CondlLlon urug CommenLs

Slnus 1achycardla Class ll lv CLher underlylng causes may need

LreaLmenL
ALLrlal lluLLer Class lA lC ll lll lv dlglLalls adenoslne venLrlcular raLe conLrol ls lmporLanL goal
anLlcoagulaLlon requlred
aroxysmal supravenLlcular 1achycardla Class lA lC ll lll lv adenoslne
Av 8lock ALroplne AcuLe 8eversal
venLrlcular 1achycardla Class ll ll lll
remaLure venLrlcular Complexes Class ll lv Mg++ salLs vCs are ofLen benlgn and noL LreaLed
ulglLalls 1oxlclLy Class l8 Mg++ salLs kCl

C|ass I Sod|um channe| b|ockers
Class IA: atrial fibrillation, flutter; supraventricular & ventricular tachyarrhythmias
quinidine` anticholinergic (moderate) cinchonism (blurred vision, tinnitus, headache, psychosis); cramping and
nausea; enhances digitalis toxicity
procainamide anticholinergic (weak); relatively
short halI-liIe
lupus-like syndrome in 25-30 oI patients
disopryamide anticholinergic (strong) negative inotropic eIIect
Class IB: ventricular tachyarrhythmias (VT)
lidocaine` ' only; '% and P's good eIIicacy in ischemic myocardium
tocainide orally active lidocaine analog can cause pulmonary Iibrosis
mexiletine orally active lidocaine analog good eIIicacy in ischemic myocardium
phenytoin digitalis-induced arrhythmias
Class IC: life-threatening supraventricular tachyarrhythmias (SVT) and ventricular tachyarrhythmias (VT)
flecainide` $'% can induce liIe-threatening '%
propafenone $'% & '%; -blocking and a

-channel blocking activity can worsen heart Iailure

moricizine '%; activity

C|ass II 8eta 8|ockers
linical Uses
lass/Drug HTN Angina Arrhy MI HF omments
Non-selective
1
/
2

carteolol X $; long acting; also used Ior glaucoma
carvedilol X X u-blocking activity
labetalol X X $; u-blocking activity
nadolol X X X X long acting
penbutolol X X $
pindolol X X $; M$
propranolol X X X X M$; prototypical beta-blocker
sotalol X several other signiIicant mechanisms
timolol X X X X primarily used Ior glaucoma

1
-selective
acebutolol X X X $
atenolol X X X X
betaxolol X X X M$
bisoprolol X X X
esmolol X X ultra short acting; intra or postoperative H%
metoprolol X X X X X M$
nebivolol X relatively selective in most patients; vasodilating ( release)

C|ass III otass|um Channe| 8|ocker
Drug Therapeutic Uses omments
amiodarone severe supraventricular and
ventricular arrhythmias
very long halI-liIe (25-60 days); lass , , & ' actions and thereIore decreases
phase 4 slope and conduction velocity; potentially serious side eIIects (e.g., pulmonary
Iibrosis; hypothyroidism)
dronedarone atrial Iibrillation and Ilutter structurally related to amiodarone, but has a much smaller volume oI distribution and
shorter elimination halI-liIe (13-19 hr); lass , , & ' actions; it may be a saIer
alternative than amiodarone Ior atrial Iibrillation/Ilutter; containdicated in severe or
recently decompensated, symptomatic heart Iailure; can cause severe liver injury in some
patients
bretylium liIe-threatening ventricular
tachycardia and Iibrillation
' only; initial sympathomimetic eIIect (norepinephrine release) Iollowed by inhibition,
which can lead to hypotension
sotalol ventricular arrhythmias;
atrial Ilutter and Iibrillation
also has lass activity
ibutilide supraventricular
arrhythmias; atrial Ilutter
and Iibrillation conversion
slow inward a

activator, which delays repolarization; inhibits a

-channel
inactivation, which increases ERP; ' only
doIetilide supraventricular
arrhythmias; atrial Ilutter
and Iibrillation conversion
very selective K

