Rhythm of the Heart

and anti-arrhythmic drugs

Class IV
 VERAPAMIL—ALREADY DISCUSSED IN CCBs
 Calcium channel blocker
 Suppress automaticity
 PSVT
 AFL or Afib.
 Ventricular arrhythmias poor efficacy
 VT—may convert to VF—THEREFORE
contraindicated
 40mg od
 Calcium channel
blockade by verapamil(4)
 PSVT—HP university question
 Attack of PSVT may be terminated by reflex vagal
stimulation(valsalva maneuver, splashing ice cold
water on face, hyperflexion)
 DOC—adenosine, Verapamil/diltiazem alternative
 Adenosine—occurs as Free base or as ATP
 Terminates---90% of the attacks of PSVT in 30 sec.
 Activates Ach sensitive k+ channels and causes
hyperpolarization
 A1---gpcr (+) on SA node, AV node
 Adrenergically induced arrhythmias control
 T1/2—10sec---taken up by RBC and endothelial
cells—--TO BE GIVEN RAPID
 Heavy coffee and tea intake ---action is
antagonised—because they block adenosine
receptors.
Advantages of adenosine over
verapamil for PSVT
 Efficacy better, titrable

 T1/2—10sec---cardiac arrest transient

 Pts not responding to verapamil

 Side effects---respiratory tract---ppt asthma


Broad uses of Anti-
arrhythmics
 Atrial Arrhythmias--- Class IV-CCBs,
( Class III except amiodarone), digoxin,
adenosine

 Ventricular Arrhythmias—Class IB---

Lignocaine

 Both---Class 1A, IC, Class II, Amiodarone

AES---NO TREATMENT—
Propranolol(40-80mg BD) only
if disturbing and
symptomatic
Atrial Flutter—cardioversion and
propafenone(class1C) (reversal to SR rhythm)
and Propranolol(classII) or CCBs +/- digoxin
control of ventricular rate
Chronic treatment

 Amiodarone
 Ventriular rate---digoxin
Atrial fibrillation
 Acute treatment and chronic treatment same
as Atrial Flutter. (Except we can add iv and
oral amiodarone for acute treatment of
reversal to sinus rhythm and maintenance of
sinus rhythm)
PSVT

Acute—adenosine –doc
Chronic----verapamil, digoxin
VES,VT,VF
 VES-LIDOCAINE—ACUTE TREATMENT
 VT and VF--AMIODARONE
 Emergency---DEFIBRILLATOR--VF OR
CARDIOVERSION—VT

 Treatment of VF---Defibrillator+/-
amiodarone( i.v /oral)

Most common drugs for ventricular arrhythmias

 VES,VT,VF
 VES-LIDOCAINE—ACUTE TREATMENT
 VT and VF--AMIODARONE
 CARDIOVERSION—VT
 Emergency---DEFIBRILLATOR--VF OR
 Treatment of VF---Defibrillator+/- amiodarone( i.v
/oral)
Most common drugs for ventricular arrhythmias
Lignocaine—50 mg bolus followed by 25 mg every 20
min.
Amiodarone—200mg slow iv inj over 60 min(oral -200 -
mg od
 Cardioversion/defibrillator

We should add
warfarin to
prevent
thromboembolism
DEFIBRILLATOR
Ventricular tachycardia
Torsedes de pointes---
Torsedes de pointes

 Anti-arrhythmics –1(a)and (c ) ,class

III,Antihistaminics,antimicrobials,antidepress
ants,antipsycotics.

Treatment
 Pacing-(Pacemaker)
 Isoprenaline--acquired
 Mg++--Congenital and acquired
 Propranolol—chronic treatment
Arrhythmias that do not
need treatment

If the patient is asymptomatic and heart is

otherwise normal

 Most AES
 Occasional VES
 1º AV block
 Bundle branch block
Assignment 3 (5 marks)
 A sales executive aged 55 yrs presented with
palpitations felt off and on both during
activity as well at rest for the last one month
or so. He also complained of tiredness and
anxiety. The pulse was irregular in volume and
frequency with average rate of
104/min,respiration-20/min BP of 130/84mm
of Hg, apex beat was irregular with average
rate of 120/min. There was no murmur. A
diagnosis of Persistent Atrial Fibrillation with
no signs of ischemia.
 It was decided to cardiovert him. He was put
on warfarin 5 mg BD for 2 days followed by 5
mg OD to adjust INR finally to 2-2.5. This was
to be maintained for 1 month before
attempting cardioversion.
 Q3a. Why the patient has been put on
warfarin therapy before attempting
cardioversion?(1 mark)
 Q3b.Can some drug be given to control his
ventricular heart rate and regularize it in
mean time?(1 mark)
 Q3c.If electrical cardioversion does not
succeed can some drug be given to revert the
heart rate to sinus rhythm?(1 mark)
 Q4d. After cardioversion can some drug be
given to maintain SR and prevent recurrence?
Eneumerate the side effects of this drug that
you have mentioned. (2 marks)