyramide)

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12
Q

A heart patient on medications is experienceing yellow vision and nausea.

Which drug might be causing this?

A

Digoxin

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13
Q

What are the major side effects of procainamide?

A

Drug induced lupus

Proarrythmic -> Torsades de Pointes, heart block

(Procainamide = IA)

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14
Q

Problems with ________ usually cause monomorphic VT

A. Automaticity

B. Reentry

C. Triggered Activity

A

B. Reentry

(Although monomorphic VT can also be caused by automaticity or triggered activity)

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15
Q

Describe the mechanism of action of lidocaine

A

Lidocaine binds to the activated and inactivated Na+ channel, but not the resting channel

This means it has little effect on normal, healthy tissue, whose channels are normally in the resting state.

Sick myocardium, however, is partially depolarized, so the Na+ channels are more likely to be in the activated or inactivated state.

Therefore, Lidocaine binds preferentially to sick myocardium to decrease the strength of the phase 0 upstroke

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16
Q

Dofetilide is a class ____ anti-arrhythmic that blocks ______ channels. It _\_creases action potential duration in heart tissues.

It can be used to _____________.

A

Dofetilide is a class III** anti-arrhythmic that blocks **K+ (and some Na+) channels. It increases action potential duration in heart tissues.

It can be used to maintain sinus rhythm in A-fib and A-flutter.

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17
Q

Which treatment strategy for atrial fibrillation involves modifying the atrial electrical properties in the SA node?

A

Rhythm control

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18
Q

Problems with ________ usually cause AVRT

A. Automaticity

B. Reentry

C. Triggered Activity

A

B. Reentry

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19
Q

Which class of anti-arrhytmic drugs are considered Ca2+ channel blocker?

A

Class IV

(Verapamil, Diltiazem)

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20
Q

What are the major side effect of digoxin?

A
  • Anorexia
  • Nausea, vomiting
  • Disorientation
  • Hallucination
  • Yellow vision

Proarrhythmic ->

  • AV nodal block (due to vagal tone)
  • Ventricular Premature Beats (due to increased Ca2+)
  • VT (due to reeentry or premature beats)
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21
Q

What are the major side effects of Quinidine?

A

Nausea, vomit, diarrhea

Cinchoism: CNS toxicity (Tinnitus, hearing loss, delerium, psychosis)

Proarrythmic -> Torsades de Pointes, Heart block

(Quinidine = Class IA)

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22
Q

Problems with ________ usually cause Ventricular Premature Beats

A. Automaticity

B. Reentry

C. Triggered Activity

A

A. Automaticity, and B. Reentry

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23
Q

Quinidine is a class ____ anti-arrhythmic that blocks _________ channels.

It can be used to ___________, and ____________, but it is most useful as an anti-malarial agent.

A

Quinidine is a class IA** anti-arrhythmic that blocks **Na+ and K+ channels.

It can be used to convert atrial fibrillation or atrial fluttur to sinus rhythm** , and **maintain sinus rhythm in atrial fibrillation patients, but it is most useful as an anti-malarial agent

(Other agents are more effective for these arrhthmias)

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24
Q

What are the major side effects of amiodarone?

A
  • Hypo- or hyper-thyroidism
  • Pulmonary fibrosis
  • Hepatotoxicity
  • Gray/blue skin discoloration

Proarrythmic -> Sinus bradycardia, AV block
Note: the only K+ channel blocker that does not cause Torsades de Pointes

(Amiodarone = class III anti-arrythmic)

