ANTIDYSRHYTHMIC DRUGS

Cardiac dysrhythmia

 deviation from normal rate & pattern of heartbeat.

 Atrial dysrhythmias  prevent proper filling of ventricles  decrease CO (1/3)

 Ventricular dysrhythmias  lifethreatening

 ineffective filling of ventricle  decrease or absent CO

Types of Arrhythmias:

1. Sinus Arrhythmias
• ANS influence SA node to change rate of firing to meet body’s demand for O2

 Sinus tachycardia
• faster than normal HR with normal- appearing ECG.

 Sinus bradycardia
• Slower than normal HR with normal- appearing ECG.

2. Supraventricular Arrhythmias
• arrhythmias that originate above ventricles but not in SA node.
• abnormal P wave but normal QRS complexes.

 Premature atrial contraction (PAC)

• ectopic focus in atria conducting impulse out of normal rhythm.

 Paroxysmal atrial tachycardia (PAT)

• sporadically occurring rapid HR originating in atria.

 Atrial flutter
• sawtoothed –shaped P waves
• regular fast atrial depolarization
• from a single ectopic focus

 Atrial fibrillation
• irregular P waves
• rapid, uncoordinated atrial depolarization
• from many ectopic foci
• bombardment of impulses at AV node  transmit many impulses to ventricles
 cause rapid, irregular & ineffective ventricular contraction.
3. Atrioventricular block (AV block)
• Aka heart block
• slow or lack of conduction at AV node

 First- degree heart block

• all impulses from SA node arrive in ventricles but takes longer time.

 Second-degree heart block

• some impulses are lost & donot get through
• slow rate of ventricular contraction

 Third-degree or complete heart block

• no impulses from SA node get thru ventricles
• much slower ventricular automaticity takes over.

4. Ventricular arrhythmias
• impulses from ectopic foci that originate below AV node.
• wide & prolonged QRS complexes + T wave inversion

 Premature Ventricular Contractions (PVCs)

• arise form single/ many ectopic foci from ventricles
• many PVCs  ominous  reflect extensive damage in myocardium.

 Ventricular Tachycardia
• several PVCs at a rapid rate.

 Ventricular Fibrillation
• bizarre, irregular, distorted wave
• fatal  reflects inability to contract coordinately  lack/total loss of CO 
lack/ no blood pumped to body or brain.
• CPR necessary.

Causes of Arrhythmias:

1. electrolyte imbalances
2. hypoxia/ anoxia
3. acidosis / accumulation of waste products
4. structural damage
5. drugs
Cardiac Action Potentials
• depolarization & repolarization of myocardial cells

5 Phases:

phase 0
• rapid depolarization caused by sodium influx.

phase 1
• initial repolarization w/c coincides with termination of Na influx.

phase 2
• plateau stage
• influx of calcium  prolongs action potential
• promotes atrial & ventricular contraction

phase 3
• rapid repolarization caused by K influx

phase 4
• resting membrane potential
 Antiarrhythmic Drugs

Class I: (Fast) Sodium channel blockers

Class Ia Class II : Beta - blockers
• disopyramide • Acebutolol
• quinidine • Esmolol
• procainamide • Propanolol
• moricixine
Class III : Prolong Repolarization
Class Ib • Bretylium
• lidocaine • Amiodarone
• mexiletine • Ibutilide
• tocainide • Dofetilide
• Sotalol
Class Ic
• flecainide Class IV: (Slow) Calcium channel blockers
• propafenone • Verapamil
• Diltiazem

I. Class I: (Fast) Sodium channel blockers

 depress phase 0 of action potential (AP)
 decrease fast Na influx into cardiac cells

slow conduction & automaticity

Class 1a
• slows conduction & prolongs repolarization
• Tx of lifethreatening ventricular arrhythmias

1. Procainamide
 associated with drug- induced SLE
 associated with severe hematologic disorders

2. Moricizine
 proarrhythmic  increase cardiac death

3. Quinidine
 DOC for long term tx of atrial arrhythmias

4. Disopyramide
 Class 1b
• slows conduction & slows repolarization
• tx of lifethreatening ventricular arrhythmias

1. Lidocaine
 first line drug for ventricular ectopy
 DOC for premature ventricular contractions (PVCs), ventricular tachycardia &
fibrillation , esp during MI

2. Tocainide
 also used for myotonic dystrophy & trigeminal neuralgia

3. Mexiletine

Class Ic
• extreme slowing of conduction with little or no effect on repolarization.
• Tx of paroxysmal atrial tachycardia (PAT) & lifethreatening ventricular arryhtmias

1. Flecainide
 proarrhythmic

2. Propafenone
 DOC for PAT

II. Class II: Beta- blockers

 decrease conduction velocity, automaticity & recovery time
 prevent sympathetic stimulation
 Tx of PVCs & SVT

1. Esmolol
 DOC for short-term tx of SVT

2. Acebutolol
 Tx of PVCs

3. Propanolol
  Tx of SVT caused by digoxin or catecholamines
 Crosses BBB
 Antianginal, antihypertensive, antimigraine headache

III. Class III: Prolong repolarization

 block potassium channels
 prolong phase 3 of AP
 emergency tx of atrial & ventricular dysrhythmias

1. Bretylium
 short-term Tx of ventricular tachycardia/ fibrillation.

2. Amiodarone tx of lifethreatening ventricular arrhythmias

3. Sotalol
 maintain NSR after conversion of atrial arrhythmias.

4. Ibutilide
 DOC to rapidly convert atrial fibrillation or flutter of recent onset.

5. Dofetilide
 use to convert atrial fibrillation or flutter to NSR.
 maintain NSR after conversion of atrial arrhythmias.

IV. Class IV : (Slow) Calcium channel blockers

 blocks calcium influx

decrease excitability & contractility

 increases refractory period of AV node

decrease ventricular response

1. Verapamil
 Tx of paroxysmal SVT
 slow ventricular response to atrial fibrillation/ flutter
 CI in AV block & CHF

2. Diltiazem
 Tx of paroxysmal SVT

Other antidysrhythmics:

1. Adenosine
 DOC for tx of SVT
 Including those caused by use of alternate conduction pathways
Ie. Wolff-parkinson –White syndrome.
 2. Digoxin
 Effective in TX of atrial arrhythmias.

SE/ Adverse effects:

1. Quinidine
• N & V , diarrhea, confusion & hypotension
• cause heartblock & psychiatric symptoms.

2. Procainamide
• less cardiac depression than quinidine
• assoc with drug-induced SLE, neutropenia, thrombocytopenia

3. Lidocaine (high dose)

• cardiovascular depression (bradycardia, hypotension)
• seizures
• blurred vision, diplopia
• CI; advanced AV block

4. Mexiletine & tocainide

• same with lidocaine
• CI: cardiogenic shock & 2nd- 3rd degree heartblock

5. Beta-blockers
• bradycardia
• hypotension

6. Bretylium & amiodarone

• N&V
• hypotension
• neurologic problems

7. Calcium channel blockers

• N&V
• Hypotension
• Bardycardia

 ALL antidysrhythmic are potentially prodysrhythmic.

Nursing Responsibilities:
1. Obtain baseline VS & ECG.
2. Check early cardiac enzymes.(LDH, CPK, aspartate aminotransferase)
3. Administer IV push or bolus over a period of 2 - 3 min.
4. Titrate dose to the smallest amount needed.
5. Give parenteral forms only if oral form is not feasible.
6. Continuous cardiac monitoring.