Acute Life-Threatening

Arrhythmias
 Adult Cardiac arrest
Advanced cardiovascular life support (ACLS )
Algorithm
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 Symptomatic Bradycardia
If unstable (hypotension, acute altered mental
status, signs of shock, ischemic chest
discomfort, acute HF) Atropine 0.5 mg
every 35 minutes (maximal dose 3 mg or
0.04 mg/kg)
If atropine fails transcutaneous pacing,
Dopamine 2-10mcg/kg/minute infusion, or
Epinephrine infusion 2-10mcg/kg/minute
C. Symptomatic Tachycardia

If unstable Treat with

synchronized cardioversion

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 Stable Symptomatic Tachycardia

If stable, determine
whether QRS complex is
narrow or wide.
 Tachycardia

QRS Complex

Narrow < ( 120) mS

Wide > ( 120) mS

Atrial Arrythmias
Ventricular rhythm
Ventricular Tachycardia
Irregular Regular
Atrial Fib PSVT Sinus
Tachycardia
Atrial Flutter
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A. Narrow complex tachycardia: Regular Ventricular rhythm
A. Vagal maneuvers and/or Adenosine 6-mg IV push followed by a
20-mL saline flush; then a 12-mg IV push (may repeat once).
- Rapid push is followed by elevation of arm to increase circulation.
Do not give adenosine for unstable or for irregular or
polymorphic wide complex tachycardias because it may cause
degeneration to VF.
Use adenosine cautiously in severe (CAD).
Do not give adenosine for asthmatic pt
Larger dosed if pt on theophylline, caffeine
Initial dose reduced to 3 mg if pt on carbamazepine or
dipyridamole, after heart transplantation and when given by
central line
B. IF Vagal maneuvers or adenosine failed to convert PSVT CCB
or B blockers can be used. If WPW syndrome, avoid verapamil,
diltiazem, and digoxin.
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Narrow complex: Irregular ventricular rhythm AF (or Atrial flutter)

a. General mgt should focus on control of the rapid ventricular

rate:
1. usually NDHPCCBs or B-blockers ; digoxin is sometimes useful
2. Rate is acceptable if it is < 110 beats/minute at rest in asymptomatic
persistent AF

b. If hemodynamically unstable, synchronized

cardioversion is recommended
c. Pts with AF for > 48 hours are at high risk of
cardioembolic events and should not be immediately
cardioverted if stable.
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Irregular (narrow complex) ventricular rhythm
(continue)
d. TEE (Transesophageal echocardiography) before
cardioversion is an alternative strategy to ensure
the absence of left atrial clot
e. Risk of thromboembolic eventis greatest within
the first 10 days
f. Cardioversion:
 f. Cardioversion:
1. If AF for up to 7 days, either elective direct
current cardioversion (DCC) or chemical
cardioversion with:
A. flecainide, propafenone, dofetilide, ibutilide, or
amiodarone (proven efficacy)
B. Digoxin and sotalol NOT recommened and may
be harmful
C. Disopyramide, quinidine and procainamide are
less effective or incompletely studied.
2. If AF greater than 7 days, either elective DCC
or chemical cardioversion with dofetilide,
amiodarone, or ibutilide (proven efficacy)
B. Wide Complex tachycardia: QRS > 120 mS,
Usually ventricular arrhrythmias
i. VT or unknown mechenism
ii. Definite SVT with aberrancy (is due
to bundle branch block or WPW
syndrome)- likely transiently slowed
or converted by adenosine
iii. Polymorphic (irregular) VT
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 Polymorphic (irregular) VT
a) Induced primarly when QTc interval is greater
than 500ms (torsade de pointes)
b) If unstable, polymorphic (irregular) requires
immediate defibrillation with the same
strategy as VF
c) If stable, intravenous Mg 1- 2 g IV bolus (max
16 g/24 hour)
 Polymorphic (irregular) VT
d) Withdrawal of QT-prolonging medications,
correction of low Mg2+ or K+ levels
1) Class I and III antiarrhythmic
2) Assess for drug interactions by CYP 3A4 (eg
azole antifungals, erythomycin)
3) QTc-prolonging drugs eg: haloperidol,
ziprasidone, droperidol, promethazine, macrolide
and quinolone antibiotics, TCAs, or drugs CI with
dofetilide such as cotrimoxazole or thiazides
D. Classification of antiarrhythmic drugs
Side Effects of Antiarrhythmic Drugs
Side Effects of Antiarrhythmic Drugs
 E. Implantable Cardioverter Defibrillators
1. For primary prevention of SCD (sudden cardiac death )
a. Previous MI, at least 40 days prior and EF of 35% or less
b. Nonischemic dilated cardiomyopathy, LVEF of 35% or less receiving optimal
chronic medications for at least 3 months
c. Syncope with structural heart disease and inducible VT/VF during
electrophysiologic study
d. High risk of life-threatening VT/VF; congenital long QT syndrome with
recurrent symptoms or torsades while receiving -blocker
e. Must have reasonable survival expectation for more than 1 year