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25
Problems with ________ usually cause **Atrial Flutter** A. Automaticity B. Reentry C. Triggered Activity
B. Reentry
26
Verapamil and diltiazem are Class ___ agents that block \_\_\_\_\_
Verapamil and diltiazem are Class **_IV**_ anti-arrhythmic agents that block _**L-type Ca2+ channels_** Prolong conduction time, refractory period in the AV node
27
What are the major side effects of dofetilide?
Headache GI effects Proarrythmic -\> Increase risk of hypokalemia, new or worse VT (ex: Torsades de Pointes) (Dofetilide = Class III anti-arrythmic)
28
**Ibutilide** is a class ____ anti-arrhythmic that blocks ______ channels. It \_\__creases_ action potential duration in heart tissues. It can be used for \_\_\_\_\_\_\_\_\_\_\_\_\_.
**Ibutilide** is a class **_III**_ anti-arrhythmic that blocks _**K+**_ channels. It _**in_**_creases_ action potential duration in heart tissues. It can be used for **_acute termination of A-fib and A-flutter_**.
29
Which antiarrythmic might be useful in a patient with a loud systolic murmur that gets louder when standing from a squatting position?
This murmer is present in hypertrophic cardiomyopathy. **Treat with disopyramide** [Thank you Nathin Shlobin!]
30
**Sotalol** is a class ____ anti-arrhythmic that blocks ______ channels. It \_\__creases_ action potential duration in heart tissues. It can be used to \_\_\_\_\_\_\_\_\_\_\_\_\_, ____________ and \_\_\_\_\_\_\_\_\_\_\_\_\_.
**Sotalol** is a class **_III**_ anti-arrhythmic that blocks _**K+_** channels **(also has some beta-blocking activity)**. It _**in**creases_ action potential duration in heart tissues. It can be used to **_maintain sinus rhythm in A-fib and A-flutter**_, _**prevent AVNRT, AVRT**_ and _**treat ventricular tachyarrythmias_**.
31
A heart patient on medications has shortness of breath and increased patellar reflexes on physical exam. What medication might be casuing this?
Procainamide Side effect = drug induced lupus, which induces arthralgia, leading to increased patellar reflexes and pleuritis (-\> shortness of breath) [We (thank you Nathan Shlobin) are pretty sure about this, but if you know of another drug suggest an edit!]
32
Amiodarone, Dronedarone, Soltalol, Ibutilide, and Dofetilide are Class ___ anti-arrhythmic agents that block \_\_\_\_\_
Amiodarone, Dronedarone, Soltalol, Ibutilide, and Dofetilide are Class **_III**_ agents that block _**K+ channels (primarily)_** Increase AP duration, Increase effective refractory period
33
Which drug is considered the most effective anti-arrythmic agent? Why isn't it always used?
Amiodarone (class III anti-arrythmic) It is not alwyas used because thee side effects can be severe * Hypo- or hyper-thyroidism * Pulmonary fibrosis * Hepatotoxicity * Gray/blue skin discoloration
34
What are the major side effects of lidocaine?
CNS toxicity (Confusion, delerium, parasthesias, **grand mal siezures**) (Lidocaine = Class IB)
35
Which agents can be used for rate control in atrial fibrillation and atrial flutter?
* Clas II * Class IV * Digoxin
36
Metoprolol and esmolol are Class ____ anti-arrhythmic agents that are ______ blockers
Metoprolol and esmolol are Class **_II**_ antiarrhythmic agents that are _**beta_** blockers Decrease slope of phase 4 depolarization(SA), decrease upstroke velocity (SA, AV)
37
What are the general treatment strategies to treat a tachyarrhythmia that arises from reentry? (ex: A-fib, A-flutter, multifocal AT, AVRT, AVNRT, Ventricular premature beats, Monomorphic VT, V-fib)
1. Increase the refractory period of the slow conducting tissue 2. Slow down conduction even further 3. Supress premature beats
38
Problems with ________ usually cause **Atrial Premature Beats** A. Automaticity B. Reentry C. Triggered Activity
A. Automaticity
39
What are the major side effects of Sotalol?
Similar to beta blockers * Bronchospasm * Depression * Cognitive impairment * Hypotension Sotalol = Class III anti-arrythmic Proarrythmic -\> New or worse VT (ex: Torsades de Pointes)
