Antiarrhythmic Drugs Class MOA + I (Na 1) AP threshold Channel 2) depol slope takes longer for Blockers) AP to be started 3) slows

ows HR 4) ventricular and atrial muscles and Purkinje fibers are more dependent on Na+ channels IA 1) prolong depol in SA node and ventricular myocytes 2) bind to Na+ channels in open state 3) block K+ channels prolongs repol of AP

Drugs

SE

Quinidine - anticholinergic effects conduction thru AV node problematic for atrial fluttering b/c it can result in excessive firing of ventricles - not for long QT syndrome b/c of risk of torsades de pointes Disopyramide - fewer GI problems - more profound anticholinergic effects - rifampin activity of disopyramide - smaller MW and higher affinity used when no response to quinidine or procainamide Procainamide - no anticholinergic effect - for ventricular arrhythmias

IB

1) alter ventricular AP by blocking Na+ channels 2) bind to inactivated and open Na+ channels, but not to resting channels 3) mildly prolong depol 4) shorten repol safe for long QT syndrome

IC

1) potent Na+ channels blockers 2) no effect on repol 3) extensive slowing of depol tx of premature ventricular contractions, paroxysmal supraventricular tachycardia, and AFib 4) strong depressant effect on cardiac function 1) suppress sympathetic activity 2) rate of depol -blockers automaticity 3) prolong repol prevent re-entry arrhythmias

II ( selective Antagonist )

Lidocaine - for emergency events to treat ventricular arrhythmias - for ventricular tachycardia - for premature ventricular contractions - bradycardia occurs b/c Na+ channels Mexiletine - life-threatening ventricular arrhythmia - adjunct to other antiarrhythmia agents (amiodarone) Phenytoin - for arrhythmia - for long QT syndrome when -blockers failed Flecainide - slows down conduction so cannot use often - MI muscles not contracting flecainide slows down conduction more Encainide Moricizine Propafenone 1st gen (propranolol) - nonselective of 1 and 2 - tachycardia induced by physical/emotional

1) 2 antagonism causes smooth muscle spasms bronchoconstriction 2) cold extremities

4) most effective for supraventricular and ventricular arrhythmias precipitated by sympathetic activity

III (K+ Channel Blockers)

1) block K+ channels inhibit repol prolong plateau phase (K+ does not leave cell while Ca2+ keeps coming in) beneficial b/c of prolonged refractory period arrhythmia re-entry 2) prolongs plateau phase harmful b/c of early after-depol torsades de pointes

stress 2 gen (metoprolol, acebutolol, bisoprolol, and atenolol) - selective of 1 3rd gen (labetolol and carvedilol) - antagonists - pindolol is partial 2 agonist Ibutilide - K+ channel activity prolong plateau phase and associated with torsades de pointes - less effect during faster rhythm and more effect at slower rates Dofetilide - K+ channel activity prolong plateau phase and associated with torsades de pointes - less effect during faster rhythm and more effect at slower rates Sotalol - K+ channel activity prolong plateau phase and associated with torsades de pointes - -blocker too - less effect during faster rhythm and more effect at slower rates Bretylium - cause NE release then
nd

3) impotence 4) exaggeration of antagonism heart block and bradycardia 5) insomnia 6) depression

1) Sotalol can cause -blocker SE (bradycardia) 2) Amiodarone has low incidence of torsades de pointes, inhibit conversion of T4 T3, and can cause AV block and bradycardia Prolong repol all Na+ channels open affinity is and even with less Na+ channels can produce AP

inhibit release for recurrent ventricular arrhythmias less effect during faster rhythm and more effect at slower rates

Amiodarone - mixed-class agent (I, II, III, and IV) - CI in cardio-genic shock, 2nd/3rd degree heart block, and severe SA node dysfunction with bradycardia or syncope - alter lipid membrane in which receptors are located - prolong repolarization IV (Ca2+ Channel Blockers) 1) act on SA/AV nodes 2) slow conduction velocity thru AV node blocks re-entry arrhythmias Verapamil - for re-entrant paroxysmal supraventricular tachycardia Diltiazem - for re-entrant paroxysmal supraventricular tachycardia 1) can cause AV block by conduction velocity 2) concomitant use with -blockers heart failure 3) digoxin levels by competing for renal excretion

Hypo and hyperkalemia cause arrhythmia Hyperkalemia = less potassium leaving cell = repol slows Hypokalemia = inc potassium efflux