Anti-Arrhythmia Drugs

Classes Class 1A Slower Categories Names Na blockers Phase 0 blockers Actions Uses Mainly ventricular arrhythmias SVT (Supraventricular Tachycardia) Side effect Can aggravate / precipitate (new) arrhythmias Quinidine : headache, tinnitus, dizziness, blurred vision Procainamide : Lupus like effect (arthralgia/arthritis) Disopyramide : atropine (antimuscarinic) like effects, may cause CHF Lidocaine: Mainly neurologic side effects Mexiletine: Tremor, blurred vision, lethargy, nausea Quinidine Prolong APD Procainamide Prolong repolarization Disopyramide Depress conduction & prolong refractory period Negative inotropic Prolong QRS (ECG)

Class 1B Faster

Na blockers

Lidocaine Mexiletine Phenytoin

Effects only on depolarized / rapidly firing tissue Decrease APD and ERP (HisPurkinje; ventricles) Increase ventricular fibrillation threshold digitalis induced afterdepolarizations (Phenytoin) Suppresses abnormal automaticity (Flecainide) Slows conduction (AV node, Ventricles) atrial/ventricular refractoriness (Propafenone)

Class 1C Slower

Na blockers

Flecainide Propafenone Ethmozine

Ventricular arrhythmias ( esp. post MI) Lidocaine: IV (rapid action, not proarrhythmic) Mexiletine: Oral Phenytoin: digitalis induced arrhythmias Ventricular arrhythmias ( esp. post MI) Flecainide: PVCs Propafenone: Supravenricular arrhythmias

Both: Exacerbation of ventricular arrhythmias (sp. Flec) Flecainide: Negative inotropic effect Propafenone: Metallic taste, constipation

Class 2 Slower

blocker Phase 2 and 4 blockers

Propranolol Metoprolol Atenolol Sotalol* Nadolol

sympathetic stimulation + membrane stabilization - Reduce automaticity in SAN and Purkinje fibres - Slow conduction and ERP in SA node - APD and ERP in atria & ventricles Block outward K+ current during repolarization Prolong repolarization Prolong APD and ERP Sotalol (class II + Class III

Ventricular arrhythmias (post MI) Supraventricular tachycardia Tachycardia associated with thyrotoxicosis Atrial Fibrillation Recurrent ventricular tachyarrhythmias

Bronchospasm (avoid in asthmatics) Hypotension / fatigue / exercise intolerance CNS effects : sleep disturbances (sp. Propranolol)

Class 3 Slower

K blocker Phase 3 blockers First line drugs

Amiodarone Sotalol* Ibutilide

Amiodarone many adverse effects not recommended as first line drug Heart: Symptomatic bradycardia and heart block Lung: Pulmonary fibrosis Liver: hepatitis Thyroid: blocks peripheral conversion of T4 to T3 Skin: photosensitivity, dermatitis, discolouration Eye: corneal microdeposits Constipation Beware: combination with blockers / digoxin

Class 4 Slower

Ca blocker Verapamil, Diltiazem

Block L-type voltage gated Ca++ channels - both activated and inactivated states blocked - affect conduction in SA and AV nodes - prolong APD and ERP (AV nodal) - suppress early & delayed after-depolarizations

Mainly supraventricular tachycardia (preferred drug) Atrial fibrillation & flutter (to slow ventricular rate)

Adenosine Others Slower

Digoxin Slower

Others

Acts through adenosine receptors Directly inhibits AV nodal conduction & ERP (less effect on SA node) Inhibits Na-K ATPase Increases force of contraction Vagotonic Blocks AV conduction Slows ventricular rate in AF

Prompt conversion of PSVT (IV bolus) (drug of choice)

Flushing, Shortness of breath (? Bronchospasm) Dizziness, headache (less common)

USE: Atrial fibrillation (to slow the ventricular rate) (Also used in heart failure inotropic action)

AE : Can cause arrhythmias Nausea / vomiting Visual disturbances