40
**Amiodarone** is a class ____ anti-arrhythmic that blocks ______ channels. It \_\__creases_ action potential duration in heart tissues and \_\__creases_ the effective refractory period It can be used to \_\_\_\_\_\_\_\_\_\_\_\_\_, ____________ and \_\_\_\_\_\_\_\_\_\_\_\_\_.
**Amiodarone** is a class **_III**_ anti-arrhythmic that blocks _**K+ (and some Na+, Ca2+)_** channels **(also has some beta-blocking activity)**. It _**in**creases_ action potential duration in heart tissues and _**in**creases_ the effective refractory period It can be used to **_suppress ventricular tachycardia_** _(but defibrillator is more effective)_, **_maintain sinus rhythm in Afib and Aflutter**_ and _**convert Afib to sinus rhythm_**.
41
A heart patient is recovering from MI but develops siezures and lethargy after 3 days in the intensive care unit. What medication might be casuing this?
Lidocaine or Mexelitine (Class IB)
42
**Propafenone** is a class ____ anti-arrhythmic that blocks ______ channels. It \_\__creases_ conduction time in heart tissues and \_\__creases_ inotropy It can be used for \_\_\_\_\_\_\_\_\_\_\_\_\_, ____________ and \_\_\_\_\_\_\_\_\_\_\_\_\_.
**Propafenone** is a class **_IC**_ anti-arrhythmic that blocks _**Na+ (and some K+)_** channels. It _**in**creases_ conduction time in heart tissues and _**de**creases_ inotropy It can be used for **_acute conversion of atrial fibrillation**_, _**maintenence of sinus rhythm in atrial fibrillation,_** and **_treatment of ventricular arrhythmia_**.
43
Problems with ________ usually cause **Multifocal AT** A. Automaticity B. Reentry C. Triggered Activity
B. Reentry
44
Flecainide and Proafenone are Class ___ anti-arrhythmic agents that block \_\_\_\_\_
Flecainide and Proafenone are Class **_IC**_ agents that block _**Na+ channels strongly, and K+ channels very weakly_** Prolong AP upstroke, decrease inotropy
45
What are the general treatment strategies to treat arrhythmias caused by automaticity? (ex: Sinus tachycardia, atrial or ventricular premature beats, monomorphic VT)
1. Hyperpolarize the membrane 2. Decrease the slope of phase 4 depolarization 3. Increase threshold potential In general, make it more difficult for the automatic focus to reach threshold and initiate an action potential
46
What are beta-blockers used for in the context of arrythmias?
Beta blockers = class II anti-arrythmic agents * Decrease the ventricular response in atrial fibrillation * Disrupt reentrant arrythmias (AVRT, AVNRT, AT) * Suprpresse premature ventricular contraction and atrial premature beats * Decrease mortality & incidence of sudden death post-MI
47
Which class of anti-arrhytmic drugs are considered **potassium channel blockers?**
**Class III** (Amiodarone, Dronedarone, Solalol, Ibutilide, Dofetilide)
48
Which tachycardias can arise from problems with reentry?
* Atrial fibrilation * Atrial flutter * Multifocal Atrial Tachycardia * AVNRT * AVRT * Ventricular Premature Beats\* * Monomorphic Ventricular Tachycardia\*\* * Ventricular Fibrillation \* = Can also arise from automaticity \*\* = Can also arise from automaticityor triggered activity, **but reentry is the main cause**
49
**Mexelitine** is a class ____ anti-arrhythmic that blocks ______ channels. It can be used for \_\_\_\_\_\_\_\_\_\_\_\_\_.
**Mexelitine** is a class **_IB**_ anti-arrhythmic that blocks _**Na+_** channels. It can be used for **_chronic suppression of ventricular arrythmias_**. (Not first line, but used sometimes)
50
Which subclass (A, B, or C) of Class I anti-arrythmic drugs has no effect on potassium channels?
**Class IB** (Low Na+, No K+ blocking) | (Lidocaine, Melilotine, Phenytoin)
51
What are the major side effects of propafenone?
Bronchospasm Proarrythmic -\> Heart block due to slow conduction, exacerbation of ventricular arrythmia (Propafenone = Class IC)
52