-channel blocker

C|ass IV Ca|c|um Channe| 8|ockers
1hree Lypes ( Lhe plnes verapamll and dllLlazem)
1he mosL smooLh muscle selecLlve class of CC8s are Lhe d|hydropyr|d|nes 8ecause of Lhelr hlgh vascular selecLlvlLy Lhese drugs are
prlmarlly used Lo reduce sysLemlc vascular reslsLance and arLerlal pressure and Lherefore are prlmarlly used Lo LreaL hyperLenslon
1hey are noL however generally used Lo LreaL anglna because Lhelr powerful sysLemlc vasodllaLor and pressure lowerlng effecLs can
lead Lo reflex cardlac sLlmulaLlon (Lachycardla and lncreased lnoLropy) whlch can dramaLlcally lncrease myocardlal oxygen demand
Note tbot JlbyJtopytlJloes ote eosy to tecoqolze becoose tbe Jtoq oome eoJs lo ploe
O amlodipine
O felodipine
O isradipine
O nicardipine
O nifedipine
O nimodipine
O nitrendipine
O Verapam|| (phenylalkylamlne class) ls relaLlvely selecLlve for Lhe myocardlum and ls less effecLlve as a sysLemlc vasodllaLor
drug 1hls drug has a very lmporLanL role ln LreaLlng anglna (by reduclng myocardlal oxygen demand and reverslng coronary
vasospasm) and arrhyLhmlas
O ||t|azem (benzoLhlazeplne class) ls lnLermedlaLe beLween verapamll and dlhydropyrldlnes ln lLs selecLlvlLy for vascular
calclum channels 8y havlng boLh cardlac depressanL and vasodllaLor acLlons dllLlazem ls able Lo reduce arLerlal pressure
wlLhouL produclng Lhe same degree of reflex cardlac sLlmulaLlon caused by dlhydropyrldlnes
alcium-hannel lockers
ardiac eIIects
O ecrease contractility
(negative inotropy)
O ecrease heart rate
(negative chronotropy)
O ecrease conduction velocity
(negative dromotropy)
'ascular eIIects
O $mooth muscle relaxation
(vasodilation)
%herapeutic Use oI
alcium-hannel lockers
O Hypertension
(systemic & pulmonary)
O ngina
O rrhythmias

Misc drugs:
Adenosine: lthough adenosine is a powerIul vasodilator, especially in the coronary circulation, it is not used clinically as a
vasodilator. %he reason is that it is very short acting and in the heart it can produce coronary vascular steal. When administered by
intravenous inIusion, it can produce substantial hypotension.
denosine is used, however, as an antiarrhythmic drug Ior the rapid treatment oIsupraventricular tachycardias. ts eIIects on
atrioventricular conduction make it very useIul in treating paroxysmal supraventricular tachycardia in which the ' node is part
oI the reentry. denosine is not eIIective Ior atrial Ilutter or Iibrillation.
Electrolytes:
Magnesium is an important ion in many enzymatic reactions, including cardiaca

-K

-%Pase. Hypomagnesemia can inhibit this

vital ion transport system and lead to cellular depolarization.
Potassium ion plays an important role in membrane potentials, particularly in the resting membrane potential. t is also very important
in the repolarization phase oI cardiacpacemaker andnon-pacemaker action potentials (phase 3).
%hereIore, hypomagnesemia (serum concentration 1.5 mg/dl) and hypokalemia (serum concentration 3.5 mg/dl; severe
hypokalemia, 2.5 mg/dl) can precipitate cardiac arrhythmias, which include ventricular tachycardia and Iibrillation, premature
ventricular complexes, supraventricular tachycardias (e.g., WolII-Parkinson-White $yndrome), atrial tachycardias, including Ilutter
and Iibrillation, and arrhythmias associated with digitalis toxicity.
For treating hypomagnesemia-associated arrhythmias, magnesium sulIate may by administered intravenously. ral magnesium
supplementation can be administered using magnesium gluconate, oxide or hydroxide salts. Potassium chloride may be administered
intravenously or orally.
Digitalis:
%herapeutic Uses oI
igitalis ompounds
Heart Failure
O inotropy
O ejection Iraction
O preload
O pulmonary congestion/edema
rrhythmias
O ' nodal conduction
(parasympathomimetic eIIect)
O ventricular rate in atrial Ilutter
and Iibrillation
Atropine: tropine is a muscarinic receptor antagonist that is used to inhibit the eIIects oI excessive vagal activation on the heart,
which is maniIested assinus bradycardia and' nodal block. %hereIore, atropine can temporarily revert sinus bradycardia to normal
sinus rhythm and reverse ' nodal blocks by removing vagal inIluences.