F.

Treatment of tachyarrhythmias: class IV drugs

1. Mechanism
a. Class IV drugs selectively block L-type calcium channels.
b. These drugs prolong nodal conduction and effective refractory period and have
predominate
actions in nodal tissues.

2. Verapamil (Calan, Isoptin)

a. Verapamil is a phenylalkylamine that blocks both activated and inactivated slow
calcium
channels. Tissues that depend on L-type calcium channels are most affected,
and it has equipotent activity on the AV and SA nodes and in cardiac and vascular
muscle tissues.
b. Although verapamil is excreted primarily by the kidney, dose reduction is necessary
in the presence of hepatic disease and in the elderly. Bioavailability following oral
administration is about 20%; much lower doses are required when administered
intravenously.
c. Verapamil is useful in reentrant supraventricular tachycardia, and it can also
reduce
ventricular rate in atrial flutter and fibrillation.
d. Verapamil has negative inotropic action that limits its use in damaged hearts; it
can
lead to AV block when given in large doses or in patients with partial blockage.
Verapamil can precipitate sinus arrest in diseased patients, and it causes peripheral
vasodilation.
e. The adverse cardiac effects of verapamil, including sinus bradycardia, transient
asystole,
and other arrthythmias, may be exacerbated in individuals taking a-adrenoceptor
antagonists; this can be reversed by atropine, -adrenoceptor agonists, or calcium.
Verapamil should not be used in patients with abnormal conduction circuits as in
Wolff-Parkinson-White syndrome.

3. Diltiazem (Cardiazem)
a. Similar in effects to verapamil, although it is a benzothiazapine. It affects both cardiac
and vascular smooth muscle. Its inotropic effects are less than with verapamil.
Diltiazems inhibitory effects on conduction through the AV node make it useful for
certain supraventricular arrhythmia.