**Lidocaine** is a class ____ anti-arrhythmic that blocks ______ channels. It can be used to treat \_\_\_\_\_\_\_\_\_\_\_, and \_\_\_\_\_\_\_\_\_\_\_\_.
**Lidocaine** is a class **_IB**_ anti-arrhythmic that blocks _**Na+_** channels. It can be used to treat **_ventricular arrythmias (especially post-MI)_** , and **_myocardial ischemia_**.
53
Which agents can be used to treat Torsades de Pointes?
* **Electrical cardioversion (first choice)** * Mg2+ * Stabilizes electrical membrane * Isoproterenol, overdrive pacing * Increase HR to decrease QT interval * Phenytoin
54
Which class of anti-arrhythmic drugs are considered **sodium channel blockers?**
**Class I** A: Moderate Na+ and K+ blocking B: Low Na+ and no K+ blocking C: High Na+ and v. low K+ blocking
55
What are the major side effects of using beta blockers to treat arrythmias?
Bronchospasm, depression, cognitive impariment, hypotension Proarrythmic -\> Bradycardia, heart block
56
**_Disopyrimide**_ is a class _**IA_** anti-arrhythmic that blocks _________ channels and binds the ____ receptor. It can be used to treat \_\_\_\_\_\_\_\_\_\_\_. It has negative ________ effects.
**_Disopyrimide**_ is a class _**IA**_ anti-arrhythmic that blocks _**Na+ and K+_** channels and binds the **_M2 muscarinic_** receptor. (Therefore, it is anti-muscarinic) It has **_negative**_ _**inotropic_** effects. It can be used to treat **_hypertrophic obstructive cardiomyopathy_**. (but it is not commonly used)
57
Which agents can be used for acute conversion of A-fib and A-flutter, as well as maintenenc of sinus rhythm?
* Class IC * Flecanide * Propafenone * Class III * Amiodarone * Sotalol * Dofetilide * Ibutilide
58
What are the side effects of Adenosine?
* Flushing * Chest burning * Chest pressure Proarrythmic -\> Atrial fibrillation (occasional)
59
Problems with ________ usually cause **sinus tachycardia** A. Automaticity B. Reentry C. Triggered Activity
A. Automaticity
60
Describe the mechanism of action of mexelitine
Mexelitine binds to the activated and inactivated Na+ channel, but not the resting channel **Therefore, it preferentially binds sick myocaridum over healthy myocardium, to inhibit the phase 0 upstroke** (Same mechanism as lidocaine, but mexelitine is orally available) (Mexelitine = Class IB)
61
Which agents can be used to suppress symptomatic PVCs and VT?
* Class II * Class IB * Class IC * Class III * Sotalol and amiodarone only * Class Ia (occasionally disopyramide) **Note: almost everything except Class IV**
62
Which drug is the first choice for diagnosis and termination of SVT?
Adenosine It gets rid of QRS complexes momentarily so A-fib and A-flutter are easier to see
63
A ________ QT interval can predispose a patient to Torsades de Pointes
A **_long_** QT interval can predispose a patient to Torsades de Pointes
64
Which subclass (A, B, or C) of Class I anti-arrythmic drugs has the greatest sodium channel blocking action?
**Class IC** (High Na+, very low K+ blocking) (flecainide, propafenone)
65
What are the major side effects of Ibutilide?
GI effects (Few extracardiac effects) Proarrythmic -\> Increased risk of Torsades de Pointes in the first few hours
66
**Flecainide** is a class ____ anti-arrhythmic that blocks ______ channels. It \_\_**_creases_** conduction time in heart tissues and \_\_**_creases_** inotropy It can be used for \_\_\_\_\_\_\_\_\_\_\_\_\_, and \_\_\_\_\_\_\_\_\_\_\_\_\_.
**Flecainide** is a class **_IC**_ anti-arrhythmic that blocks _**Na+ (and some K+)**_ channels. It _**increases**_ conduction time in heart tissues and _**decreases_** inotropy It can be used for **_acute conversion of atrial fibrillation**_, and _**maintenence of sinus rhythm in atrial fibrillation_**.
67
What is the mechanism of action of class II anti-arrythmic drugs? What are they used for?
Class II anti-arrhythmic drugs are beta blockers * Decrease **slope** of phase 4 depolarization in the **SA node** * Decrease **upstroke velocity** in the **SA and AV node** They are used to... * Decrease the ventricular response in atrial fibrillation * Disrupt reentrant arrythmias (AVRT, AVNRT, AT) * Suprpresse premature ventricular contraction and atrial premature beats * Decrease mortality & incidence of sudden death post-MI