2. For secondary prevention of SCD

a. Previous episode of resuscitated VT/VF, hemodynamically unstable VT with no
completely reversible cause, or sustained VT in presence of heart disease
b. Must be receiving optimal chronic medications (-blockers, ACE inhibitors)
c. Must have reasonable survival expectation for more than 1 year

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F. Chronic Drug Therapy for Ventricular Arrhythmias
1. -Blockers
a. Considered mainstay therapy

b. Effective in suppressing ventricular ectopic beats and in reducing SCD in a spectrum of

cardiac disorders in pts with and without HF (nonsustained VT)
2. Amiodarone
a. No better than ICD in reducing SCD as a lone agent; no mortality benefit

b. Can be used to treat symptomatic nonsustained VT if -blockers not effective when ICD not indicated

c. Can be used in combination with -blockers to decrease firing of ICD (defibrillator storm)

3. Sotalol
a. No mortality benefit

b. Can suppress VT and be used to decrease frequency of ICD firing

c. Graeter proarrhythmic potential, avoid in pt with severly depressed LVEF or significant HF,
renal dosing required

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G. Treatment of arrhythmias in special populations
1. Heart failure
a. Avoid class Ia and Ic agents
b. Amiodarone and dofetilide (used for atrial
arrhythmias only) have a neutral effect on
mortality in pt with LV dysfuntion post-MI
c. Dronedarone (used in atrial arrhythmias only) is
CI in pt with HF with recent decompensation
requiring hospitalization or NYHA class IV; risk of
death is doubled in these pts
Treatment of arrhythmias in special populations
2. Acute MI
a. Avoid class Ia and Ic agents
b. CAST trial with class Ic agents (encainide, flecainide)
showed increased mortality when used to treat
post-MI non-life threatening arrhythmias, avoid class
Ic agent in pts with structural heart disease
c. Class Ia, increased mortality in post-MI survivor
d. Amiodarone and dofetilide (used for atrial
arrhythmias only) have a neutral effect on mortality
in pt with LV dysfuntion post-MI
 H. drug-induced arrhythmias
1. Drug-induced QT prolongation
a. Ensure proper renal/hepatic dosing adjustment
b. Review electrolyte abnormalities and thyroid
function tests
c. Ensure that all electrolytes are maintained at critical
levels: K+ greater than 4mmol/l and less than 5
mmol/l and Mg2+ greater than 2mg/dl
d. Ensure that all ECG parameters are within normal
limits ( eg QT interval less 500ms)
2. Bradycardia or AV block
a. B-blockers, CCB, digoxin
b. Administer antidote if approperiate (eg calcium for
CCB)
3. Review drug interactions
Case1:
C.D. is a 68-year-old man admitted after an episode of syncope, with a
presyncopal syndrome of seeing black spots and experiencing dizziness
before passing out. Telemetry monitor showed sustained VT for 45
seconds. His medical history includes HF NYHA class III, LVEF 30%, MI 2,
HTN 20 years, LV hypertrophy, diabetes mellitus, and diabetic
nephropathy. His drugs include lisinopril 5 mg/day, furosemide 20 mg 2
times/day, metoprolol 25 mg 2 times/day, digoxin 0.125 mg/day,
glyburide 5 mg/day, and aspirin 325 mg/ day. His laboratory tests show
BP 120/75 mm Hg, HR 80 beats/minute, BUN 30 mg/dL, and SCr 2.2
mg/dL. Which one of the following is the best therapy to initiate for
conversion of his sustained VT?

A. Amiodarone 150 mg intravenously for 10 minutes; then 1 mg/minute

for 6 hours; then 0.5 mg/minute.
B. Sotalol 80 mg 2 times/day titrated to QTc of about 450
milliseconds.
C. Dofetilide 500 mcg 2 times/day titrated to QTc of about 450
milliseconds.
D. Procainamide 20 mg/minute, with a maximum of 17 mg/kg. 24
Case2:
S.L., a 64-year-old woman, presents to the emergency department with a
chief concern of palpitations. Her medical history includes HTN controlled
with a diuretic and inferior-wall MI 6 months ago. She is pale and diaphoretic
but able to respond to commands. S.L.s laboratory parameters are within
normal limits. Her vital signs include BP 95/70 mm Hg and HR 145
beats/minute; telemetry shows sustained VT. Although initially unresponsive
to -blockers, S.L. is successfully treated with lidocaine. Subsequent
electrophysiologic testing reveals inducible VT, and sotalol 80 mg orally twice
daily is prescribed. Two hours after the second dose, S.L.s QTc is 520
milliseconds. Which one of the following changes would be best with
respect to S.L.s antiarrhythmic regimen?

A. Continue sotalol at 80 mg orally twice daily.

B. Increase sotalol to 120 mg orally twice daily.
C. Discontinue sotalol and initiate dofetilide 125 mcg orally twice daily.
D. Discontinue sotalol and initiate amiodarone 400 mg orally 3 times/day.

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 Thanks