Antidysrhythmic Agents

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Antidysrhythmics
Dysrhythmia
• Any deviation from the normal rhythm of the heart

Antidysrhythmics
• Drugs used for the treatment and prevention of disturbances in cardiac rhythm

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Cardiac Cell
• Inside the cardiac cell, there exists a net negative charge relative to the outside of the cell.

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Resting Membrane Potential: RMP
• This difference in the electronegative charge. • Results from an uneven distribution of ions (sodium, potassium, calcium) across the cell membrane. • An energy-requiring pump is needed to maintain this uneven distribution of ions. • Sodium-potassium ATPase pump

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Instructors may wish to insert: EIC Image # 61: Heart and Conduction System EIC Image # 63: Resting Membrane Potential of a Cardiac Cell
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Action Potential
• A change in the distribution of ions causes cardiac cells to become excited. • The movement of ions across the cardiac cell’s membrane results in the propagation of an electrical impulse. • This electrical impulse leads to contraction of the myocardial muscle.

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Action Potential
Four Phases
• The SA node and the Purkinje cells each have separate action potentials.

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Instructors may wish to insert: EIC Image # 64: Action Potentials: Phases (SA Node) EIC Image # 65: Action Potentials: Purkinje Fiber EIC Image # 66: Action Potentials: Intervals
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Vaughan Williams Classification
• System commonly used to classify antidysrhythmic drugs

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Vaughan Williams Classification
• Class 1
– Class Ia – Class Ib – Class Ic

• Class II • Class III • Class IV • Other
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Vaughan Williams Classification
Class I
• Membrane-stabilizing agents • Fast sodium channel blockers • Divided into Ia, Ib, and Ic agents, according to effects

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Vaughan Williams Classification
Class I moricizine
• General Class I agent • Has characteristics of all three subclasses • Used for symptomatic ventricular and lifethreatening dysrhythmias

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Vaughan Williams Classification
Class Ia quinidine, procainamide, disopyramide
• Block sodium channels • Delay repolarization • Increase the APD • Used for atrial fibrillation, premature atrial contractions, premature ventricular contractions, ventricular tachycardia, Wolff-Parkinson-White syndrome
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Vaughan Williams Classification
Class Ib tocainide, mexiletine, phenytoin, lidocaine
• Block sodium channels • Accelerate repolarization • Decrease the APD • Used for ventricular dysrhythmias only (premature ventricular contractions, ventricular tachycardia, ventricular fibrillation)
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Vaughan Williams Classification
Class Ic encainide, flecainide, propafenone
• Block sodium channels (more pronounced effect) • Little effect on APD or repolarization • Used for severe ventricular dysrhythmias • May be used in atrial fibrillation/flutter

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Vaughan Williams Classification
Class II Beta blockers: atenolol, esmolol, petaprolol, propranolol
• Reduce or block sympathetic nervous system stimulation, thus reducing transmission of impulses in the heart’s conduction system • Depress phase 4 depolarization • General myocardial depressants for both supraventricular and ventricular dysrhythmias
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Vaughan Williams Classification
Class III amiodarone, bretylium, sotalol, ibutilide
• Increase APD • Prolong repolarization in phase 3 • Used for dysrhythmias that are difficult to treat • Life-threatening ventricular tachycardia or fibrillation, atrial fibrillation or flutter—resistant to other drugs • Sustained ventricular tachycardia
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Vaughan Williams Classification
Class IV verapamil, diltiazem
• Calcium channel blockers • Depress phase 4 depolarization • Used for paroxysmal supraventricular tachycardia; rate control for atrial fibrillation and flutter

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Vaughan Williams Classification
Other Antidysrhythmics digoxin, adenosine
• Have properties of several classes and are not placed into one particular class

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Antidysrhythmics
Digoxin
• Cardiac glycoside • Inhibits the sodium-potassium ATPase pump • Positive inotrope—improves the strength of cardiac contraction • Allows more calcium to be available for contraction • Used for CHF and atrial dysrhythmias • Monitor potassium levels, drug levels, and for toxicity
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Antidysrhythmics
adenosine (Adenocard)
• Slows conduction through the AV node • Used to convert paroxysmal supraventricular tachycardia to sinus rhythm • Very short half-life • Only administered as fast IV push • May cause asystole for a few seconds • Other side effects minimal
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Antidysrhythmics: Side Effects
ALL antidysrhythmics can cause dysrhythmias!!
• Hypersensitivity reactions
– Nausea – Vomiting – Diarrhea – Dizziness – Blurred vision – Headache
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Antidysrhythmics: Nursing Implications
• Obtain a thorough drug and medical history. • Measure baseline BP, P, I & O, and cardiac rhythm. • Measure serum potassium levels before initiating therapy.

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Antidysrhythmics: Nursing Implications
• Assess for conditions that may be contraindications for use of specific agents. • Assess for potential drug interactions. • Instruct patients regarding dosing schedules and side effects to report to physician.

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Antidysrhythmics: Nursing Implications
• During therapy, monitor cardiac rhythm, heart rate, BP, general well-being, skin color, temperature, heart and breath sounds. • Assess plasma drug levels as indicated. • Monitor for toxic effects.

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Antidysrhythmics: Nursing Implications
• Instruct patients to take medications as scheduled and not to skip doses or double up for missed doses. • Patients who miss a dose should contact their physician for instructions if a dose is missed. • Instruct patients not to crush or chew any oral sustained-release preparations.
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Antidysrhythmics: Nursing Implications
• For class I agents, monitor ECG for QT intervals prolonged more than 50%. • IV infusions should be administered with an IV pump.

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Antidysrhythmics: Nursing Implications
• Patients taking propranolol, digoxin, and other agents should be taught how to take their own radial pulse for 1 full minute, and to notify their physician if the pulse is less than 60 beats/minute before taking the next dose of medication.

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Antidysrhythmics: Nursing Implications
• Monitor for therapeutic response:
– Decreased BP in hypertensive patients – Decreased edema – Regular pulse rate or – Pulse rate without major irregularities, or – Improved regularity of rhythm

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