68
Problems with ________ usually cause **Polymorphic VT** A. Automaticity B. Reentry C. Triggered Activity
C. Triggered Activity
69
Which class of anti-arrhytmic drugs are considered **beta-blockers**?
Class II | (Metoprolol, Esmolol, many others)
70
Which anti-arrythmic drug is most likely to cause grand-mal siezures?
Lidocaine, Mexelitine
71
Problems with ________ usually cause **Atrial Fibrillation** A. Automaticity B. Reentry C. Triggered Activity
B. Reentry
72
A heart patient on medications is experiencei tinnitus and delerium. What medication might be casuing this?
Quinidine or Disopyrmide
73
Which anti-arrhythmic drugs are classified in the "miscellaneous" category?
Digoxin Adenosine Mg2+
74
Which treatment strategy for atrial fibrillation involves slowing down the AV node?
Rate control
75
What are the effects of **digoxin** on the heart? What is it used for?
* Effects * **Positive inotropy** * Digoxin blocks the Na+/K+ ATPase * This increases the amount of Na+ in the cell * This decreases the activity of the Na+/Ca2+ exhanger (which normally pumps Ca2+ out and Na+ in) * **Vagomimetic:** slows conduction through SA node, Atria, AV node * Uses * Control ventricular response in A-fib and A-flutter * Use with beta blocker, Ca2+ channel blocker * Heart failure: Last resort agent to increase systolic function *
76
What might cause the appearane of retrograde P waves on an ECG?
Retrograde P-wave = P-wave after the QRS complex Due to reentry (AVNRT)
77
The two major treatment strategies to treat atrial fibrillation, atrial flutter, and atrial tachycardia are __________ control and ___________ control. Describe each one briefly
The two major treatment strategies to treat atrial fibrillation, atrial flutter, and atrial tachycardia are **_(ventricular) rate_** **_control_** and **_rhythm control_**. * **_Rate control_** * Slow down the **AV node** to control the ventricular rate * Leave the atria in fibrillation * **_Rhythm control_** * Modify the atrial electrical properties in the **SA node** to resotre sinus rhythm
78
What are the major side effects of mexelitine?
Nausea, vomiting, confusion, delerium, parasthesias, grand-mal siezures (same as lidocaine) **Proarrythmic:** may exacerbate ventricular arrythmia, sinus bradycardia (Mexelitine = class IB)
79
What agents can be used to disrupt SVT, such as AVNRT and AVRT?
* Adenosine (1st choice for diagnosis and treatment) * Class II * Class IV * Class III (amiodarone, but rarely used becaues others are less toxic)
80
What are the effects of **Adenosine** on the heart? What is it used for?
* Effects * Binds A1 Adenosine receptors * Causes hyperpolarization and heart block * Activates K+ channels * Blocks L-type Ca2+ channels * Inhibits funny current * Uses * Diagnosis and treatment of SVT **(1st choice)** * Terminates reentrant rhythms
81
Which classes of anti-arrythmic drugs can prolong the QT interval on the eletrocardiogram?
Class III: K+ channel blockers Class IA: Na+ and K+ channel blocker
82
What are the side effects of flecainide?
Confusion, irritability Proarrythmic -\> Heart block due to slow conduction, may exacerabate ventricular arrythmia (Flecainide = class IC)
83
Problems with ________ usually cause **AVNRT** A. Automaticity B. Reentry C. Triggered Activity
B. Reentry
84
Which tachycardias can arise from problems with automaticity?
* Sinus tachycardia * Atrial premature beats * Ventricular premature beats\* * Monomorphic Ventricular Tachycardia\*\* \* = Can also arise from reentry \*\* = Can also arise from reentry (major cause) or triggered activity
85
What are the major side effects of veramapil?
* Constipation * Peripheral edema * Hypotension Proarrythmic -\> Sinus bradycardia, heart block

CVB by Minnie (Madeleine) (43 decks)

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